Bringing Choosing Wisely to the Underserved

Recent expansions in health care access have highlighted the need for greater support of historically underserved populations, including those who are people of color, low income, newly insured or limited in health literacy. The Connecticut Choosing Wisely® Collaborative, in partnership with other local organizations, recently completed a grant project that focused on understanding the unique challenges and concerns of underserved patient populations and ways to effectively address them through Choosing Wisely approaches and materials.

The “Enhancing Patient/Clinician Communication: Leveraging Choosing Wisely® as a Tool for Achieving Health Equity” grant project ran from January 2015 through September 2016 and was funded by the Connecticut Health Foundation.

The Collaborative’ s initial research – consisting of a literature review and environmental scan – revealed that many other groups were just beginning to explore ways to introduce Choosing Wisely to underserved patients.

The Collaborative then organized a series of four focus groups with clinicians, community health care workers, and underserved English-speaking patients and Spanish-speaking patients to gather input about care experiences, trust and patient-provider relationships. The groups were shown the Choosing Wisely “5 Questions to Ask Your Doctor” poster and were asked for feedback and their comfort level in engaging in conversations about care choices.

Some patients described interactions with clinical staff that they interpreted as slights based on their race, ethnicity or income level. The project team used this information to develop scripts for care team members to encourage an environment that increases patient comfort and invites questions and conversation.

The Collaborative also used feedback from the focus groups to create point-of-care pilot projects to enable two Federally Qualified Health Centers (FQHC) to adapt Choosing Wisely materials and approaches specific to each site. This work was made possible through a partnership that aligned with the Community Health Center Association of Connecticut (CHCACT)’s “Transforming Clinical Practices Initiative (TCPi)” grant. One pilot site served a rural, mostly white patient population, and the other served an urban, mostly Hispanic patient population. Three-quarters of patients at both sites were covered by Medicaid.

Each pilot ran for two weeks and included staff orientation, training and utilization of Choosing Wisely patient materials from Consumer Reports in English and Spanish, including brochures at check-in, posters in exam rooms, and wallet cards for patients. Staff received conversation scripting and prompts, videos, and other campaign materials. Staff completed surveys and evaluations of the pilot, and about 250 patients provided feedback through surveys.

Results showed that most patients at both sites found the “5 Questions” useful and felt the wallet cards empowered them to ask their clinicians questions. Many clinical staff thought the Choosing Wisely materials should be distributed by clinicians in the exam rooms; however, patients liked receiving materials at check-in. While many patients said they felt comfortable discussing the questions with front desk staff and medical assistants, these staff members felt questions should be directed to the clinical staff. Clinicians reported that having the “5 Questions” materials prominent and visible helped to reinforce their efforts to engage patients in care conversations and shared-decision making.

Following the pilot projects, the Collaborative created the following recommendations for incorporating the Choosing Wisely “5 Questions” into clinical practice:

• Provide patients with some explanation and context when given the “5 Questions” materials to ensure they understand their purpose and how to use them
• Offer ongoing, role-specific training, scripting and support for everyone on the care team and at the site to successfully implement and sustain use of Choosing Wisely at the point of care
• Involve staff in determining the best placement of Choosing Wisely materials and signage
• Start using Choosing Wisely in a single-site department or care team to incorporate as seamlessly as possible into clinic workflows before adding additional departments and care teams
• Seek out engagement from supervisory staff to ensure buy-in and engagement from all staff
• Continue to refine materials to address issues of language and literacy, including explaining the concept of “risk,” to meet the needs of staff and patients who use them

The Collaborative concluded that the Choosing Wisely campaign and Consumer Reports materials have great potential for helping all patients achieve health equity and high-quality care.

The Collaborative plans to release the project report on www.choosingwiselyct.org soon and received an additional grant from the Connecticut Health Foundation to discuss report findings. For more information, please contact Nancy Yedlin at the Donaghue Foundation yedlin@donaghue.org or Lauren Vo at the Connecticut Center for Primary Care lvo@prohealthmd.com.