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Enhancing Patient/Clinician Communication:

Leveraging Choosing Wisely as a Tool for Achieving Health Equity

July 2017

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Enhancing Patient/Clinician Communication: Leveraging Choosing Wisely as a Tool for Achieving Health Equity

Executive Summary

The Connecticut Choosing Wisely® Collaborative (CCWC) is a diverse multi-stakeholder group that is committed to the widespread adoption of Choosing Wisely in Connecticut. In partnership with other local organizations and with support from a grant from the Connecticut Health Foundation, the CCWC conducted a project to explore and provide insights about how the Choosing Wisely campaign can be used as a tool for promoting health equity by empowering and encouraging underserved patients to engage in conversations about their health and healthcare.

CCWC’s aims were two-fold: to gather perspectives from underserved consumers about their relationships and communication with their healthcare providers, making healthcare choices, and understanding healthcare costs; and to test Choosing Wisely’s “5 Questions” as a tool for empowering consumers to have these conversations during their healthcare visits. The CCWC conducted a literature review, a series of focus groups, and a pilot study to introduce Choosing Wisely at the point of care to get feedback from patients and those who serve them. CCWC hoped to learn what materials and approaches had the greatest potential to empower these patient populations.

Four focus groups helped the CCWC gather input on care experiences, trust, and patient-clinician relationships. All groups were shown the Choosing Wisely “5 Questions” and asked for feedback on the materials, as well their comfort level in engaging in conversations about care choices. We took all of the input we received — including both positive and negative experiences about healthcare interactions — into account in the design of the pilot and related materials, including scripting for care team members that invites questions and conversation.

The CCWC partnered with others to create two point-of-care pilots. The pilots gave health centers experience with Choosing Wisely and helped them adapt materials and approaches for each site. Each pilot ran for two weeks and included staff orientation and training. Staff and patients used the Choosing Wisely materials in

English and Spanish for eight days, including brochures at check-in, posters in exam rooms, and wallet cards for patients.

Most patients participating in the point-of-care pilots found the “5 Questions” useful and felt the wallet cards in particular empowered them to ask questions of their clinicians. A majority of the clinicians reported that having the “5 Questions” materials offered greater opportunities to engage their patients in shared decision-making. The feedback received from staff through surveys and debrief discussions suggested that all members of the care team should be provided with on-going role-specific training and all staff should be actively involved in promoting a “question-friendly” environment to encourage patients to ask questions.

Through our Federally-Qualified Health Center pilots, we concluded that the “5 Questions” have great potential to empower consumers to make choices about their healthcare options by changing the conversation dynamic between underserved consumers and their care teams. Feedback from the focus groups and point-of-care participants suggested that Choosing Wisely must continue to refine materials to address issues of language, literacy, and cultural appropriateness. Participants suggested that health care delivery systems should focus more attention on encouraging patient empowerment overall to set the stage for Choosing Wisely.

Thanks to the Connecticut Health Foundation for supporting this work and the participants in our focus groups and point-of-care pilots who shared

their opinions and insights with us.

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Background and Context

The Connecticut Choosing Wisely® CCWC, in partnership with the Community Health Center Association of Connecticut (CHCACT), has completed work on a grant from the Connecticut Health Foundation (2015) entitled “Enhancing Patient/Clinician Communication: Leveraging Choosing Wisely as a Tool for Achieving Health Equity.” The grant began in January 2015 and was completed September 30, 2016.

Through a collaboration of the ABIM Foundation (American Board of Internal Medicine) and Consumer Reports, Choosing Wisely tools, resources, and interventions have been developed, tested, and are widely available to promote more effective engagement with patients. In an overlap of timing, as interest and exposure for Choosing Wisely began to grow, the Affordable Care Act increased access to healthcare and highlighted the need for greater support of historically underserved populations. These populations include people of color and those who are low-income, newly insured, or have limited literacy skills.

This is the context for our grant project, which explored the use of Choosing Wisely materials. A focus of the project was to assess how the campaign’s “5Q” could better facilitate communication between underserved patients and the teams who care for them. These populations may have had little or no exposure to the Choosing Wisely campaign and may not have been asked for their feedback about conversations with their care team in the past.

Our project had two main aims:

•Gather insights from underserved consumers about their relationships and communication with their healthcare clinicians, as well as their thoughts on making healthcare choices and understanding healthcare costs.

