Cli presentation 6 19-15-web

blueshieldcafoundation.org

blueshieldcafoundation.org June 19, 2013

patient engagement and primary care redesign in california’s safety-net clinicsPresenter:Gary LangerLanger Research Associateslangerresearch.com@LangerResearch


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?


they matter!

here’s why…

page 3


bscf surveys, 2011-2014: overview

page 4

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)

blueshieldcafoundation.orgpage 5

2011: where we started


satisfaction with care

page 6

26%

22%

42%

6% 3%quality-of-care ratings among low-income cali-

fornians

excellent

very good

good

not so good

poor

48% ex or vg, but 51% only good or worse


all all clinic users cchc users kaiser/priv. doc users

28% 32%21%

28%

30%31%

42%21%

very interested

somewhat

page 7

broad interest in changing where you go for care

58%

63% 63%

49%


“good” care is not good enough

page 8

% interested in changeif care is not so good or poor 74%

if care is good 68%

if care is excellent or very good 45%


positive ratings of patient experience

all all clinics CCHCskaiser/

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%


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


2012: empowerment & engagement


next-step research questions

page 12

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?


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)

page 13

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?


healthcare decision making

initially if clear information about treatment options is pro-

vided

59%

81%

39%

17%

% who want an equal say in care decisions

% who prefer to leave decisions to their care provider


information attenuates group differences in desire for an equal say

page 15


what we learned (b)

page 16

• 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


the keys to patient centeredness

page 17

connectednessa sense that someone at your healthcare facility knows you well;

successful patient-provider relationshipstrust, communication and collaboration between patients and providers

continuityseeing 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


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%


a model of patient engagement

page 19

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


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 engagement2012 BSCF survey of low-income Californians

page 20

connectedness

continuity

engagement

empowerment:


48%

35%

have someone who knows you well

among those who have team-based careamong those who do not haveteam-based care

getting there: one promising pathconnectedness can be achieved through alternative models

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.


2013: information & communication in patient-provider

relationships


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


information and communication are essential

page 24


the power of relationshipsvirtually 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


leveling the playing field

page 26

higher- incomepatients

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%


decision support activities

page 27

(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


decision support activities

two or fewer three to eight all nine

33%

40%

27%

page 28

(among low-income Californians who’ve faced a major medical decision in the past 12 months)

average: 4.9


how decision support impactspatient engagement & satisfaction

% very involved in the de-cision-making process

% very satisfied with the decision-making process

38% 41%

75% 76%

fewer than five five or more

# of support activities:


2014: delivering on a promise


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


significant advances in satisfaction

page 32

48%

59%

31%

44%41%

38%

53%

66%

38%

50%47%

44%

2011 2014

+5 points in overall satisfaction = an additional 400,000 low-income californians who are highly satisfied with the quality of their care


advances among clinic patients

page 33

courtesy wait times feeling welcome

family care availability of appts

see same provider

49%

23%

48%

36% 37% 36%

62%

34%

58%

46% 46% 45%

2011 2014

others:cleanliness +8continuing care +7affordability +7

sig. gains in 9 of 15 items tested


connectedness continuity have a personal doctor

31%

47%

35%

44%

60%

44%

2011 2014

connectedness & continuityamong clinic patients

providers’ communication +12time spent with provider +8

connectedness among CCHC patients +17among other clinic patients +10

connectedness if newly ACA-insured +17connectedness if previously insured +10


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


integrated behavioral healthand related services


interest vs. availability

page 37


the impact of ibh services

page 38

% rating their quality of care as excellent or very good

substance abuse services

behavioral health counselor

47%

42%

60%

62%

service available not


conclusions


drivers of satisfaction


patient satisfaction: more factors

compared with other clinics, CCHCs stand out forcultural competence (79% vs 65%)and social service referrals (38% vs. 17%)


things safety-net providers can do

page 42

• 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


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


blueshieldcafoundation.org June 19, 2013

questions please… and thank you!

Presenter:Gary LangerLanger Research Associateslangerresearch.com@LangerResearch

Cli presentation 6 19-15-web

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