Patientengagementinprimarycare:Howfamilyphysicianscanpartnerwithpatients

AnjanaSharma,MDMASBeatriceHuang|MalO’Connor,Ph.D |RachelWillard-Grace,MPH| KevinGrumbach,MD

FamilyMedicineforAmerica’sHealth:PatientEngagementDayWebinarpresentation

April4,2019

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

AboutUs

AnjanaSharma,MDMASAssistantProfessorofFamily&CommunityMedicine

BeatriceHuangProjectManager,Analyst

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

PollQuestion#1– Aboutyou• Whatdisciplinesdowehaverepresentedonthecall?(selectallthatapply)

1. Qualityimprovementorpatientexperienceleads2. Nursing3. Primarycareclinicians(MD,DO,NP,PA)4. Patients/patientadvocates5. Clinicorhospitalmanagement

• Whatisyourpracticesetting?(Selectallthatapply)1. Soloorsmallprimarycarepractice2. Mediumsizepractice(5-10providers)3. Largepracticesetting4. Rural5. Suburban6. Urban7. Federallyqualifiedhealthcenterorsafety-netclinic8. Academicinstitution

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Overview

• Whatispatientengagement?

• Evidencebaseforpatientengagement

• FamilyMedicineforAmerica’sHealthcasestudies

• Toolsforgettingstarted

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Patientengagementisahot topic!

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Whatispatientengagement?

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Poll#2:Whatisyourdefinitionofpatientandfamilyengagement?1. Patientadherenceorcompliancewithmedicalcare2. Digitalportalsordigitalappstoimprovehealth3. Healthliteracy4. Patientfeedback,insurveysorinadvisorycouncils5. Communityinputintohealthcareneeds6. Patientadvocacyforhealthcarelawsandpolicies

Hint:allofthesearecorrect,butwhichisclosestforYOU?

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Whatdoespatientengagementactuallymean?

“Patients,families,andcaregiversworkingwithhealthcarestaffin

partnershiptoimprovehealthcare”

LEVELOFPATIENTENGAGEMENT

PATIENTENGAGEMENTACTIVITIES

CASEEXAMPLE

INDIVIDUALShareddecision-making,motivationalinterviewing,healthcoaching,self-managementtools

Apatientlogsontotheirelectronicmedicalrecordandrecordstheirownbloodpressure

ORGANIZATIONALLEVEL(clinic,hospitalorsystem-level)

Patientexperiencesurveys,suggestionboxes,town-hallmeetings,patientadvisorycouncils,patientsworkingonqualityimprovementorsafetycommittees

Apatientadvisorycouncildevelopsanewpamphlettopublicizemammogramstotheirpatientpopulation

POLICYAdvocacyorganizationslobbyingforhealthcarecauses

AType2Diabetesorganizationmeetswiththemayortoadvocateforasugarybeveragetax

AdaptedfromCarmanKL,Dardess P,MaurerM,etal.Patientandfamilyengagement:aframeworkforunderstandingtheelementsanddevelopinginterventionsandpolicies.Healthaffairs.2013;32:223-31.

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Whyshouldweengagepatients?• Justiceissue:shiftcontrolbacktohistoricallyoppressedpopulations

• Ethicalissue:It’stherightthingtodo

• Utilitarianissue:• HelpsforPCMHcertification• RequiredforFQHCs• Attractsconsumers• Itmakeshealthcareinterventionsmoreeffective(?)

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Makingthecaseforpatientengagement:What’stheevidence?

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

DoesPatientEngagementAffectOutcomes?

• Strongerevidenceforindividual patientengagement• PatientActivationMeasure(PAM)• SharedDecisionMaking• Motivationalinterviewing• Healthcoaches

• Lessevidenceforclinic-level patientengagement• Butweareworkingonit….

HibbardandGreene.HealthAff 2013;Staceyetal.CochraneSyst Rev2011;Bennettetal.Fam Pract Manag.2010

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

SystematicReview:Results

• Results:639articlesfound,32selectedforfinalreview

1. 17casestudies/anecdotalimpactsonpatientsatisfaction,reducedfalls,improvementstoclinicandhospitallayouts

2. 4communitybasedstudies:improvedcolorectalcancerscreening,inhaleruse,BPcontrol

3. 1clusterRCT:patientadvisorsidentifiedprioritiesmorealignedwiththePCMHandChronicCareModel

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Clinicaloutcomes• Coloradobasedqualityimprovementinitiativesof“bootcamptranslation”– communityadvisorshelpedtranslatehealthmessages• Bloodpressure• Asthma• PCMHmessaging• Colorectalcancerscreening

AnjanaSharma2018 13Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Clinicaloperations

• Customerservicetraining• Eveningaccess/drop-inhours• Feedbackonwebportals• Advancedirectivepacket

SharmaA,AngelL,BuiQ.PatientAdvisoryCouncils:GivingPatientsaSeatattheTable.Familypracticemanagement.2015Jul-Aug;22(4):22-7.SharmaAE,KnoxM,Mleczko VL,Olayiwola JN.Theimpactofpatientadvisorsonhealthcareoutcomes:asystematicreview.BMChealthservicesresearch.2017;17(1):693.

