Rethinking Shared Decision-Making: Delivery of Care Options in a Telehealth World

Abstract

Telehealth modalities have given patients options for delivery of care, and in some cases increased access to care. However, great effort needs to be made by providers and clinic staff to ensure patients are given choice in their delivery of care methods and technological support to work toward equity in care. We propose applying the BEACH model for shared decision-making to help providers support patients in choosing the best care delivery method, while also encouraging providers to seek further education on telehealth competencies. Lastly, we stress the importance of the clinical staff in ensuring patient autonomy, education, and support when choosing telehealth modalities of care.

Introduction

The delivery of health care has undergone significant transformation, with telehealth emerging as a critical component of modern care. While in-person visits dominated health care for much of the 20th century, the COVID-19 pandemic accelerated the need for virtual care solutions. As hospitals and clinics halted nonemergent visits in early 2020, telehealth became a vital tool for ensuring continuity of care. Today, patients not only have more options for how they receive care but are also empowered to choose the modality that best suits their needs. Allowing for patients to have choice in how they receive care is a foundational piece of patient equity. Patient equity is a concept that ensures that each patient gets the care that they need in the way that they need, when they need it. However, to ensure equitable access, health care providers must support patients in making informed decisions about their care delivery methods, particularly as telehealth becomes more integrated into standard practice.

During the pandemic, the prevalence and utilization of telehealth modalities skyrocketed, increasing over 2,000% in a matter of weeks. ¹ Telehealth refers to the exchange of medical information through synchronous (real-time, audio-video or audio only) or asynchronous (store-and-forward) modalities. Telehealth has provided patients and clinicians a way to accommodate logistical needs; a service that has proven to be helpful for patients during pre, during and post pandemic eras. ² Prior to COVID-19, less than 1% of all physician visits in the United States happened over telehealth. Within 1 month that scaled to over 50%, with postpandemic numbers remaining above prepandemic levels. Virtual house calls became the norm, with technology allowing physicians to visit their patient’s homes yet again. Although many patients embraced telehealth during the pandemic, they did so without choice. Throughout the evolution of health care, one thing has remained constant: patients have not been active participants in determining how they would like to receive care.

Telehealth modalities have given patients options for delivery of care and in many cases increased access to care. ³ Telehealth is here to stay, and we know telehealth can work to provide good patient care when in-person visits would be less favorable (e.g., pandemic, time constraints, lack of provider access). ⁴ Yet, telehealth is not a single solution. The satisfaction seen among patients is highly dependent on demographics, health compliance, and their previous experience with telehealth. ⁴ Put simply, patients know their own circumstances.

Thus, we propose reapplying the well-recognized shared decision-making (SDM) concept to patient-provider conversations when choosing their best delivery of care option(s). SDM is, most simplistically, defined as, “decision-making process jointly shared by patients and their health care providers.” ⁵ The process includes three common “talks” to give patients a voice, present options coherently, and they agree to these practices: team talk, option talk, and decision talk. ⁶ SDM is important because it allows for Patient Centered Care (PCC), but it also provides patients with the measure of their rights in the medical setting. ⁷

Patient Centeredness and SDM

Throughout the history of managed care, there has been a common argument: patient centeredness is the most important variable in medical encounters. PCC is the concept that the patient’s needs should guide the agenda and outcome of the interactions between doctor and patient. ⁸ Or as Martin Crowie writes “Clinicians should learn to ask not only ‘what is the matter?’ but ‘what matters?’ In other words, what are the patient’s interests, concerns, and fears about the specific conditions, symptoms, or treatment options?”. ⁹ To achieve PCC physicians and medical care researchers have looked at what encourages PCC. Discussion on the matter has surrounded power dynamics in the clinical setting, nonverbal communication, agenda setting, and even the demographics of the medical interlocutors. ^10,11,12 Researchers have tried to break down PCC to these extensive parts, but when looking at the larger influence on PCC, it is clear: SDM is what allows the patient to maintain the central focus of the medical encounter. ¹³ The need for SDM has been an ever-present need in medicine. However, with the influx of telehealth use during the pandemic and subsequent new standard of care delivery, ensuring that patients have a voice, are involved in, and agree with how they receive their care is of the highest necessity.

The Three Talk Model of SDM

Patients need to have autonomy and choice when deciding delivery of their care. Every patient has varying circumstances which would make telehealth a benefit or challenge. Although telehealth can increase access for populations, lack of technology, internet, or knowledge of telehealth tools can limit telehealth access for others. Patients need a space and time to educate clinicians on their needs, preferences, and barriers regarding delivery of care modalities. ^14,15 Providers can address this concern by considering the Three Talk Model of SDM. ¹⁶ This model provides practical and evidence-based options for how SDM can happen in a medical setting while also keeping the patient in control of their health care. The need to use and evolve models such as this are evermore imperative with the rise and scope of telehealth care in our postpandemic world. The Three Talk Model allows the doctor to find out what is the matter and what matters to the patient. ⁹ Whereas option and decision talk allow the provider and the patient to work together to discover all the possibilities for their health and health outcomes. ⁶ There is evidence that this approach can influence health behaviors, especially when there is an elevated level of trust in the provider-patient space; trust built through effective communication. ¹⁷

The BEACH Model: Delivery of Care SDM

We propose that SDM starts at initial patient visits, where clinicians educate their patients about options for delivering care and the benefits and limitations of digital health care modalities. ¹⁴ We developed a framework of SDM called BEACH that clinicians can follow for delivery of care SDM.

Build rapport.

Educate patients of their options.

