Melanie Gregory, Ida Institute's senior audiologist, describes the Patient Journey Tool and explains how it can be used by clinicians.
Most client histories have roots long before the hearing loss is even recognized and continue long after the last visit with the hearing care professional. By understanding the hearing loss journey, professionals can better address the entire client experience and collaborate with clients to gain better outcomes. We developed the Possible Patient Journey tool to assist hearing care professionals in taking the client's point of view into account. It is one way of illustrating the hearing loss journey and is designed to support clients, clinicians, and students in visualizing or “mapping” the journey. The journey tool may be used as a starting point for understanding the complex phases and numerous milestones of hearing loss. Practitioners can also use the information gathered from the client to inform the motivational interviewing process.
The term 'patient journey' has been used extensively in the medical field to describe the experiences a typical patient takes within a treatment regime. We believe that this concept can be used within the field of hearing care, as it creates a wider, richer context for the interaction between the client and professional. We hope that this model is useful in dialogues with people with hearing loss, their families, colleagues, and students. As with all models, it has its shortcomings, as it tries to explain a complex reality in a simple way. On the other hand, models are ideal to foster discussion and should be challenged, remodeled, and reconfigured.
The Traditional Medical Model
Traditionally, when we talk about the patient journey, we are talking about the treatment protocol that we follow with patients in the medical model. In the medical model, the approach to information-gathering is physician-centered and focuses on problems and symptoms. Clients are not encouraged to share their stories. The medical model requires practitioners to assume a more “responsible” persona in discussion that revolves around solutions, details, providing answers, being right or wrong, and performance. In this role, the professional is the expert and is responsible for what takes place in the clinical encounter. He or she provides the answers, points out the right way to do things, and focuses on the details.
In the medical model, the patient interview or “intake” is characterized as an exchange of information about the patient's disease that is relevant to the interviewer's professional purposes. Clinicians see and define the journey from the medical point-of-view. When did the problem start? What are the symptoms? There is usually a type of symptoms checklist. What the medical model does not take into account is the fact that people come into the clinical encounter with their own unique set of experiences based on their social environment, communication needs and cultural backgrounds.
Changing the Model to be More Person-Centered
The Patient Journey tool enables the person with hearing loss and the practitioner to engage in the rehabilitation process on equal footing. One of the most important characteristics of the person-centered approach is that the interaction between the clinician and client is perceived as a “meeting of experts.” In this case, the hearing care professional is the expert in the field of audiology and the client is the expert in his or her own experience of hearing loss. In this more responsive, person-centered model, professionals are more open to a dialogue that engages the client and hears his or her point of view. Multiple perspectives and processes are involved so that the choices provided take into account the unique experiences and needs of the client. By conveying an understanding of key elements of the client's story, it is possible to incorporate motivational interviewing to empower clients to become joint decision makers in their treatment plans. With this kind of approach, we convey to clients that the clinical encounter is about their concerns and their interests. According to Miller and Rollnick, motivational interviewing techniques can facilitate behavior change by helping clients to explore and resolve their ambivalence about a behavior change.
The medical model contrasts with the person-centered model in their different approaches to exploring the hearing loss journey. The former is practitioner-led; the latter is a collaboration between the practitioner and client. When the practitioner uses language focused on symptoms and signs, and the client focuses on his or her experience with hearing loss, a mismatch occurs, making it very difficult to develop trust. Establishing trust and respect for clients and their unique experiences is critical to building a positive relationship with them. The Pew-Fetzer Task Force on Health Professions Education and Relationship-Centered Care reported that the relationship clients have with their healthcare providers can be one of the most therapeutic aspects of the clinical encounter: “Appreciating the patient's experience of health and illness and his or her need for and right to care and respect creates the conditions for preserving the dignity and integrity of the patient within the practitioner-patient relationship.”
Benefits of a Person-Centered Approach
When a person-centered approach is used, research indicates that there are fewer malpractice claims, greater client satisfaction, improved client adherence — and this approach does not take longer to implement. Abdel-Tawab and Roter found that person-centered consultations took only one minute longer than physician-centered consultations. In addition, when doctors used a person-centered approach, a threefold increase in client satisfaction and compliance was observed.
