Presentation by Gary Langer on research on patient engagement and primary care redesign in California's safety-net clinics, produced from 2011-14 in partnership with Blue Shield of California Foundation, at the Clinic Leadership Institute, San Francisco, California, June 15, 2015.
2. blueshieldcafoundation.org
a question to start…
who’s offering – or developing…
page 2
team-based care?
healthcare navigators?
training in effective communication?
e-mail or text communication?
behavioral health services?
patient portals?
decision aids?
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bscf surveys, 2011-2014: overview
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research aims:
• help safety-net facilities navigate changes brought about by
the ACA
• measure patient engagement, satisfaction and loyalty; identify
paths to enhance these outcomes via primary care redesign
• establish a baseline (2011) and repeat assessment (2014) of
low-income patients’ healthcare experiences to track change
measured via:
• annual statewide random-sample surveys of low-income
californians below 200% of the federal poverty line; rigorous
methodology
• sample higher-income residents for comparison (2013, 2014)
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“good” care is not good enough
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% interested in change
if care is not so good or poor 74%
if care is good 68%
if care is excellent or very good 45%
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positive ratings of patient experience
all all clinics CCHCs
kaiser/priv.
doc.
cleanliness of facility 59% 52% 54% 69%
courtesy of staff 58% 49% 55% 67%
people ‘like you’ welcome there 56% 48% 57% 66%
communication with doctor 55% 50% 58% 64%
convenience 54% 49% 48% 63%
understanding of your medical history 50% 40% 46% 62%
involvement in decisions 49% 41% 49% 61%
amount of time doctor spends with you 48% 43% 51% 59%
ability to see the same doctor 45% 36% 44% 62%
timely appointments 44% 37% 37% 57%
affordability 41% 40% 48% 41%
availability of continuing care 39% 33% 41% 48%
ability to see a specialist 38% 30% 42% 50%
time spent in the waiting room 31% 23% 33% 44%
availability on nights/weekends 20% 17% 19% 21%
average ex/vg ratings on these items:
overall = 46%
all clinics = 39%
CCHCs = 45%
kaiser permanente/priv. doc.= 56%
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top predictors of satisfaction w/care
among low-income californians
five critical factors:
• courtesy of staff
• patient involvement in medical decisions
• cleanliness of facility
• amount of time provider spends with the patient
• holding your personal doctor in high regard
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next-step research questions
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a) many low-income patients are reluctant to have a
strong say in their care. what would make them feel
more empowered to take an active role?
b) what factors drive strong patient-provider
relationships, given their clear role in patient satisfaction
and loyalty?
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what we learned (a)
• patients’ willingness to be involved in their care
soars when they’re assured of decision support
(i.e., clear information about treatment options)
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question: is it your preference to leave decisions about
your health care mostly up to the doctor or nurse, or
would you prefer to have an equal say with the doctor
or nurse in decisions about your health care?
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healthcare decision making
59%
81%
39%
17%
initially if clear information about
treatment options is provided
% who want an equal say in care decisions
% who prefer to leave decisions to their care provider
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what we learned (b)
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• most critically, when patients say that they want a
regular personal doctor they mean that they
want connectedness and continuity
…. these build confidence and promote
empowerment, which powerfully predicts
patient engagement, satisfaction and loyalty
…and when connectedness and continunity are
present, having a regular personal doctor drops
out of the equation
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the keys to patient centeredness
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connectedness
a sense that someone at your healthcare facility knows you well;
successful patient-provider relationships
trust, communication and collaboration between patients and
providers
continuity
seeing the same care providers over time;
produce: empowerment,
patients’ information, comfort, comprehension and confidence
satisfaction and loyalty
engagement,
the extent to which patients take a role in their care
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impact of connectedness & continuity
personal
connection?
see same provider
most/all the time?
yes no yes no
satisfied with care 65% 38% 59% 33%
very informed about care 64% 37% 56% 35%
very comfortable asking Qs 73% 54% 70% 48%
always understand provider 56% 37% 53% 33%
very confident in decisions 62% 52% 59% 51%
great deal of say in care 45% 34% 42% 32%
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a model of patient engagement
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controlling for other factors, connectedness and
continuity predict empowerment (feeling well-
informed, being comfortable asking questions,
understanding answers and being confident in one’s
ability to make healthcare decisions)
information is key – it also independently predicts
comfort, understanding and confidence
each of the empowerment measures predicts
engagement - taking an active role in healthcare
decisions – a central goal of patient-centered care
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confident you can make healthcare
decisions
provider usually explains things in
a way you understand
comfortable asking
provider questions
feel informed about your health
the route to engagement
2012 BSCF survey of low-income Californians
page 20
connectedness
continuity
engagement
empowerment:
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48%
35%
have someone who knows you well
among those who have team-
based care
among those who do not have
team-based care
getting there: one promising path
connectedness can be achieved through alternative models
51% 51%
32%
have someone who knows you well
private doctors' office patients overall
clinic patients with team-based care
clinic patients who lack team-based care
in part because it establishes the connectedness they seek,
patients with team-based care are more likely to feel very
informed about their health, to understand providers’
explanations and to be satisfied with their care overall.