•Test the “5 Questions” as a tool for empowering consumers to have these conversations during their healthcare visits.

To accomplish these aims, the CCWC conducted a literature review, a series of four focus groups, and a pilot study in two Federally Qualified Health Centers (FQHCs) to introduce Choosing Wisely at the point of care. In the study, we sought feedback from patients, as well as the clinicians and staff who serve them.

Our project was designed and executed in conjunction with experts who contributed a variety of important perspectives. (See “Key Collaborators” section below.)

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Literature Review and Environmental ScanOur work began with a review of available literature on the factors that impact patient-clinician relationships. These factors include trust, cultural competency, patient-clinician communication dynamics, health literacy, and cost. This review helped us identify contextual factors that could affect receptivity to the Choosing Wisely “5 Questions.” We also conducted an environmental scan through phone interviews with local, state, and national colleagues. We focused on medical groups and health systems using Choosing Wisely materials to learn more about their work with specific patient populations. We asked for feedback

on potential strategies, outcomes, and lessons learned. We also sought advice for developing projects at the point of care that promote conversations between patients and clinicians about healthcare choices. We learned that while many groups were beginning to ask questions about how to use Choosing Wisely tools with underserved populations, there were not enough models in place that focus on the unique patient empowerment, cultural competency, linguistic access, and health literacy challenges for this population. To address these gaps, we conducted a series of focus groups.

Focus GroupsWe conducted four focus groups: one with clinicians; one with community healthcare workers, navigators and assisters (hereafter referred to as assisters); and two with consumers who were predominantly low income and people of color, with one conducted in English and one in Spanish. All participants were recruited in partnership with local community organizations (See Key Collaborators). All focus groups explored a range of topics including care experiences, trust and patient/clinician relationships.

We asked clinicians:

•Which of the “5 Questions” were most likely to be asked by their patients.

•Whether new patients or established patients were more likely to ask these questions.

We asked the participants in the assister group and both consumer groups to comment on:

•What others had said were important traits or attitudes for clinicians and whether that differed from their own opinions.

•How comfortable they were engaging in conversations about care choices with clinicians.

We showed the Choosing Wisely “5 Questions” and offered companion wallet cards to participants in all groups (clinicians, assisters, and consumers in both English and Spanish), and asked for feedback and reactions to all the Choosing Wisely materials. We also showed participants in the

English-speaking groups results from a nationally representative survey and asked them to comment on traits of clinicians who practice low-value care. In total, 42 people, predominantly African-American and Hispanic, participated in the focus groups. In both consumer groups, a majority of the participants had Medicaid coverage and a majority had acquired insurance within the past two years. Each focus group lasted approximately 2.5 hours and all participants were offered cash cards for attending.

Using the results, our team identified ways in which people from historically underserved groups view their interactions with the healthcare system and are willing to actively engage in conversations about healthcare.

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Highlights from Focus Groups

Patient-Practitioner relationships

▶ Participants in all groups generally agreed that an honest, respectful relationship is key to building trust between practitioners and patients, and that this is the basis for conversations about care. Most participants in the consumer groups knew they wanted a clinician who listens and knows them. Spanish-speaking consumers described this concept as personalismo.

▶ Several participants in the consumer and assisters groups cited negative care experiences that they attributed to race, income, insurance status, or limited English-language proficiency. These personal experiences affected their views on patient-physician relationships

▶ Spanish-speaking consumers felt their clinicians generally do not spend enough time with them to allow for discussions about care choices, and said they do not see the same clinician enough times to develop trusting relationships.

Choosing Wisely materials

▶ In general, participants in all groups liked the Choosing Wisely materials because they invited dialogue.

▶ Many participants recommended that the “5 Questions” be prefaced with more general statements that encouraged people to “get healthy” or take charge of their health. Many also had suggestions for revised wording (see “Improving Choosing Wisely materials” section below).

▶ Spanish-speaking participants felt more work was needed to make the Spanish translations of the Choosing Wisely materials more relatable. For example, they suggested adding a message such as “You have the right to ask questions” or “It’s okay to ask questions.”

Conversations about care

▶ Participants in all groups generally agreed that practitioners and patients should engage in conversations about care and care choices.

▶ Consumers and assisters were generally more interested in talking about the costs of care; clinicians were more reluctant to engage in cost conversations.

