The homeless man sat cross-legged on his hospital bed, bent at the waist, his head tucked to his chest. He didn’t need to speak for Johns Hopkins social worker Katie O’Neil to understand him.
“Without actually talking, he was telling me to leave the room,” O’Neil says. “He let me know that he wasn’t ready to talk about his addiction or his homelessness yet. It took everything I had, but I walked out of his room.”
When people with serious illnesses aren’t ready to confront the life adjustments often key to getting better, both patients and providers face frustration and may even lose hope.
Stephen Wegener, director of the Division of Rehabilitation Psychology and Neuropsychology, has designed a program to train health care professionals to work with patients whose priorities might differ from their own. In two half-day sessions, trainees learn to recognize patient cues — spoken and unspoken — that reveal patients’ readiness to confront their health issues.
“When a patient is more worried about a sore knee than about hypertension, we have to collaborate with that patient by taking the knee seriously, then addressing the hypertension in the same visit,” says Wegener. “The key to patient engagement is provider engagement.”
O’Neil’s patient was admitted to Johns Hopkins Bayview Medical Center with life-threatening breathing problems. But his addiction and homelessness served as barriers to making the life adjustments required to get healthy and stay out of the hospital.
O’Neil returned the day after she left and started a conversation with the man. Little by little, they made progress together. “Fast forward a few months and he’s off the streets for the first time in about 15 years,” she says. “He’s been through an inpatient rehab program, and he’s got a roof over his head. He’s absolutely engaged with his primary doctor and his care team.”
Wegener says that major changes in patient behavior often happen slowly. The Patient Engagement Training program shows providers how to acknowledge more incremental steps taken in a healthy direction.
“We have to accept people where they are,” he says. “And we have to make sure that every interaction we have with patients moves them closer to taking action.”
Training is currently taking place within the Johns Hopkins Community Health Partnership (J-CHiP), a program that helps patients who live in the neighborhoods closest to The Johns Hopkins Hospital and Johns Hopkins Bayview take an active role in their own care. Funded in part by the federal government, J-CHiP serves as a proving ground for ideas and projects designed to remove obstacles that can lead to health crises and preventable, repeated, and costly inpatient stays.
One such idea is getting health care providers to change their own behaviors, which Wegener says can be as tough as getting patients to alter theirs. “We’re taking the same approach with the trainers as we take with the patients,” he says. “Different people are in varying degrees of readiness for this.”
To date, the trainings have been held for nurses, social workers, community health workers and other nonphysicians who have direct contact with patients. Wegener says training for physicians will be part of the next phase. Ultimately, he says, the patient engagement concept will extend into the overall hospital culture.
Wegener has embedded “champions” of the concept on J-CHiP care teams. To maintain the program’s momentum, those champions revisit topics of patient engagement at staff gatherings.
Nonjudgmental listening and empathy are key to helping patients make life changes when they don’t seem motivated. “They’re not bad people,” he says. “And they’re not noncompliant. They’re just not ready yet.”