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

ABFMSurveyonPatientEngagement• Results:Familydocs(1,368)practicinginambulatorysetting

76.5%

52.9%

18.8% 23.8%

20.5%

31.1%

0%

20%

40%

60%

80%

100%

Surveys Suggestionboxes

Boardsofdirectors

Patientadvisorycouncils

PatientparticipationinQIactivities

Any"highintensity"approach

”lowintensity” ”highintensity”

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

ABFMSurveyonPatientEngagement

• Notables:• Patientexperiencesurveysarehighlyprevalent• Ofallpractices,31%havehigh-intensitypatientengagement• OfallPCMHs,58.5%havehigh-intensitypatientengagement

• WhatpredictsHIGH-INTENSITYPatientEngagement(patientsinQIorpatientadvisorycouncils):• Practicesize:aOR 3.30,95%CI(1.96,5.57)• PCMHstatus:

• CertifiedPCMHaOR 2.19(1.62,2.97)• %Vulnerablepopulationsserved:aOR 1.83(1.18,2.84)

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Poll#3:Whatpatientengagementactivitiesdoyouhaveatyoursite?1. Patientadvisorycouncils2. Patientsonourgoverningboard3. Patientfeedbacksurveys4. PatientsbelongtoQIteams5. Townhallsorcommunitymeetings6. Informal,one-on-onefeedback

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

FamilyMedicineforAmerica’sHealth:PatientEngagementTacticTeam

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Commonconcernsaboutpatientengagement

• Patientengagementisonlypossibleinsystemswithlotsofresources• Patientsandfamiliesaren’tinterestedorabletoprovidefeedbacktotheirclinic• There’snoreturnoninvestmentinengagingpatientsandfamilies• Patientengagementisn’tpossibleatmypracticebecause[___]

ProjectPurpose:Toidentifyandshareinnovativestrategiesforpatientengagementattheorganizationallevelindiverse practicesettings!

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Whatdidwedo?

• Setting: InterviewedclinicleadersacrossNorthAmerica• Recruitment:Conveniencesamplingtoidentifypracticesrepresentingdiversegeographicregionsandpracticecharacteristics• Interview:Telephone-based,withinterviewguide• Aim: toassessorganizational-levelpatientengagement,howtheymadeitwork,andwhatimpactithad

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Whatdidwefind?

21interviewswereconductedfrom2016to2017

13sitesdescribedorganizationallevel

ofpatientengagement

13casestudiesdeveloped

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

CaseStudySites

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SiteDemographics

PracticeSetting Count(n=13)Rural 5

Urban 6

Suburban 2

PracticeType Count(n=13)

Private 5

Public 8

Academic 4

PracticeSize Count(n=13)

Small 3

Medium 5

Large 5

*Beinganacademicsitewasnotmutuallyexclusivewithbeingaprivate/publicsite

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

St.Michael’sHospitalAcademicFamilyHealthTeamToronto,Canada

Lowintensity

Highintensity

SiteProfile• Practicetype:Urbanacademicsite• Practicesize:Large(42,000patients)• Patientdemographics:Professional,youngfamilies,lowincome,immigrant,refugees

Whatdidtheydo?• Invited10,000patients;350volunteered!• Randomlyselected36(age,gender,housing,selfreportedhealth)• Patientengagementday– 1dayeventwherepatientsidentifiedpainpointsandprovidedrecommendations

Whatwastheresult?• Pagesofthoughtfulrecommendations(ex.Plexiglass,notunderstandingwhyresidentswouldleave)• Reenergizedpatientsandstaff• Demonstratedvalueofpatientengagement

“Manypeoplejumpintopatientadvisorycommitteesandtheymaynotalwaysbereadyforthat…Evenbringingpatientstogetherforadayisgreatanditwasgreatforourteam.”