▶ Practitioners were uncomfortable discussing cost because of their limited ability to access relevant cost information. Some felt that patients with Medicaid may not be concerned with out-of-pocket costs.

▶ Practitioners viewed medication reconciliation as a good opportunity to spark conversations about low-value care, especially for new patients. But they were also concerned about workflow challenges that might be created by using prescriptions as the entry point for Choosing Wisely conversations.

▶ Whether they are using a family member or translation service provided by the office/clinic, Spanish-speaking consumers felt uncomfortable expressing important personal information through a translator.

“The doctor has said, ‘Are you the doctor now?’ ... From that experience, I will not ask any other doctor about costs or effects…. I know people who have not asked for reasons similar to mine. They start to ask questions and then the doctor asks if they are now the clinician…. What I’m trying to say is that having a bad experience with one doctor can affect how you feel about other doctors.”

– Spanish-language consumer on clinician’s response to questions

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Key takeaways from the Focus Groups

▶ We heard from our consumer focus groups, who were predominately low-income and people of color, about how they view their interactions with the healthcare system and ways they are willing to actively engage in conversations about care choices. Many shared stories that illustrated positive experiences with clinicians who listened and knew them well. We also heard about difficulties consumers who have experienced healthcare inequities face in speaking up, and ideas about how the healthcare system and care team could be improved. For example, consumers felt that

clinicians are rushed and do not have enough time to spend with them, or that their lack of “good” health insurance made it difficult to receive care.

▶ In our focus groups, some individuals described interactions with clinical staff that they interpreted as slights based on their race, ethnicity, or income level. These (sometimes) subtle racial insults are known as micro-aggressions.1 Although the impact of micro-aggression on clinical staff-patient interaction was not a focus of our study, the phenomenon was raised as a potential barrier to effective use of the “5 Questions.”

▶ The project team used this feedback to develop materials for the pilot study. This included scripting for care team members that recognized this underlying context, to foster an environment that increases patient comfort and invites questions and conversation. We noted the need for practices to be more “question-friendly” starting in the waiting room, because conversations about care choices extend beyond the exam-room encounter. All members of the care team should create a welcoming environment that invites patients to ask questions.

1. DeAngelis, Tori, “Unmasking ‘racial micro aggressions,’” www.apa.org/monitor/2009/02/microaggression.aspx

“You take that patient who’s that bold, to go in there and advocate for themselves, and they go to the doctor’s office, they’re not seen as that advocating patient. They’re seen as someone who is ‘uppity,’ who is hostile, and who is just there to make the doctor’s life miserable. I’ve had people who say ‘You know what, I did everything you told me to do, and I felt horrible. I felt lower than a dog.’”

– Assister focus group feedback on patient’s experience asking questions of their clinician

“Look at [patients] as someone you love and you value, you will treat them differently. You will sit down with them, you will tell them exactly what you think is wrong. You will tell them we’re going to do this together and we’re going to work on this, and we’re going to get through this… Regardless of my race, my color, my creed, my pocketbook, talk to me like you love me and you care about me and I think we’d be 150% better and healed.”– Advice from an assister during the focus group, when

asked how to encourage patients to feel comfortable

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Point-of-Care Pilots

For the final phase of the grant, the CCWC partnered with Community Health Center Association of Connecticut (CHCACT) to create two point-of-care pilots that gave two FQHCs experience with Choosing Wisely and customized materials and approaches. The project aligned well with the CHCACT’s “Transforming Clinical Practices Initiative (TCPI)” grant, which cited Choosing Wisely as an approach to promoting patient/family engagement and reducing the use of low-value services. In 2015, CHCACT received a 4 year, $17M TCPI grant from the Centers for Medicare and Medicaid Services (CMS) that provides Connecticut’s federally-qualified health centers with tools and resources to improve quality of care, increase patients’

access to information, and spend healthcare dollars more wisely. The CCWC, working closely with CHCACT staff, used insights from the focus groups, Choosing Wisely campaign materials, and point-of-care implementation guides to design the pilots.

Our point-of-care pilots were designed to answer the following questions related to underserved patients:

•Do the Choosing Wisely “5 Questions” help promote conversations between care teams/practitioners and patients/families?

•How can the Choosing Wisely “5 Questions” best be woven into the practice workflow?