Studies have also shown that attention to a client's “psychological, familial, social, cultural and environmental contexts allows the tailoring of treatments to individual situations . . . can lead to improved outcomes, more cost-effective care and more efficient care delivery.” The quality of client outcomes is inextricably tied to the audiologist's ability to listen to the client's perspective and to explore the client's readiness and motivation for treatment: in short, to provide person-centered care and an understanding of their journey.
A Possible Patient Journey
The Patient Journey tool shows the different phases and stages that a client experiences when they have a hearing loss. The tool can help you understand the experience of hearing loss through the eyes of the client. By understanding and discussing their unique journey, you can address the client's entire experience and work together to gain a better outcome. The tool is inspired by the collaborative efforts of 65 hearing healthcare professionals worldwide who attended the Ida seminar series on Defining Hearing.
Individuals may experience the various phases and milestones of the hearing loss journey at different times. As people become more aware of their hearing loss, they move from a problem they had not previously recognized to a situation that requires attention and action. However, the pace at which they travel from one milestone to the next and their level of consciousness as they do so is uniquely their own. People with hearing loss, like other people with chronic illness, manage their hearing loss long before they see a hearing care professional. People with hearing loss must make decisions about communication everyday for the rest of their lives. These are self-management choices, and it is an extraordinary demand on a person. This reminds us that we must listen to the factors that influence clients' perceptions of their hearing loss, so that we can better help them make changes that are effective. Tools like A Possible Patient Journey can assist us in this endeavor.
A Metaphor or Framework
The journey metaphor gives us a framework to consider our clients' experiences from their viewpoint. It creates a common ground from which client and practitioner can work together. The metaphor of the journey also shifts the thinking from a traditional case history intake to more textured and rich experience sharing that engages both the clinician and the client. The journey tool is a way to help us hear clients' stories in their own words, enables us to hear what is most relevant and important to a particular client, and what hearing loss means to him or her.
By the time a person with hearing loss comes to visit us, they have usually experienced several different stages or phases. Many of those stages are recognizable, but clients also bring unique characteristics of their journey with them. In recognition of each individual's unique experience of hearing loss, the Patient Journey tool uses broad phrases and suggests experiences typical of each phase to enhance practitioner and client understanding of the broader context of hearing loss.
The Different Stages of the Journey
In this phase, the person with hearing loss is experiencing communication problems but may be “managing” without acknowledging the problem. They may also feel bewildered or frustrated. Family and friends may begin to notice the person's hearing difficulties.
At this phase, the client realizes that hearing loss is impacting his or her social and work life. They may recognize their hearing loss and begin to map the problems it causes. The client may “self-test” by raising the TV volume or by attempting to control other environmental sounds.
The person with hearing loss reaches a tipping point and is ready to consult a hearing care professional. The client gathers information about hearing loss from a variety of sources, including his or her personal network, general practitioner, media, and the internet.
The client actively seeks referral to a hearing care professional. They meet a hearing care professional for an interview and case history, hearing test, and recommendations, leading to decision making.
The person with hearing loss takes action. They seek counseling, treatment, hearing solution fittings, and consider other assistive devices. The client develops new communication strategies and may accept or reject of the recommendations of the hearing care professional.
The client undergoes a process of adaptation and change. They observe the social impact and continue to self-evaluate the success or failure of the treatment outcome. The problem is resolved or the client becomes aware of new problems.
Relapse or Permanent Exit
Using the Patient Journey Tool
It is possible to use the Patient Journey as a hard copy. The visual image of the journey may provide a concrete way of describing and comparing a client's own path to the composite journey shown in the hard copy. By locating the client's experience on the continuum, the hearing care professional can convey possible next steps and communicate that the appointment is not the end of the journey. Significant events highlighted by the client can be the basis for motivational interviewing. As such, the tool can be referred to and added to throughout the rehabilitation process.
The Patient Journey tool can be used for teaching purposes where students are encouraged to create journey models based on their experience with clients, and to engage with fellow students about their experience of their clients' journeys. When using the Patient Journey as an experiential learning exercise, many of our seminar participants have commented on the cyclical nature of the journey, and that for many it resembles a spiral learning process rather than a linear experience.
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