Faculty Bibliography

BACKGROUND: At Bellevue Hospital Center (BHC), we have a robust Unannounced Standardized Patient (USP) program, where trained actors portraying real patients in the clinical setting, incognito, assess the residents' skills following their visit. We sought to determine the relationship between USP ratings of residents' skills and clinical outcomes among the residents' continuity patient panels to define educationally sensitive patient outcomes. METHODS: We assembled a retrospective cohort of PGY 2 internal medicine residents with at least 2 USP visits between 7/1/14-6/30/15 and ambulatory care patient panels at BHC. The two outcome variables were the percentage of hypertensive patients in the residents' panel with blood pressure (BP) <140/90, and the average of the most recent glycosylated hemoglobin (HbA1C) result among the residents' patients with diabetes. The predictor variables included mean USP ratings of residents' clinical skills and mean faculty rating of the residents' clinic notes (scored for quality on a 0 to 3 scale). USPs used a behaviorally anchored checklist (not done, partly done, well done) for the following domains: communication, case specific assessment, patient education, physical examination, professionalism, management plan, patient satisfaction, and patient activation measure. We tested the correlations between USP scores with BP and HbA1C control, and then developed multivariate, linear regression models of USP scores on BP and HbA1C scores, respectively, each controlling for Avg. Chronic health score (ACHS, derived by scoring different clinical conditions by acuity and used to determine if the panel is getting sicker over time) and total number of patients in the panel (TNPP) because these variables were correlated with both the outcome and predictor variables. RESULTS: 29 PGY 2 residents had a mean of 2.5 (SD 1.0) USP visits during the study period. Residents' patient panels size varied (median 124, range 62- 171) and mean patient age was 48 years (SD 1.4). Patient Activation scores were correlated with Average Chronic Health Score (r = .482, p = .008) and Panel Average last A1c (r = -.311, p = .10). Patient activation scores explained 16% variance in the mean panel last HgA1c, (adjusted R2 .137, p = .08). Case specific Assessment & Patient Education skills across USP cases explained 21.5% of the variance and the Average Chart Note Score explained 14.4% of the variance in % of Hypertension controlled (adjusted R2.378, p < .009). CONCLUSIONS: This exploratory study suggests that learnable resident clinical skills are associated with quality of care indicators for HTN and DM control. In particular, being able to activate patients, assess and educate them and write high quality notes are pathways to quality care. Next steps are to confirm these findings in a larger dataset. Doing so will help align medical education with patient safety and care quality and provide guidance for educational and clinical research aimed at improving the health of populations served

NEEDS AND OBJECTIVES: Team-based primary care (PC) is seen as the best way to provide proactive, patient-centered quality care. However, developing these team-based skills is difficult in the ever-shifting, stressful healthcare environment. We sought to develop effective training to enhance team functioning at an urban safety-net hospital, with the goal of clinical transformation (e.g. improving clinic flow, enhancing care for patients with diabetes). SETTING AND PARTICIPANTS: Team training intervention at Bellevue Hospital's Adult Ambulatory Care Center, flagship of the NYC Health & Hospitals (H +H), serving poor, diverse patients with complex medical and social needs. There are 4 adult PC teams, each with 8 attending physicians, 20 residents, 1-2 physician assistants, 2 nurses, 5 patient care associates (PCA), and 2 clerical associates (CA), all caring for a panel of ~7,500 patients. To date, we have completed a training cycle for one team, with 26 members: 10 providers (7 MDs, 2 PAs, and 1 NP), 4 RNs, 5 PCAs, 3 CAs, and 4 residents participating. We are scheduled to complete training of a second team in February 2017, with the other 2 to follow. DESCRIPTION: We partnered with a parallel NYC H + H effort, enabling a seamless NYU-HRSA/NYC H + H program with increased time allotted. This includes 4 three-hour workshops co-led by NYC H + H and NYU-HRSA faculty. Each workshop blends activating, team-building exercises for teams; mini-lectures on topics like roles and responsibilities, communication skills, huddles, and experiential activities using the team's patient data. This is reinforced with seven, 30-min biweekly meetings to follow up on teamidentified topics and facilitate team members' quality improvement projects. EVALUATION: A 31-item (each item rated 0-3), retrospective pre/post survey was administered to trainees after training, addressing individual skills and attitudes (16 items) and team functioning (15 items)14 of 26 participants (54%) in team 1 completed the survey, and Team 2 participants will complete the survey in Feb. 2017. Training resulted in increased rating of individual skills t = 4.86, p < .0001) and team functioning (t = 4.02, p = .003). Additional metrics, including tracking teams' QI efforts and assessing patient experience (e.g. Unannounced Standardized Patient reports) and administrative and panel level data, are ongoing. DISCUSSION/REFLECTION/LESSONS LEARNED: Implementation of successful team training in an under-resourced, urban primary care setting is challenging. It demands flexibility, tailoring to participants' concerns; and responding to changing clinical and administrative circumstances. Essential to success was partnering with team members to guide the training