5 QUESTIONS to Ask Your Doctor Before You Get Any Test, Treatment, or Procedure

Do I really need this test or procedure?

¿Necesito realmente esta prueba o procedimiento?

What are the risks and side effects?

¿Cuáles son los riesgos y efectos secundarios?

Are there simpler, safer options?

¿Existen opciones más sencillas y seguras?

What happens if I don’t do anything?

¿Qué pasa si no hago nada?

How much does it cost, and will my insurance pay for it?

¿Cuánto cuesta, y lo va a pagar mi seguro?

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Use estas 5 preguntas para hablar con su médico sobre qué pruebas, tratamientos y procedimientos necesita y cuáles no necesita.

Use these 5 questions to talk to your doctor about which tests, treatments, and procedures you need — and which you don’t need.

5 PREGUNTAS para hacerle a su médico antes de cualquier prueba,

tratamiento o procedimiento

5 Questions wallet card and poster in English and Spanish

Learn more: choosingwiselyct.org

Learn more: choosingwiselyct.org

•What changes would patients and care teams recommend to Choosing Wisely developers that would make the tools more effective?

•How can the CHCACT/FQHCs build on what is learned to address TCPI goals to promote patient/family engagement and reduce cost?

We selected two clinic sites based on their interest and availability. One is in a rural area with a predominantly Caucasian, low-income population, and the other is in an urban setting with a predominantly Hispanic population that used Choosing Wisely materials in both English and Spanish. At both sites, about three-quarters of the patients had health coverage through Medicaid.

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Each pilot ran for two weeks and began with an initial set-up meeting with leadership and key staff, to provide a more in-depth overview of the pilot design, conduct a walk-through of the site and identify materials needed for implementation, including materials and signage placement. We provided staff with an in-person live training session covering what the Choosing Wisely campaign is and why it is important, role-play with practice conversations,

and video examples of Choosing Wisely conversations. At check-in, patients were handed a Choosing Wisely brochure with space to write down their questions and a wallet card. Front desk staff encouraged patients to discuss the “5 Questions” with their care team. There were “5 Questions” posters hanging in each exam room and in reception waiting areas. The Choosing Wisely materials, which were customized for the pilot, contained English and Spanish in the same piece and were

branded with each clinic’s name and logo. Staff was invited to share ongoing feedback through online surveys and were debriefed at the end of the two-week trial. A total of 53 staff surveys were completed. Patients were invited to provide feedback via a survey in English or Spanish at the end of their visit, and were given a $10 Walmart card on completion to encourage participation. About 250 patients completed the survey.

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Use the space below to write down your questions and thoughts before your appointment. You can also uses this space to write down information that you learn during your visit, or questions that you have for your next visit.

Utilice el siguiente espacio para anotar sus preguntas y pensamientos antes de su cita. Puede utiliza este espacio para anotar la información que se aprende durante su visita, o preguntas que usted tiene para su próxima visita .

5 Preguntas Para hacerle a su médico antes de cualquier prueba, tratamiento o procedimiento

5 Questions To Ask Your Health Care Provider Before You Get Any Test, Treatment, or Procedure

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Do I really need this test or

procedure? ¿Necesito realmente esta prueba o procedimiento?

What are the risks and side effects? ¿Cuáles son los riesgos y efectos secundarios?

Are there simpler, safer options? ¿Existen opciones más sencillas y seguras?

What happens if I don’t do anything?

¿Qué pasa si no hago nada?

How much does it cost, and will my insurance pay for it?

¿Cuánto cuesta, y lo va a pagar mi

seguro?

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Everyone needs help with health information at some point. You are not alone if you find things confusing at times. It’s important to ask your provider questions to make sure you understand what you can do to be healthy. Use these 5 Questions to talk to your provider about which tests, treatments and procedures you need — and which you don’t need.

5 Preguntas Para hacerle a su médico antes de cualquier prueba, tratamiento o procedimiento

5 Questions To Ask Your Health Care Provider Before You Get Any Test, Treatment, or Procedure

Choosing Wisely® is an initiative by the ABIM Foundation and Consumer Reports to help care providers and patients make smart and effective care choices together.

Elegir sabiamente es una iniciativa de la Fundación ABIM y Consumer Reports para ayudar a los proveedores de atención y cuidado de los pacientes a tomar decisiones inteligentes y eficaces juntos.

