1. Improving Outcomes in Medical Education and Primary Care: Activating Students to Activate Patients to Activate Students Darwin Deen, M.D., M.S. Dept. of Community Health & Social Medicine Sophie Davis School of Biomedical Education City College of New York Lauren Berliner MS-III SUNY Downstate College of Medicine

2. Presenter Disclosures (1)The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Darwin Deen No relationships to disclose

3. Who we are Sophie Davis –7-year BS-MD Program –City College: undergraduate education with the first two years of medical school –Six cooperating medical schools: final two years of clinical training –Mission: Offer medical education to individuals from underserved communities, those of limited financial resources, and of ethnic backgrounds underrepresented in the medical profession

4. What we do Sophie students graduate with a service commitment to practice primary care in underserved communities CHASM –Health, Medicine, & Society I-V Culture, Health & Illness; Community Oriented Primary Care; Field Work in Community Medicine; Fundamentals of Epidemiology; U.S. Health Care System –Longitudinal Clinical Experience –Patient Doctor I, II (4 th year) Intro to Primary Care & Medical Interviewing –Clinical Decision Making/Evidence Based Medicine

5. Components of the Course  Interviewing curriculum  Interview each other  Large Group Discussions  Doc.com modules  Interview Practice  Interview Observation/Feedback  Self-Reflection  Primary Care curriculum  Readings  Small Group Discussion  CHC-based Activities  Service Learning

6. Early Clinical Exposure Everyone agrees that early clinical exposure is beneficial for medical students, but what should the content of that exposure be? Is it better to have students in the role of observers, or is it better to engage them in working with patients? What are they prepared to do?

7. What is Patient Activation Patient Activation = an individual's ability and readiness to take on the role of managing their health and medical care. Health care works best when doctors and patients collaborate in decision-making: - screenings - diagnostic tests - specialist referrals - behavioral changes - therapeutic decisions

8. Many people don’t have the information needed to participate in this decision making process and aren’t involved with their health or the services they receive…. Its IMPORTANT for patients to understand the value of information gathering….

9. That’s Where Patient Activation Comes In Goal of Patient Activation –Change patients from being passive to active participants, on an equal footing with their doctors in the decision making process. Process of our Intervention – Help patients understand why questions are important – Help patients relate question-asking to decisions about their HC – Help patients be more comfortable asking questions of their health care providers Created in collaboration with the Right Question Institute

10. Chronic Care Model

11. Patient-Centered Medical Home Care is facilitated by... health information exchange and other means to ensure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner Quality and safety are hallmarks of a medical home for which patients actively participate in decision-making Source: http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home

12. Goals Activating Patients –to identify methods to improve the ability of patients of lower socioeconomic position or minority status to share in decision-making about their health and health care Activating Students –to create a service-learning experience for medical students at community health centers increasing their exposure to primary care and augmenting the doctor-patient communication curriculum

13. Outcome measure: the PAM 1.When all is said and done, I am the person who is responsible for managing my health. 2.Taking an active role in my own health care is the most important factor in determining my health and ability to function. 3.I am confident that I can take actions that will help prevent or minimize some symptoms or problems associated with my health. 4.I know what each of my prescribed medications does. 5.I am confident that I can tell when I need to go get medical care and when I can handle a health problem myself. 6.I am confident I can tell a doctor concerns I have even when he or she does not ask. 7.I am confident that I can follow through on medical treatments I need to do at home.

14. Outcome measure: the PAM 8.I understand the nature and causes of my health problems. 9.I know the different medical treatment options available for my health conditions. 10.I have been able to maintain the lifestyle changes for my health condition that I have made. 11.I know how to prevent problems with my health. 12.I am confident I can figure out solutions when new situations or problems arise with my health. 13.I am confident that I can maintain lifestyle changes, like diet and exercise, even during times of stress.

15. Stages of Patient Activation Hibbard, et al 2004 Stage 1: May not yet believe that the patient role is important, may still believe that patients are passive recipients of care. Stage 2: Lack the basic facts or have not connected the facts into a larger understanding about their health or recommended health regimens. Stage 3: Have the key facts and are beginning to take action but may lack confidence and skill to support new behaviors. Stage 4: Adopted new behaviors but may not be able to maintain them in the face of life stress or health crisis. Hibbard recommends different resources be applied for interventions with patients based on PAM stage.

16. Regular exercise, low fat diet, fruits & vegetables and PAM Stages

17. Consumerist Behaviors and PAM Stages

18. Description of The Intervention Designed to help patients gain the confidence to ask questions of their doctors Practice formulating questions Learn the difference between open- and closed-ended questions

19. Trained medical students work with patients in the health center waiting room The Patient Activati on Interven tion Step1: Understanding Decisions in Everyday Life What did you eat for breakfast? Step2: Understanding Decisions in a Healthcare Setting What is a decision? Role of asking questions in making a decision Step3: Choosing a Focus new complaint, follow-up, medication, treatment, referral Step4: Brainstorming of Questions Generate questions related to focus Step5: Identifying Types of Questions Open-ended vs. Close-ended Step6: Prioritizing Questions What are the 3 most important questions? Patient Brings List of Questions to Healthcare Visit Average time: 10 minutes

20. HOW WE TEACH IT

21. The Patient Doctor Course Each year, Sophie Davis students are placed as volunteers in health centers across New York City. Here they are asked to conduct a project to help the patients be more involved in their care. Last year, each center decided that they would like their project to be, “Patient Activation.”

22. Teaching Patient Activation Lecture on the basics of Shared Decision Making and the importance of Patient Activation Students arranged in groups of 10 and assigned to a (senior student) trained facilitator Role play of multiple patient vignettes to help gain experience with activating different types of patients

23. Application After learning these skills, the students were ready to go into the waiting rooms of New York City health centers and help patients participate in their health care decisions.