BACKGROUND: Patient experience is an important quality indicator, and healthcare organizations spend considerable resources assessing patient satisfaction. Yet a view of patient experience gleaned from patient satisfaction measures tends to show high levels of reported satisfaction, with little variation. Unannounced standardized patients (USPs) have been used to assess providers' clinical skills, but can also provide other information about the healthcare encounter. This study examined the concordance between USP and patient reports of care at the same site. METHODS: Data was gathered at Bellevue Hospital Primary Care Clinic, a city safety-net hospital. USPs assess internal medicine residents training there, and complete a behaviorally anchored checklist of resident skills and interactions with other staff, wait times, ease of clinic navigation, and perceptions of team functioning. Data from 155 USP visits from July 2015-Oct 2016 was used in this study. Independently, as part of team-training efforts in the Primary Care Clinic, patient satisfaction surveys were collected, addressing similar issues. At the end of a clinic visit, research assistants unrelated to patient care asked patients to complete a 30-item survey. 118 surveys were completed between July-November 2016. 11 items appeared on both scales (though worded slightly different) and were used in this comparison. These included questions about clerical (CA) and patient care associates (PCA), and providers (MDs, NPs, PAs), provision of information, team functioning and clinic environment. Of the 11 items, 4 had the same response choices. 7 had differing numbers of responses (eg 4 vs 3 point Likert scales), evenly distributed across patient and USP scales. For each of these items, we collapsed items so to maximize positive ratings (eg. on a 4 point scale from poor to excellent, "good" and "excellent" were combined rather than "good" and "fair"). Chi-square analyses were computed to examine group differences. RESULTS: On chi-square analyses, 9 of the 11 items significantly differed between the USP and patient groups, with patients more likely to have positive ratings. These included rating PCAs as friendlier (x² = 8.67(1,206), p = .003) and providers better at answering questions (x² = 11.75 (2,265), p = .003); reporting that they received sufficient/clear instructions about medication refills and follow-up (x² = 29.5(2,264), p = .0001); finding the clinic atmosphere calmer than did USPs (x² = 10.5 (2,265), p=.005) and noting that the team functioned better (x² = 7.31(2,268), p = .026). There were no significant differences in willingness to recommend the clinic or on clarity of CAs' communication. CONCLUSIONS: Results of this study document the differing perspectives of patients and USPs. Consistent with previous work, patients in our study tended to rate most items higher than did the USPs. USPs provide a different, and likely a more critical look at the clinical setting and this information can enhance efforts to improve patient experience. (Table Presented)