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health information, sources and trust
• information and communication drive a virtuous cycle that
produces stronger patient-provider relationships and an
empowered, engaged and satisfied patient population
• a broad gap exists between the information patients have
and what they desire to make good medical decisions
• fewer than half currently rely on doctors as their top source
of health information; as many rely on media sources
• feeling very informed peaks among patients who have
team care, healthcare navigators, e-mail and text
opportunities, patient portals and decision aids, as well as
caregivers who communicate effectively
page 23
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the power of relationships
virtually every key outcome is predicted by the quality of
patient-provider relationships: satisfaction with care, trust
in medical professionals, confidence, empowerment
and engagement
page 25
• top predictors of positive patient-provider relationships:
• feeling informed about one’s health
• having care providers who encourage an active role
• having as much of a say in health decisions as desired
• connectedness
• using alternative care strategies and tools
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leveling the playing field
page 26
higher-
income
patients
low-income patients
strong
patient-
provider
relationship
weaker
patient-
provider
relationship
satisfied with quality of care 69% 53% 21%
confident in decision making 68% 65% 39%
have as much say as desired 61% 53% 28%
very informed about health 55% 49% 10%
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decision support activities
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(among low-income Californians who’ve faced a major medical
decision in the past 12 months)
listened to your preferences and concerns
asked about goals
discussed multiple options
referred you to more information
discussed taking no action
described risks of options
described benefits of options
gave time to consider options
discussed options vs. goals
29. blueshieldcafoundation.orgpage 29
how decision support impacts
patient engagement & satisfaction
38% 41%
75% 76%
% very involved in the decision-
making process
% very satisfied with the
decision-making process
fewer than five five or more
# of support activities:
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clear strides
page 31
• low-income patients’ ratings of the quality of their care
overall, specific aspects of their facilities’ services and their
communication with their providers all have improved
• critically, connectedness and continuity are up – the
precursors of engagement, satisfaction and loyalty
• gains have occurred among newly ACA-covered patients
and the previously insured alike
• latinos’ care experiences have improved in particular,
helping to eliminate their previous shortfall in overall
satisfaction
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significant advances in satisfaction
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48%
59%
31%
44%
41%
38%
53%
66%
38%
50%
47%
44%
overall cleanliness waiting times availability
of appts
care for
family
availability
of specialists
2011 2014
+5 points in overall satisfaction = an additional 400,000 low-income
californians who are highly satisfied with the quality of their care
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advances among clinic patients
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49%
23%
48%
36% 37% 36%
62%
34%
58%
46% 46% 45%
courtesy wait times feeling
welcome
family care availability of
appts
see same
provider
2011 2014
others:
cleanliness +8
continuing care +7
affordability +7
sig. gains in 9 of 15 items tested
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31%
47%
35%
44%
60%
44%
connectedness continuity have a personal doctor
2011 2014
connectedness & continuity
among clinic patients
providers’ communication +12
time spent with provider +8
connectedness among CCHC patients +17
among other clinic patients +10
connectedness if newly ACA-insured +17
connectedness if previously insured +10
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unfinished work
page 35
• some advances are modest in size, and they’re not
consistent across all facility types and patient groups
• loyalty has not yet improved, suggesting that deeper
and longer-term improvements are needed
• patient experiences and satisfaction continue to lag
among low-income patients compared with their
higher-income counterparts
• latinos still trail whites in the key areas of
connectedness and continuity of care
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the impact of ibh services
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% rating their quality of care as excellent or very good
47%
42%
60%
62%
substance abuse
services
behavioral health
counselor
service available not
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things safety-net providers can do
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• watch the basics; cleanliness and courtesy matter
• enhance connectedness and continuity, e.g., via
team-based care and healthcare navigators
• train providers to better communicate with their
patients – listening as well as providing clear guidance
with options
• increase communication options (e.g., web, e-mail or
text-based)
• provide the range of services patients desire
• develop new ways to empower and engage patients
in their care and support their decision making
43. blueshieldcafoundation.orgpage 43
and why
• patients who have a personal connection with their place of care
are more likely to feel informed, to be comfortable asking their
providers questions, to understand their providers and to be
confident in their ability to make decisions
• continuity encourages the free flow of information and patient
understanding, as well as comfort and confidence
• even in the absence of connectedness and continuity, comfort,
understanding and confidence can be improved by providing
patients with relevant, easy-to-understand information
• alternative care models (team care, health coach) and
technology can increase connectedness and continuity and
foster engagement and satisfaction as effectively and more
efficiently than the traditional patient-provider model
