5 Things About Choosing Wisely and the Safety Net

What does the Choosing Wisely conversation between clinicians and patients look like when it occurs within a safety net delivery system? Two Choosing Wisely programs recently shared what they have learned while working with clinicians serving predominantly low-income patients and/or patients whose first language is not English.

One program is a 600-bed public hospital in Los Angeles and the other includes two Federally Qualified Health Centers (FQHCs), including one very small rural center in Connecticut.

While the geography and settings were vastly different, some common themes emerged. Dr. Eric Wei from the LAC+USC Medical Center, Los Angeles County Department of Health Services, and Heather Adams, Karen Pasquale, and Russell Dexter from the Connecticut Center for Primary Care shared experiences, challenges, and insights:

1. Be wary of using a financial argument to garner support for Choosing Wisely from senior leaders within the safety net. Since safety net organizations are typically under-resourced, the goal of reducing costs by reducing inappropriate services doesn’t resonate in these settings. Alternatively, focus on how reducing inappropriate services can decrease delays to access those services, increase patient satisfaction and engagement, and increase patient safety.
2. For a variety of reasons, safety net entities are challenged in establishing a consistent relationship between a patient and an individual clinician. It’s common for patients to see different clinicians each visit. As a result, it can be challenging for clinicians and patients to have a long-term relationship, which is often how trust is established. Without established trust, a patient may not feel comfortable speaking up about whether a test is needed or following the recommendation of a provider.
3. It can be challenging to keep a large team up-to-date and trained on Choosing Wisely. This is not unique to the safety net, but it can add to the existing challenges. In-person training, while difficult to schedule, was found to be more effective than training via email.
4. Just because a patient may have historically experienced barriers to access care, don’t assume the patient will be predisposed to want more tests or treatments. When the potential for harm or inappropriateness of care is communicated in an effective way and patients understand what is being asked and why, they usually agreed.
5. The Choosing Wisely materials – both in English and Spanish – are effective and helpful tools to use in a safety net setting. Both programs are testing different ways to use the tools, but both agreed they were a great way to facilitate discussion.

One final insight that may be also be found in more traditional clinical settings was the recognition of unintended consequences that can occur as the result of changing a patient’s behavior.

In Los Angeles, eliminating the unnecessary tests that had been performed in the days before a cataract surgery also reduced the time the provider spent preparing the patient for the surgery. Even though the tests were not needed, the time spent educating the patient on steps needed to be taken prior to the surgery was valuable, and that education was not as reliably given without the pre-op testing visits.