Sutter Center for Integrated Care Using AHRQ Guide in Patient Materials

Sutter Health's Center for Integrated Care (SCIC), a division of Sutter Health, is using the AHRQ publication, Taking Care of Myself: A Guide for When I Leave the Hospital, to help patients record their health care histories and state their treatment goals. As part of its efforts to coordinate across clinical settings to achieve patient-centered care, SCIC adapted the guide from AHRQ's Re-Engineered Discharge (RED) Toolkit, a discharge planning resource to help patients prepare for life at home after a hospitalization.

SCIC includes the AHRQ guide in patients' personal health records. In particular, the publication is being used by home care patients who are clients of Sutter at Home. This division of Sacramento, California-based Sutter Health, has a network of 24 acute care hospitals, physician practices, and home and community services.

While personal health records often are thought of as electronic documents similar to electronic health records (EHRs), SCIC's personal health records are paper documents. These allow patients to keep track of health- and wellness-related information, according to Jennifer Pearce, M.P.A., SCIC health literacy program manager.

"From a health literacy perspective, an EHR is only as good as the access people have to computers and the Internet," Ms. Pearce said. "Our paper tool gives all patients the opportunity to keep the same information in a manner that is comfortable and usable to them."

The personal health record enables patients to keep track of their health information, such as surgery and medication history, and gives guidance on how to ask their health care team questions. But it also gives significant space to nontraditional, open-ended questions such as "I want to feel ____," "I need help with _____," and "My spiritual life and culture: _____."

"Our goal is to identify what matters most to each and every patient so this can drive our care delivery. We call this our ‘always event,'" said Paula Suter, R.N., B.S.N., M.A, SCIC's clinical director. This has proven popular both with patients and physicians, who say they appreciate the opportunity to understand their patients in a more holistic way, Ms. Suter explained.

Sutter Care at Home started using the personal health record in 2012 and distributes approximately 1,000 folders per month. It's available free on the Sutter Intranet so anyone in the system can download and use it.

Feedback has been positive, and SCIC is now advocating for the personal health record to be adopted system-wide as part of the network's "One Sutter" initiative, according to Beth Hennessey, R.N., B.S.N., M.S.N., SCIC's executive director.

"We are on a mission to personalize our care delivery and allow the voice of the patient to guide our care across all touch points in our system," Ms. Hennessey said. "That's why we want to hardwire this [personal health record] across all care settings and consistently deliver an exceptional patient experience."