– Dr.TaraKiran,DirectorofQualityImprovement

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

MedicalAssociatesClinicGlasgow,Kentucky

Lowintensity

Highintensity

SiteProfile• Practicetype: Rural,Independentclinic• Practicesize: Small(severalthousandpatients)• Patientdemographics:Rural,geriatric.Serves12countiesinAppalachianMountainregion

Whatdidtheydo?•Manypatientsnotbringingmedicationswasaproblemespeciallywithgeriatricpop.• PatientQualityCircles–quarterlyforumswherepatientscometogether• Broughtissuetoapatientqualitycirclemeeting

Whatwastheresult?• Onesuggestionwastoprintreminderonappointmentcards,whichresultedinmorepeoplebringingintheirmedications•Morepatientsnowvolunteertheirinputregardingclinicprocesses

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

HypertensionEquityGroupSanFrancisco,California

Lowintensity

Highintensity

SiteProfile• Practicetype:Urban,publichealthsystem• Practicesize:Large(currentlyservesover120,000individuals)• Patientdemographics:Underserved,safetynetpatientpopulation

Whatdidtheydo?• Patientsserveasactiveworkgroupmembers• Participateinmonthlymeetingstoreviewdataanddesignstrategies,presentedatmeetings

Whatwastheresult?

• Patientguidedinterventions• Homebloodpressuremonitoringtoolkit–moretailoredforB/AAcommunity• Foodpharmacy

•Missionstatement

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Commonconcernsaboutpatientengagement

• Patientengagementisonlypossibleinsystemswithlotsofresources• Patientsandfamiliesaren’tinterestedorabletoprovidefeedbacktotheirclinic• There’snoreturnoninvestmentinengagingpatientsandfamilies• Patientengagementisn’tpossibleatmypracticebecause[___]

Misconceptions

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Finalpoll:Whatinformationwasneworsurprisingforyou?

1. Patientorcommunityinputcanmakequalityimprovementprojectsmoreeffective

2. Overone-thirdoffamilymedicineclinicsintheUSareengagingpatientsinadvisorycouncilsorqualityimprovement

3. Patientengagementhappensatsoloandsmallpracticesaswellaslargerclinics

4. Patientengagementisabrandingstrategy-- itmayincreasepatientsatisfactionandconsumerretention

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Conclusions• Patientadvisorsgeneratenovelideasforserviceimprovement.

•ThereisNOone-size-fits-allforpatientengagementatthecliniclevel.

• Patientengagementstrategiescanbetailoredtothecapacityoftheclinicandneedsofthecommunity.

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Toolsforgettingstarted

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

“TOP10PATIENTENGAGEMENTTIPS”#10:Sendperiodicemailstoyourpatientstosharewellnesseducationandclinicupdates.#9:Holdaone-timepatientengagementdaywherefolkscanprovideinputandreceivehealtheducationinatownhall-styleformat.#8:Setupapatientadvisorycouncilandaskparticipantstodiscusssocialneedsthataffectthehealthoftheircommunity.#7:Askyourpatientadvisorycounciltobrainstormideastoreduceappointmentwaittimes.#6:Invitepatientadvisorstoproviderecommendationsonbrandingyourclinic.

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

“TOP10PATIENTENGAGEMENTTIPS”

#5:Involvepatientsinyourstrategicplan,missionandvision.#4:Includepatientadvisorsinqualityimprovement(QI)byputtingmembersonQIteamsandworkinggroups.#3:Considerhavingpatientadvisorsreviewaggregatedata,runchartsandhelpbrainstormnewQIprojects.#2:Haveyouradvisorycouncildiscussclinicprotocolsforspecificdiseases,suchasHIVinfectionanddiabetes.#1:Askyourpatientadvisorstosharetheirstoriesofstructuralracismanddiscusshowracisminmedicineaffectshealthoutcomes.

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Nextstepstolearnmore

• Tookits,videos,andmoreat• https://cepc.ucsf.edu/patients-transformation-partners

• InstituteforPatientandFamily-CenteredCare• http://www.ipfcc.org/

• AgencyforHealthcareResearchandQuality• https://www.ahrq.gov/professionals/quality-patient-safety/patient-family-engagement/index.html

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Acknowledgements• Participatingsitesandtheirpatientpartners• CFARTeam(Mal,ChristianCarman,WyattGolledge)• FMAHealth EngagementTacticTeamMembers• CarolynGaughan,CAE,KAFP• SusanHogeland,CAFP• AAFPandACOFP,andallmemberorganizationsofFMAHealth

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.

Thankyou!Let’scontinuetheconversation:

#PatientEngagementDay2019,#PatientEngagement

AnjanaSharmaanjana.sharma@ucsf.edu - @AJSharmaMDCenterforExcellenceinPrimaryCare- @UCSFCEPC

DepartmentofFamily&CommunityMedicineUniversityofCalifornia,SanFrancisco

Copyright2019,TheRegentsoftheUniversityofCaliforniaCreatedbyUCSFCenterforExcellenceinPrimaryCare.