For more information, you can visit these websites:

Para obtener más información , puede visitar estos sitios en el web :

Choosingwisely.org

Consumerhealthchoices.org

Choosingwiselyct.org

Todo el mundo necesita ayuda con información de salud en algún momento. Usted no está solo si encuentras cosas que confunden a veces. Es importante acer preguntas a su medico para asegurarse de que entiende lo que puede hacer para estar saludable. Use estas 5 preguntas para hablar con su médico sobre qué pruebas, tratamientos y procedimientos necesita y cuáles no necesita.

5 Questions tri-fold brochure in English and Spanish

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Highlights from the Pilots

Feedback from patients

▶ Patients at both sites found the “5 Questions” useful and felt the wallet cards in particular empowered them to ask their clinicians questions.

▶ Many patients said they plan to use the materials in future medical visits.

▶ Many of the patients who chose not to use the “5 Questions” said they felt no need, had no questions, or had already received the information they needed from their clinician.

▶ Some patients said they didn’t understand or know how to use the materials.

Feedback from staff

▶ Both clinical and administrative staff members were very engaged in the pilot. Staff at

addition to financial concerns, regardless of insurance status.

▶ While many patients said they preferred discussing the questions with front desk staff and medical assistants, these staff members were uncomfortable answering them and felt they should be directed to the clinical staff.

Feedback from clinicians

▶ Clinicians reported that having the “5 Questions” materials prominently displayed reinforced their efforts to engage patients in care conversations and shared decision-making.

▶ Many clinical staff felt that the Choosing Wisely materials should be distributed by clinicians in the exam rooms; however, patients liked receiving materials at check-in.

both sites felt it was easier to incorporate the “5 Questions” than they expected, but did note that it added time to clinical interactions.

▶ Administrative staff said they frequently needed to explain the purpose of the materials and how to use them.

▶ Staff thought that cost would be the most common question asked by patients, but the question most frequently asked by patients at both sites was “What are the risks and side effects?”

▶ Staff said their patients experienced the cost of healthcare in ways other than out-of-pocket expenses. Patients were also concerned about lost time at work or attending to family obligations. These were expressed, in

Try saying this: “I know that you have a lot on your plate right now and many concerns that we need to talk through. Can you tell me what your top two most important concerns are right now? We’ll tackle those first, and if we have time, we’ll work through some of the others. If we can’t get through all of your questions today, we’ll set up another visit so we can work through them some more.” What if my patient has a question that I can’t answer?

Think about this: We know that we don’t always have all the answers, or the time to look them up right then and there.

Try saying: “I don’t have that answer right now, but let me find out and I’ll get back to you so we can talk about it together.” If this is related to clinical judgment or evidence-based practice resources: Please contact the Choosing Wisely team with suggestions for topics about which you would like further information.

How should I answer my patient when he/she asks me question 4: what if I don’t do anything?

Think about this: Here is another place where you can emphasize the importance of active monitoring and close-follow up (see question above). What if my patient asks question 5: what does it cost? And I don’t know the answer?

Try saying: “It’s hard for us to know the exact cost for each person because each person faces different circumstances—I wish it were easier! Here are a couple of options we can try: First, try to contact your insurance company, there should be a number on the back of the card. They would be able to tell you what’s covered and what isn’t. If this is related to a medication, you can try asking at your pharmacy. They can find out how much the medicine costs. If you still have questions, call us back and we will put you in touch with our billing person, X. How can I use these questions in the visit if we’re not talking about ordering an unnecessary test?

Think about this: The 5 questions could also be used to encourage a patient to do something positive for his/her health, whether this is a new medication, a screening test that is necessary, or even for healthy eating and exercise. You can use the list of questions to explain why the patient needs this (Q1), what are the risks and side effects of doing this (Q2), if there is a simpler, safer option (Q3) or if this is the simplest, safest option, what will happen if he/she doesn’t do this (Q4), and what it will cost, if anything (Q5). What if my patient is really resistant to this?

Try saying: “I get the sense that this doesn’t sound right to you. So tell me what you’re thinking. What are you hoping would happen today?” What if this takes too much time? What if my patient wants to talk about many problems?

Think about this: We understand that these conversations can be challenging to fit in a typical clinical day and that it can be difficult with patients you don’t know very well. It might be a good idea to ask your patient to prioritize their concerns.

What if my patient asks for a test that I don’t think is necessary?

