The facilitator then introduces the process of the meeting. She says that in meetings like this, the team has found it helpful to start by getting a brief description from each member who is willing to speak about what is currently going well or is working in the patient’s healthcare and what their one or possibly two top concerns are for the patient’s care. She is clear that whatever is currently working is part of the foundation on which the group is building. (The foundation metaphor tends to settle people, make them for comfortable, and create a period at the start of the meeting that is less stressful than they worried it might be.) She says that after the group has identified the foundation, what is working, she will ask the group to help identify the next step in building toward better care, something that is doable by the people in this room with leadership from the patient. Then the group will take a minute to identify resources that might be needed and attempt to leave with a brief but clear plan for taking the next step.
The facilitator confirms briefly that this plan sounds acceptable to the patient and people attending the meeting. In most cases the patient and other meeting members are happy to have the meeting led and to follow what to the team seems to be a familiar set of steps. They tend to agree quickly. If a family member raises a concern or a complaint at this point, the facilitator makes clear that the person is raising just the sort of concern that we hope for as part of the “current situation” portion of the meeting. In all likelihood addressing that concern will be part of the plan.
After the crucial step of asking the patient and family for permission for the team to start the descriptions of the present situation, she asks the doctor to go first. The doctor delivers a brief “sign out” of the patient’s medical situation with some attention to the challenges that attend any person’s attempt to adequately manage such a medical picture. The doctor uses the mindset of the Minimally Disruptive Medicine approach , to describe the “footprint” of care and self-management for the patient. This makes for an easier time finding what the patient is doing right in their relationship with the team and in their own care. It is a patient-centered view introduced at the start of the meeting. Having the doctor at the beginning prevents a problem that can arise later if the patient or a family member should make a comment about the patient’s health that is medically uninformed. Their embarrassment when they need to be corrected can set back the cooperation which had built to that point in the meeting. After the medical summary, doctor adds something complementary about the patient. This may require a bit of the reframing that has been part of the transparency training for the T.E.A.M. Way. Finally, she suggests one or two concerns about the patient’s health or healthcare briefly, building off the foundations of what is working that they listed earlier, if possible.
The next to be recognized is likely to be the team member who spends the most time with the patient or who knows the patient the best from the past. This is the person who, more than likely, can do a robust job of pointing out the aspects of the patient’s behavior and of their relationship to the team that are working best. Their top concern is listed as a follow-up to the descriptions of what is working or has worked in the past. Because of their time with the patient, any brief mention of solutions that have been identified or of attributions that have been part of the patient’s activation can be good to mention. Then other team members in turn speak very briefly in the same pattern descriptions of what is working and what their top concern or two for the patient are.
By the time the team members have finished, there have been multiple descriptions that could be reframes of previous behavior, solutions that have been gleaned, and attributions that increase the patient and family members’ experience of the team work that has gone well and the patient’s role in supporting that team work. A patient who has been argumentative might have been called “always willing to share what is on his mind” or “doesn’t try to hide from the team the parts of his life that make his self-management very difficult.” A patient who never argues but who rarely takes her medicine and has not cut back on her drinking may have been described as “protecting us from things that keep her plan from working so that we can both enjoy our visits together” or “a considerate member of her family who seems to try to keep us from asking about her home life so that the privacy of her family members is protected.”
By the time the three or four team members have finished their brief contributions, patients and family members are likely to be a bit more relaxed. The meeting is shaping up to be less blaming and more supportive than they expected. They have also been exposed to a way of working that sets a tone for the meeting. As the process continues with the patient and the family or agency members, the facilitator actively moves the conversation from person to person, making the transitions by reflecting the contribution of each person. This makes each person experience themselves as heard. A bit of pressure toward brevity is maintained by the facilitator by the reminder that we are looking for only one or two concerns that can help us identify the next step toward better health. If there is overt blaming, a reminder that we are all here to help the patient with his journey to better health can help to defuse it.
The reframing skills of the facilitator can be very useful when the family members disagree as they are having their turns to talk.
Example of the “what is working discussion” and reframing
Since I got my own place, I get to be in charge of myself and my own medication.
I think he is not taking his meds as regularly as when we got to see what he was taking and when. I am not sure this is a step forward.
So, it sounds like your family has made real progress because Marvin is managing a lot more in his life, but there is no less caring on the part of his parents. They worry like most parents when they can’t know as many details about his life. Does that sound right?
Identifying the Next Step
When all of the people in the meeting who want to speak about what is working and what their top one or two concerns are have finished, the facilitator tries to make a summary statement, reiterating the general picture of what is working well and repeating a very brief synthesis of the main concerns that have been offered. She asks the assembled participants what would be the next step on the way for more effective healthcare for the patient. She reiterates the charge that we are looking for one step that is doable by the patient and people in this room, one that will be noticeable when it works. At this point, she leaves a silence. It is hoped that the first suggestion comes from the patient or family members. If it needs to come from one of the team members, a great deal of checking back to confirm support from the patient, agency representatives, and family members will be part of vetting the idea. The facilitator my want to check to see if there are other ideas, saying that the more choices we have, the greater the chance that we will pick an idea that is a good choice and the more choices we have to fall back on if the first one is not helpful. When an idea is settled upon (e.g., the patient will begin walking three times a week and three designated family members will each take one day to walk with him), the facilitator checks with the patient about what others can do to help. Sometimes family or team members are perceived as helpful if they check on how the plan is going and sometimes the patient thinks it is more helpful not to check. Whichever way the patient requests, the people who are requested too respond a certain way are asked it that would be possible, at least as a trial. If they don’t agree, they can be asked how they think they can best support the step that was identified.
The roles of the healthcare team are also detailed. Sometimes the doctor or the team member who spends the most time with the patient can ask to do their own check. The doctor says that often additional exercise will contribute to some health metric (e.g., lowering of HbA1c). She will monitor that number for the patient to see if he is getting a benefit in addition to feeling better from the exercise. The care manager may say that it has sometimes been hard in the past for the patient to keep exercising. If this time the patient keeps going beyond 2 weeks, she would like to ask him what he is doing to keep things working this time and to share what they learn with the other family members who were at the meeting. That way they will all learn more about what works for the patient. If possible, the actions of the team are defined as fitting into the plan of the patient and family. If that definition doesn’t fit, the team is described as supporting the plan in trying to do their part to help the patient stay healthy.
At this point, the meeting has taken 20 minutes to ¾ of an hour. A brief arrangement is made for follow-up. Usually the follow-up can be the summary at the patient’s next visit with the team. It is shared with the people who came to the meeting and worked on behalf of the patient, assuming the patient doesn’t want to limit the distribution in some way. The meeting is not reassembled unless there is a reason that is clear to both the team and the patient. The hope is that after the meeting, the team and patient are doing better at working together for the patient’s health. If the patient customarily comes to visits with family members, those people would be likely to continue coming unless the patient is functioning more autonomously than before. When the other family members continue to come, it is still possible to continue to notice or to stress what the patient is accomplishing with their support, rather than what they should do to guide or care for the patient.