Ask preferences.

Collaborate on decisions.

Handoff to support staff.

The BEACH Model is rooted in Elwyn’s Three Talk Model with some clear delineations. First, we emphasize the development of a relationship between the patient and the provider, a key feature of patient equity that is not included in Elwyn’s approach. The other key difference is the handing off to support staff. Support staff have had little spotlight in the world of telehealth but have continuously played an important role in the use and utilization of telehealth services. By implementing these persons in this proposed model, we believe we can better evaluate the role that support staff play and the impact that they have on patient telehealth experiences in future scholarship. Moving onto the model itself, the remainder of this paper details the five parts of the BEACH Model.

Build rapport

When conversing and making decisions with patients, the first step is always building rapport and trust. Additionally, the relationship between the clinician and patient is important to health outcomes. ¹⁸ Providers need to provide care, but there are a variety of delivery of care formats (virtual visits, satellite offices with nurses, asynchronous care/communication, etc.) to provide excellent care to patients while doing no harm. Clinicians need to build rapport, be attentive, and listen to patient concerns and needs. ^2,18,19

Educate

Once rapport is built, providers should educate patients on their care delivery options. Patient education is an important piece of care delivery SDM since telehealth involves technologies that may be unfamiliar to patients. ¹⁵

Ask preferences

Providers should ask patients about their preferences after patients are informed of their choices. Providers should ask patients what options they prefer based on values, access/limitations, and circumstances, and attentively listen. Attentiveness is crucial in building a good patient-provider relationship. ²⁰ Klaver and Baart describe attentiveness as “…professionalism based on charity.” ²⁰ That professionalism allows for a medical care relationship to form.

Collaborate

Next, providers and patients collaborate to decide on the best care delivery methods for their individual circumstances. At this step, the provider should explain why telehealth modalities may or may not be clinically appropriate for some visits or care needs.

Hand-off

Lastly, the provider engages in hand-off to the support staff so they can further educate patients in technology (if needed) and are informed of patient choices regarding delivery of care for scheduling purposes. The inclusion of the staff hand-off allows for the maintenance of rapport. The provider can advocate for the patient’s preferences and decisions during the encounter. The staff experience is a facet of patient satisfaction. It is helpful to ensure that staff interactions are consistent with the care the patient has already been provided with this model. ²¹

Discussion

With the increase in delivery of care modalities in this age, patients and providers need to make choices about the best methods. We posit that SDM be reapplied to patient encounters discussing future delivery of care methods. The “Three Talk Model” for SDM is a great tool for patients and providers. ²² We used the Three Talk Model to inform the BEACH Model of SDM for delivery of care decisions.

SDM is a skill accomplished with varying expertise based on patents’ & providers’ personality, expectations, medical care goals, and culture/population. ²³ Yet, because it is a skill, it is teachable and can be mastered with time. Clinicians need to learn about delivery of care SDM through continuing medical education (CME) activities. Telehealth CME for clinicians should include (1) understanding and communicating the benefits of telehealth for patient care, (2) implementing a model for telehealth education and empowerment in the clinical setting, and (3) incorporating SDM regarding delivery of care options during initial patient appointments. ¹⁴ Additionally, a robust CME program on telehealth would address all of the American Association of Medical Colleges (AAMC) telehealth competencies.

The AAMC has outlined telehealth competencies for medical students, residents, and practicing physicians. ²⁴ Many physicians may not know about these competencies or know how to grow in telehealth competencies. The telehealth competencies that align with our delivery of care SDM framework are in Table 1. Domain 1.1 addresses the “education” portion of the BEACH model. Domain 1.2 aligns with the “asks preferences” part of the model. Domain 2 aligns with the “collaborate” part of the model with the provider working to accommodate patients’ needs and preferences. However, Domain 2 is also about working with the staff for a considerate “hand-off” part of the model, especially when clinics have a digital support staff.

Table 1.

AAMC Telehealth Competencies Aligned with Delivery of Care Shared Decision-Making

Domain 1: Patient Safety and Appropriate Use of Telehealth
1a. Explains to patients and caregivers the uses, limitations, and benefits of telehealth—that is, the use of electronic communications technology to provide care at a distance.	1b. Explains and adapts practice in the context of the limitations and benefits of telehealth
2a. Works with diverse patients and caregivers to determine patient and caregiver access to technology to incorporate telehealth into patient care during real or simulated encounters	2b. Works with diverse patients and caregivers to evaluate and remedy patient and practice barriers to incorporating telehealth into patient care (e.g., access to and comfort with technology)

Domain 2: Access and Equity in Telehealth
2a. Defines how telehealth can affect health equity and mitigate or amplify gaps in access to care.	2b. Leverages technology to promote health equity and mitigate gaps in access to care.
3a. When considering telehealth, assesses the patient’s needs, preferences, access to, and potential cultural, social, physical, cognitive, and linguistic and other communication barriers to technology use	3b. When considering telehealth, accommodates the patient’s needs, preferences, access to, and potential cultural, social, physical, cognitive, and linguistic and other communication barriers to technology use

The innovation this model brings to medical communication in telehealth includes increased access to care and patient empowerment. However, it must be noted that for patient empowerment and access to care to increase, patients will need additional support to ensure equity. Some facilities are staffing digital equity specialists: staff persons who can work one-on-one with patients to ensure that their care, education, and access needs are met regarding telehealth modalities. As initiatives such as this increase, we may see another great shift in health care delivery. From the home to the clinic, now the hospital to the computer; the role for SDM and specialized staff persons are more essential.