Faculty Bibliography

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.

STUDY OBJECTIVE: Our objective is to determine whether a point-of-care intervention that navigates willing, low-acuity patients from the emergency department (ED) to a Primary Care Clinic will increase future primary care follow-up. METHODS: We conducted a quasi-experimental trial at an urban safety net hospital. Adults presenting to the ED for select low-acuity problems were eligible. Patients were excluded if arriving by emergency medical services, if febrile, or if the triage nurse believed they required ED care. We enrolled 965 patients. Navigators escorted a subset of willing participants to the Primary Care Clinic (in the same hospital complex), where they were assigned a personal physician, were given an overview of clinic services, and received same-day clinic care. The primary outcome was Primary Care Clinic follow-up within 1 year of the index ED visit among patients having no previous primary care provider. RESULTS: In the bivariate intention-to-treat analysis, 50.3% of intervention group patients versus 36.9% of control group patients with no previous primary care provider had at least 1 Primary Care Clinic follow-up visit in the year after the intervention. In the multivariable analysis, the absolute difference in having at least 1 Primary Care Clinic follow-up for the intervention group compared with the control group was 9.3% (95% confidence interval 2.2% to 16.3%). There was no significant difference in the number of future ED visits. CONCLUSION: A point-of-care intervention offering low-acuity ED patients the opportunity to alternatively be treated at the hospital's Primary Care Clinic resulted in increased future primary care follow-up compared with standard ED referral practices.

Background: Having a usual source of primary care is known to improve health. Currently only two-thirds of ED patients have a usual source of care outside the ED, far short of Healthy People 2020's target of 84%. Prior attempts to link ED patients with primary care have had mixed results. Objectives: To determine if an intervention directly linking low-acuity patients with a primary care clinic at the time of an ED visit could lead to future primary care linkage. Methods: DESIGN: Pseudo-randomized controlled trial. SETTING: Urban safety-net hospital. SUBJECTS: Adults presenting to the ED 1/07-1/08 for select problems a layperson would identify as low-acuity. Patients were excluded if they arrived by EMS, had a PCP outside our hospital, were febrile, or the triage nurse felt they needed ED care. Consecutive patients were enrolled weekday business hours when the primary care clinic was open. Patients were assigned to usual care in the ED if a provider was ready to see them before they had completed the baseline study survey. Otherwise they were offered the intervention if a clinic slot was available. INTERVENTION: Patients agreeing to the intervention were escorted to a primary care clinic in the same hospital building. They were assigned a personal physician and given an overview of clinic services. A patient navigator ensured patients received timely same-day care. Intervention group patients could refuse the intervention and instead remain in the ED for care. Both clinic and ED patients were given follow-up clinic appointments, or a phone number to call for one, as per usual provider practice. ANALYSIS: The main outcome measure was primary care linkage, defined as having one or more primary care clinic visits within a year of the index ED visit for patients with no prior PCP. Results: 1,292 patients were potentially eligible and 853 were enrolled (662 intervention and 191 controls). Groups had similar baseline characteristics. Nearly 75% in both groups had no prior PCP. Using an intention to treat analysis, 50.3% of intervention group patients with no prior PCP achieved successful linkage (95%CI 45.7-54.9%) vs. 36.9% of the control group (95%CI 28.9-45.4%). Conclusion: A point-of-care program offering low-acuity ED patients the opportunity to instead be seen at the hospital's primary care clinic resulted in increased future primary care linkage compared to standard ED referral practices