Translating Patient-Centered Strategies into Clinical Practice to Overcome Healthcare Disparities

1. Translating Patient-Centered Strategies into Clinical Practice to Overcome Healthcare Disparities Lisa A. Cooper, MD, MPH Professor of Medicine, Epidemiology, and Health Policy & Management Johns Hopkins University School of Medicine Johns Hopkins Bloomberg School of Public Health

2. I have received no financial support for consultation, research or evaluation or have a financial interest relevant to this presentation. I will not reference unlabeled/unapproved uses of drugs or products. I have received no financial support for consultation, research or evaluation or have a financial interest relevant to this presentation. I will not reference unlabeled/unapproved uses of drugs or products.

3. Patient-centered care* One of the six domains of quality of care Customizes treatment recommendations and decision making in response to patients� preferences and beliefs Informed by an understanding of patients� needs and environment, which includes home life, job, family relationships, cultural background, and other factors Characterized by informed, shared decision-making, and development of patient knowledge and skills needed for prevention and self-management behaviors Improves patient satisfaction and health outcomes

4. Patient-Physician Partnership to Improve HBP Adherence Design: Randomized controlled trial, factorial design Population: 42 primary care MDs and 279 ethnic minorities and poor persons with high blood pressure (HBP) Setting: 15 urban, community-based clinics in East and West Baltimore Interventions: Communication skills training on interactive CD-ROM for MDs; Patient coaching and activation by community health worker Main Outcomes: patient-physician communication, patient adherence, and BP control at 3 & 12 mo follow-up Design: Randomized controlled trial, 2X2 factorial design Population: 50 primary care physicians and 500 ethnic minorities and persons living in poverty with uncontrolled hypertension Setting: urban, community-based clinics in Baltimore Interventions: Communication skills training program on interactive CD-ROM for physicians; coaching by community health worker to increase participation in care and encourage adherence for patients Main outcomes are adherence (appointment-keeping, prescription refills, pill counts, self-report) and blood pressure control, with secondary outcomes including patient-physician communication, patient satisfaction, health service utilization, and cardiovascular events. Opportunities for collaborators/trainees: analyses or ancillary studies of patient-physician communication, health literacy, blood pressure control, cardiovascular outcomes, access to care, health service utilization, psychosocial and cultural factors related to adherence, physician and patient attitudes, measurement of cultural competence Design: Randomized controlled trial, 2X2 factorial design Population: 50 primary care physicians and 500 ethnic minorities and persons living in poverty with uncontrolled hypertension Setting: urban, community-based clinics in Baltimore Interventions: Communication skills training program on interactive CD-ROM for physicians; coaching by community health worker to increase participation in care and encourage adherence for patients Main outcomes are adherence (appointment-keeping, prescription refills, pill counts, self-report) and blood pressure control, with secondary outcomes including patient-physician communication, patient satisfaction, health service utilization, and cardiovascular events. Opportunities for collaborators/trainees: analyses or ancillary studies of patient-physician communication, health literacy, blood pressure control, cardiovascular outcomes, access to care, health service utilization, psychosocial and cultural factors related to adherence, physician and patient attitudes, measurement of cultural competence

5. PPP Clinical Sites & Partners Baltimore Medical System (BMSI) Jai Medical Center Johns Hopkins Outpatient Center Johns Hopkins Community Physicians (JHCP) Total Health Care University of Maryland Medical Center Owings Mills Crossroads (Baltimore County) BMSI 4 clinics JHCP 5 clinics Jai 3 clinics Total Health Care 3 clinics UMMS 1 clinic 10 clinics all togetherBMSI 4 clinics JHCP 5 clinics Jai 3 clinics Total Health Care 3 clinics UMMS 1 clinic 10 clinics all together

6. Design: Randomized controlled trial Population: 27 primary care providers and 132 African American patients with depression Setting: 10 urban, community-based clinics in Baltimore, MD and Wilmington, DE Interventions: Standard quality improvement program Patient-centered, culturally tailored program Outcomes: depression resolution, guideline-concordant care, and patient ratings of care at 6 & 12 mo follow up standard depression intervention for patients (delivered by a depression case manager) and physicians (review of guidelines and structured mental health consultation) to a patient-centered intervention for patients (incorporates patient activation, individual preferences, and cultural sensitivity) and physicians (incorporates participatory communication skills training with individualized feedback on interactive CD-ROM)standard depression intervention for patients (delivered by a depression case manager) and physicians (review of guidelines and structured mental health consultation) to a patient-centered intervention for patients (incorporates patient activation, individual preferences, and cultural sensitivity) and physicians (incorporates participatory communication skills training with individualized feedback on interactive CD-ROM)