BACKGROUND: The shift toward a Patient Centered Medical Home has redefined healthcare delivery to be a patient centered affair. While this is beneficial, it also calls for patients to be more activated in the doctor's office and responsible in their self-directed care outside of the office. For patients with chronic diseases, the burden of illness is even higher and requires significantly more effort in disease selfmanagement. We developed 4 hour Patient Empowerment Program (PEP) to bridge that gap through a program training patients with diabetes in the skills necessary to communicate effectively with providers and engage in shared decision making (SDM). Previously, we reported improved diabetes self-care behaviors at 6 months post intervention based on standardized questionnaires. This study examined participants' perspectives on PEP from 1-2 years post intervention. METHODS: 71 patients with type 2 diabetes mellitus were recruited from 2 urban safety-net hospitals to participate in PEP. 33 patients completed the intervention and 28 patients completed a 6-month follow-up assessment. Participants were predominantly low-income, racial minorities, with limited health literacy (Newest Vital Sign M= 2.21, SD = 1.67). We reached 22 of those 28 participants, at 11 to 20months post intervention (M= 16, SD = 2.31). They were interviewed via telephone, with structured open-ended questions asking them to reflect on what they took away from the classes, and whether they'd behaved differently during doctor visits or cared for their diabetes differently since the classes. A qualitative analysis was made of these responses, using Dedoose software to assist in analysis. RESULTS: All 22 patients recalled PEP and could identify key concepts from it. Participants referenced the doctor-patient relationship, from "how to improve relationship with my doctor" to "practicing role of doctor and patient in interaction and relationship". 86% of participants identified changes in their behavior since PEP- 36% identifying that they share more information with their doctor now than they did before, 18% reporting that they ask more questions, and another 18% reporting that they are more proactive in their diabetes care. When asked about their diabetes self-management, prevalent themes were better diet/food choices, exercise, and adherence to medication. 3 patients reported losing weight since the classes. CONCLUSIONS: Despite follow up occurring almost a year later for some, and almost 2 years for others, the message of PEP was clear and compelling. Participant's perspective on their role as a patient changed from a passive recipient of healthcare to a more engaged and activated one. They felt empowered to participate in SDM with their doctors and more comfortable speaking up for their preferences. While further validation is necessary, PEP offers an important way to prepare patients to become true partners with their providers

BACKGROUND: In the patient-centered medical home model of health care, both health care providers (HCPs) and patients must understand their respective roles and responsibilities, view the other as a partner, and use communication skills that promote shared decision making. This is particularly necessary in chronic conditions where outcomes depend on behavior change and in underserved populations where the burden of chronic disease is high. OBJECTIVE: The objectives of this study are to determine if a Patient Empowerment Program (PEP) (1) is acceptable to patients and feasible across multiple clinical sites; (2) will increase patient preference for control in medical decision making, improve patient perceptions of patient-HCP communication, and increase patient activation; (3) is associated with an increase in diabetes self-management behaviors; and (4) has an effect on hemoglobin A1c (HbA1c) level. METHODS: This study recruited English-speaking adult patients with type 2 diabetes mellitus from three urban clinical sites in New York City and randomized them to an immediate intervention group that completed the PEP intervention or a deferred intervention group that served as a wait-list control and completed the PEP intervention after 3-4 months. The PEP intervention consists of two facilitated small group sessions. Session 1 focuses on defining HCP and patient roles in the medical encounter by introducing ideal communication behaviors in each role and by providing both positive and negative examples of patient-HCP encounters. Session 2 focuses on practicing communication skills by role-playing with actors who serve as standardized health care providers. After the role play, participants set goals for their own health care and for future interactions with their HCPs. Outcome measures include the Patient Activation Measure; Ask, Understand, Remember Assessment; Krantz Health Opinion Survey; SF-12v2 Health Survey; Diabetes Self-Management Questionnaire; and HbA1c. These measures will be assessed at the time of enrollment, after the waiting period (deferred intervention only), and then postintervention at 1 week, 3 months, and 6 months. RESULTS: Study recruitment occurred from November 2014 to June 2015, with a total of 80 patients enrolled. To date, 45 participants have attended at least one session of the PEP intervention. Further intervention sessions and post-intervention follow-up are ongoing, with data collection set to be completed in April 2016 and results of data analysis available by June 2016. CONCLUSIONS: From preliminary participant self-report data, our PEP intervention is acceptable to low-income, low-health literate patients and feasible to hold across multiple clinical sites. Participants have reported learning specific ways to change their behaviors at their next HCP visit (eg, stating their opinions, asking more questions). With the forthcoming quantitative data on participant attitudinal and behavior change, the PEP intervention may ultimately empower participants within the medical encounter and improve health outcomes.