Oregon Primary Care Association Empathic Inquiry: A Patient-Centered Approach to Social Needs Screening Stephanie

Ariel Singer Presentation Objectives CHC Transformation Director asinger@orpca.org 503-228-8852, ext. 244 Presentation Objectives Share Oregon PRAPARE experience and vision Define Empathic Inquiry and how it grew from the organization’s PRAPARE work Share an Empathic Inquiry Quality Improvement Tool for patient-centered conversations Stephanie Share objectives of the day Share expectations Teaser of information Ask question and share stories along the way

Oregon Primary Care Association Leading the transformation of primary care to achieve health equity for all. 32 community health centers serve over 425,000 Oregonians across the state. Oregon’s community health centers are a network, innovating and transformation health care. OPCA supports health centers by building capacity and elevating the health center voice.

Our Journey Empathic Inquiry AHEAD 3x10 PRAPARE APCM PCPCH OPCA Mission PCPCH PRAPARE 3x10 Empathic Inquiry AHEAD Became involved with PRAPARE Project team APCM We started small by segmenting patient populations to screen Developed a patient-centered approach to conducting social needs screening to patients

Listening is an inherent good for patients and professionals. It is helpful to remember that although we are health care professionals, we are also all patients. Take a moment to look to your own experiences as a patient and reflect on the feeling of being in that position. First of all, we really don’t know what prior experiences each patient is walking into the health care interaction with. We don’t know if they have a history of trauma that causes them to be hyper-vigilant or to have a lower threshold for distress. We don’t know if they have the emotional weight of prior bad experiences with health care systems, either from personal experience or experience with loved ones. Consider the wide variety of very routine ways in which being a patient can be uncomfortable or distressing, even if you don’t have a significant history of trauma. As a small enclosed space, just being asked to stay in an exam room might be challenging for some patients. We conduct procedures that cause people physical pain, such as injections or blood draws. We conduct procedures that are physically invasive and very intimate. We require people to be weighed in a public space; just being weighed at all might carry a lot of negative associations. We create physical vulnerability by asking people to take off their clothes and wear a non-closing gown. © Oregon Primary Care Association

Motivational interviewing Input from Patients and Stakeholders Trauma Informed Care Organizational framework that involves understanding, recognizing, and responding to effects of trauma. Motivational interviewing Collaborative conversation style that uses empathy and acceptance to help strengthen motivation for and commitment to change. Input from Patients and Stakeholders Gathered through focus groups and interviews with patients, community health workers, and community health leaders Empathic Inquiry A conversational approach to social needs screening that promotes partnership, affirmation and patient engagement. Behavioral guidance on patient-centered and strengths-based communication for front-line professionals, as well as system and process design considerations Screening tool agnostic Implementation tools and training curriculum

Start with Relationship Engaging Start with Relationship Consider how to create a welcoming and safe environment in your health center. If possible, conduct the social needs screening conversation at the end of the visit, so that the patient has more time to get comfortable while at the primary care clinic. Introduce yourself and your role at the clinic. Explain the what, why and how long of the screening process and/or Empathic Inquiry follow up conversation. Ask permission to have conversation, acknowledge the potential sensitivity of some questions and give permission to decline at any point. Ask if the patient has any questions.

Create and Convey Understanding Empathizing Create and Convey Understanding The goal of the Empathic Inquiry conversation is for the patient to feel understood and respected as you gather information about their life experiences, and for you to find out what their priorities are. If the Empathic Inquiry conversation is conducted as a follow up to a completed screen, briefly summarize the results of the screen and ask the patient an open-ended question about their priorities. If the screening process is embedded within the Empathic Inquiry conversation, use open-ended questions to find out about the patient’s experiences. Use open-ended questions to find out more about the patient’s perspectives on their experience. Use open-ended questions to ask patients about their interests, hobbies, and sources of enjoyment and meaning. Convey understanding through attentive non-verbal listening cues, including eye contact and body language as appropriate. Convey understanding through reflective listening.

Supporting Focus on Strengths Affirmations help to shift focus from the challenges patients face to the strengths they possess. Positive feedback builds patient empowerment and promotes self-efficacy and self-confidence. Provide affirmations of patient’s strength and resilience. Empathy-based affirmations that respond to a specific characteristic or behavior are the most powerful.

Summarizing and Action Planning End with Empathy and Collaboration A good summary ensures that everyone is in agreement about the priorities and next steps following the conversation. Summaries convey empathy and support collaboration. Summarize key points from the conversation to demonstrate understanding. Check to see if you’ve missed anything that the patient considers a priority. Use open-ended questions to find out whether the patient wants referrals to other team members or community resources, if available and appropriate. Acknowledge that for areas where resources are not available, the primary care team will use this information to support care planning and health promotion in partnership with the patient. Ask patient permission to follow up, if appropriate.

Participant Experience Pre-post participant survey showed increases in: Confidence and comfort in conducting SDH screening Perceptions of patient partnership Perceptions of patient autonomy Ariel © Oregon Primary Care Association

Patient Demographics Patient survey post interview (n = 132) 60% female, 35% male, 2% non-binary, 4% missing 69% between 31 and 64 years old 86% had not graduated college 90% have HH income less than $50k/year 64% white, 15% Latino, 8% multiracial Carly Focus on results from the patient surveys - 116 English, 16 Spanish 60% female, 35% male, 2% non-binary, 4% missing 69% between 31 and 64 years old 86% had not graduated college 90% have HH income less than $50k/year 64% white, 15% Latino, 8% multiracial -Selection bias, who was in the clinic, offer opportunity to win a card. © Oregon Primary Care Association

Patient Experience 92% agreed that they now have a stronger relationship with their care team 97% agreed that social needs screening was good use of their time 90% agreed that it was appropriate for the care team to ask about social needs 71% agreed that they know more about how the clinic could help them with non- medical needs 72% agreed that they had the information needed to reach out to new resources after the discussions with their care team © Oregon Primary Care Association

Improving care is a matter of changing how we listen. Data Patients Care Listen to your data to find the people who are experiencing poor health. Listen to your patients to learn about their lives, understand their circumstances, their priorities and their ideas for improving their health and well-being. Develop new ways of providing care to meet their needs and measure the impact. Listen to your care process and outcome measures, staff engagement and patient experience data to drive iterative improvement. LISTEN Conceptual framing of our approach. Will be taking about more specific stuff in subsequent slides. Each slide corresponds with specific example for how we facilicate transformation in the learning community. Trying to have transformation efforts address both technical and relational aspects of care. Not only trying to support listening in learning community but trying to support effort to listening efforts to patients.

Questions? Ariel Singer Transformation Director asinger@orpca.org 503-228-8852 ext. 244