7. Bridge Clinical Sites & Partners 10 clinical sites all together: BMSA 1 clinic- part of GBMC BMSI 1 clinic- Middlesex JHCP 5 clinics Sinai 1 clinic Westside Health, DE 1 clinic Henrietta Johnson, DE 1 clinic 10 clinical sites all together: BMSA 1 clinic- part of GBMC BMSI 1 clinic- Middlesex JHCP 5 clinics Sinai 1 clinic Westside Health, DE 1 clinic Henrietta Johnson, DE 1 clinic

8. Recruitment Clinicians Via letter from medical director and PI CME credit and individualized feedback on communication style Organizations given incentive for MD/NP/PA participation in research (~$200/clinician) Patients Via claims data and invitation letter or onsite by RA Consent obtained in person Intervention assignment done onsite for one study and one the phone for the other Monetary compensation ($75) and educational materials given to all participants

9. Challenges Community-based participatory approach requires time from investigators and practice leaders Staff training and supervision needs are intensive Enrollment of diverse clinicians and patients is difficult in a non-integrated and fragmented healthcare system Patients and clinicians do not always understand or trust research methods and results Urban, community-based practices are reluctant to change current care models in an environment that demands high productivity with limited resources (e.g., no electronic medical records, lack of specialized staff)

10. What works? Meeting with medical directors and practice leaders ahead of time to align priorities and get leadership commitment Ongoing communication with medical office staff to specify roles of interventionists vs. clinicians and staff Adapting delivery methods to meet needs of practices Offering incentives and benefits to practices and patients Culturally and linguistically appropriate messages and materials that are simple and concise Interventionists that are culturally sensitive and have experience in community Intensive training and oversight of interventionists Ongoing communication - face to face contact was crucial. For example, for our communication skills training program, it was done on the physician�s own time on their own computers at some sites and at other sites, we provided laptops and schedule a workshop onsite. The need for this adaptation was discovered through discussions with practices. To meet with providers, we went to the practices and met with the providers at their staff meetings, rather than holding a dinner meeting offsite. For academic detailing, we then scheduled individual meetings at a time they designated as convenient for them, for example during their administrative time. For patients, some practices were open access, did not have databases that could be easily be used to identify eligible patients, and patients are employed or difficult to reach by phone, so it is easier to enroll them onsite as they come in rather than by phone. Worked with front office staff to design interest cards and signs to give patients a way to sign up or opt out. We used a two-stage screening process to minimize interruptions in the flow of patient care and provided laptop or written versions in sites were there no private room for an interview. We provided a toll-free number for patients to call in for their intervention contacts since our intervention program spanned a large geographic area. For the patients in one study, we provided a photonovel written at a 5th grade reading level with the health education messages embedded in a story that included photographs of real community members, community health workers, and doctors. We used community health workers and social workers as interventionists Ongoing communication - face to face contact was crucial. For example, for our communication skills training program, it was done on the physician�s own time on their own computers at some sites and at other sites, we provided laptops and schedule a workshop onsite. The need for this adaptation was discovered through discussions with practices. To meet with providers, we went to the practices and met with the providers at their staff meetings, rather than holding a dinner meeting offsite. For academic detailing, we then scheduled individual meetings at a time they designated as convenient for them, for example during their administrative time. For patients, some practices were open access, did not have databases that could be easily be used to identify eligible patients, and patients are employed or difficult to reach by phone, so it is easier to enroll them onsite as they come in rather than by phone. Worked with front office staff to design interest cards and signs to give patients a way to sign up or opt out. We used a two-stage screening process to minimize interruptions in the flow of patient care and provided laptop or written versions in sites were there no private room for an interview. We provided a toll-free number for patients to call in for their intervention contacts since our intervention program spanned a large geographic area. For the patients in one study, we provided a photonovel written at a 5th grade reading level with the health education messages embedded in a story that included photographs of real community members, community health workers, and doctors. We used community health workers and social workers as interventionists

11. Conclusions: Translation Strategies Implement quality improvement strategies across different sites Develop toolkits (e.g., training manuals, outcomes measurement tools) for dissemination Customize/adapt interventions for special populations & settings with input from community members, clinicians, and healthcare delivery systems Engage in ongoing dialogue to improve upon existing strategies Evaluate implementation effort Ensure adequate resources & technical assistance Create partnerships between funding agencies, researchers, policy-makers, and communities Simplify messages and make them consistent