Overcoming Communication Barriers in the Care of Diverse Patients: The IDEALL Project: Overcoming Communication Barriers in the Care of Diverse Patients: The IDEALL Project Dean Schillinger MD Hali Hammer MD Jorge Palacios MA Ivonne McLean Audrey Tang FNP Michelle Schneiderman MD Christine Ho MD Ben Lui MD Alex Li MD Margaret Handley MPH, PhD UCSF Primary Care Research Center, San Francisco General Hospital


Improving Diabetes Efforts Across Language & Literacy: Improving Diabetes Efforts Across Language & Literacy Family Health Center, General Medicine Clinic, Chinatown Health Center, UCSF Collaborative Research Network Supported by The Commonwealth Fund, The California Endowment, AHRQ, California Health Care Foundation, and the SF Department of Public Health


Background: Background Health systems place high literacy and language demands on patients Growing body of evidence linking communication barriers to outcomes Interactive communication can affect outcomes Little is known about the extent to which population-based approaches can successfully engage high-risk patients with diabetes Public-sector settings rarely have systematic disease mgmt programs tailored to vulnerable populations


Slide4: Health Literacy Level Associated with Diabetes Outcomes (Tight Control: HbA1c7.2%) (Poor Control: HbA1c>9.5%) Adjusted OR=0.57, p=0.05 Adjusted OR=2.03, p=0.02 Schillinger JAMA 2002


Diabetes Patients with Limited Health Literacy Experience Lower Quality Communication: Diabetes Patients with Limited Health Literacy Experience Lower Quality Communication (Often/Always) (Often/Always) (Often/Always) (Never/Rarely/ Sometimes) OR=3.2;p<0.01 OR=3.3;p=0.02 OR=2.4;p=0.02 OR=1.9;p=0.04 32% 13% 13% 13% 26% 21% 33% 20% Schillinger Pt Ed 2004


Slide6: Poor adherence Inadequate self-care Poor self-management Poor problem solving skills Low self-efficacy Inability to navigate system Power/advocacy Trust in health system Environmental: nutrition air quality physical activity safety occupational risks Poverty/scarcity Poor understanding of disease processes Poor recall/comprehension of advice and instructions Passive Communication Non-disclosure of FHL problem Non-traditional health beliefs Low self-efficacy Framework for Limited Health Literacy & Poor Health Outcomes COMMUNITY-LEVEL FACTORS WORSE CLINICAL OUTCOMES WORSE FUNCTIONAL OUTCOMES HIGHER UTILIZATION OF SERVICES INEFFECTIVE VISIT-BASED CLINICIAN-PATIENT COMMUNICATION INEFFECTIVE HOME-BASED MONITORING & CLINICAL SUPPORT Insurance Provider availability Navigation of health bureaucracy Schillinger, IOM 2004


Aims: Aims Develop, implement and evaluate diabetes self- management support strategies tailored to the literacy and language needs of patients in a public delivery system Focus on self-care and patient-generated action plans using one of two models: Assistive Technology Model: Automated Telephone Disease Management (ATDM) Interpersonal Model: Group Medical Visits (GMV) Describe patient engagement with the process and activities generated by each approach


Automated Telephone Disease Management (ATDM): Automated Telephone Disease Management (ATDM) Interactive touch tone response technology Weekly surveillance & health education (39 weeks=9 mos) In patients’ preferred language (English, Spanish or Cantonese) Generates weekly reports of out-of-range responses Live phone follow-up through a bilingual nurse


Group Medical Visits (GMV’s): Group Medical Visits (GMV’s) 6-10 patients in monthly group meetings (9 months) In patients preferred language (English, Spanish, or Cantonese) Facilitated by a bilingual health educator and a primary care provider A pharmacist present at end of each group visit Encourage patients to become active in self-care through participatory learning and peer education


Slide10: Randomize Patients w/HbA1c>8.0 & Administer Baseline Questionnaires (n= 399) 6-10 Patients Health Educator Primary Care Physician Usual Care (n= 133) Monthly Group Medical Visits Clinic (n= 133) Weekly Interactive Technology (n= 133) Nurse Care Manager Primary Care Physician Weekly ATDM Patient Cantonese-Speaking Group English-Speaking Group Spanish-Speaking Group Administer Follow-Up Questionnaires (Satisfaction, Self-Care, Self-Efficacy, Functional Status, Glycemic Control, Utilization) IDEALL PROJECT OVERVIEW


Preliminary Research Questions: Preliminary Research Questions To what extent do ATDM and GMV’s engage patients? To what extent do these self-management support interventions generate activities that could improve clinical outcomes? Can a patient-activated telephonic surveillance system identify threats to patient safety and promote safer practice?


Methods: Methods Documentation of clinical interactions via standardized electronic records Clinical database review performed Compare rates of Patient Engagement and Activities Generated by the ATDM call-backs and GMV’s, overall and stratified. Unit of analysis = individual patient Review ATDM records to quantify and describe potential adverse events identified Unit of analysis = individual ATDM encounter


Preliminary Results – 8/2004: Preliminary Results – 8/2004 554 patients approached 71 refused to participate 89 ineligible for study 27 deferred enrollment 47 still “in the pipeline” 293 patients enrolled and randomized Only 15% “non-Hispanic white” 55% with limited health literacy 58% with limited English proficiency Mean HbA1C = 9.8%


Measures of Engagement: Measures of Engagement Attended 1 Session** Returned 1 Call Calls completed Attended GMV “Moderate”/ “Full” Participation Generated callbacks ATDM GMV


Literacy*, Language, and Engagement: Literacy*, Language, and Engagement *Literacy was only assessed among English and Spanish speakers


Activities Generated : Activities Generated 100 0


Promoting Patient Safety – ATDM sample: Promoting Patient Safety – ATDM sample Can a patient-activated telephonic surveillance system identify threats to patient safety and promote safer practice among vulnerable patients? 10 patients x 9 months 34 disclosures of potentially unsafe situation 30 potentially adverse events prevented


Preliminary Conclusions: Preliminary Conclusions Both self-management support interventions: generate significant levels of patient engagement and clinical activity Patients with limited health literacy and/or limited English proficiency appear more likely to engage May be useful adjuncts to improve the care of high risk patients in a public health setting Levels of engagement and kinds of activities generated may vary by type of intervention, Pharmacological management Psychosocial concerns ATDM may serve an additional surveillance function to promote patient safety


Next Steps: Next Steps Continue enrollment and expand to other sites in San Francisco: Chinatown and Silver Avenue Health Centers Examine effects of ATDM and GMV on: patient satisfaction and self-efficacy self-management activities glycemic control relative resource use Expand descriptive study of patient safety Examine contextual factors associated with patient engagement and effectiveness, both quantitatively and qualitatively