Think about this: Try to understand the patient’s concerns and find out why they are looking for more testing.

Try saying: “I can see that this issue (pain, etc) is really bothering you. Let’s talk more about what is happening so we can choose the best test. What are you worried about?”

Try saying: “I can understand how this is really worrisome for you. (explain the most likely causes of symptoms and red flags we would watch out for). Sometimes the best test to start with is not the most expensive one.

Think about this: Try talking about simpler, safer options, and emphasize the risks and benefits of the test itself. We can also explain when the test should be ordered, and what we should watch out for

Try saying: “I think there is a simpler, safer option here. There are some other things I think we should try first (then explain them). Tests can be helpful but they can also be harmful. Even an x-ray exposes you to radiation. That test would be used if you had X, but right now it sounds like that isn’t happening. If this happens, then we should consider doing that test. I want you to keep me updated on how you’re feeling, and look out for these signs. If any of those things are happening, you should come back because we might need to do some testing at that point. How do I tell my patient we really need to not order any testing and instead, “wait-and-see”?

Think about this: It’s really important to make sure the patient knows that his/her concerns have been heard and understood. Acknowledge the role of testing as a future option, and make a plan for close follow-up. Patients sometimes respond better to the idea of “active monitoring” or “watchful waiting” versus “wait-and-see”

Try saying: “Before we order a test, we need to find out a little bit more about what is going on. How about we try X and we’ll monitor the situation to decide what we need to do next. We’ll keep a close eye on what’s happening, so I’ll need you to update me on how you’re feeling.”

Try saying: “I can see that this is really worrisome to you. I’m glad you came in so we could talk about it. How about we try X and you can set up an appointment in (ex. 4 weeks) to come back. If you’re better by then, it’s okay to cancel the appointment, but if this is still going on, we can talk about our next steps.”

What do I say? Try these… We have provided some sample scripting here for common patient encounters, but it is important to use phrasing that is the most comfortable for you when you talk with your patients. These scenarios are a work-in-progress! Please let us know which ones are most helpful and how you would improve these questions and answers for future patient encounters.

For check-in/front desk: Hi Mr./Mrs/Ms._____. Now that you have checked in for your appointment, I have some materials for you. Here is a brochure and a wallet card that have a set of questions on them. You might want to ask some of them in your visit with Dr./APRN. At the end of the visit, please come see Corin (or come back to the front desk) when you check out. She’ll give you a quick survey to see if you used these questions and what you thought of them. If you can take a couple minutes to help us, we have a gift card for you.

For MA/rooming: I see that you have the Choosing Wisely® 5 questions card in front of you. Please take a look at them while you’re waiting and decide if any of those questions stand out as very important that you want to ask today? We’ll do our best to answer all of your questions during your visit.

For provider: I see that you have some questions with you today. In looking over these –are there any that you especially would like us to cover? What is most important for you to address during our visit today? If we are unable to get to everything today, we will make a plan to have you come back and talk about them some more.

For Corin collecting surveys (or front desk/check out): I see that you have some Choosing Wisely® materials in your hand. Would you like to come over and fill out a quick survey? We have a gift card for you if you can take a couple minutes to help us. These surveys will help us try to figure out if patients find these helpful for r their visit and what works and what doesn’t with these Choosing Wisely® materials.

Sample scripting for common patient encounters

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Key takeaways from the Pilots

Through our FQHC pilots, we concluded that the “5 Questions” have great potential to empower consumers to make choices about their healthcare options by changing the conversation dynamic between underserved consumers and their care teams. Care teams included administrative and clinical staff.

▶ Patients were willing to use the “5 Questions” and many saw them as an invitation to ask questions.

▶ Care team staff members were willing to use materials as a way to initiate a conversation and invite questions from patients.

▶ Further refinement and adaption of the materials, including adding messaging that encourages patient empowerment — such as “Knowledge is Healthy” or “Take Charge of Your Health” — is recommended.

▶ Choosing Wisely must continue to address issues of language and literacy, including explaining the concept of “risk” and ensuring that materials in languages other than English meet the needs of staff and patients who use them.

▶ Patients experienced the cost of healthcare in ways other than

direct financial cost, regardless of insurance status. Many were concerned about time lost from work or being with family.

▶ Patients were motivated to ask about possible side effects of treatments and testing.

▶ All members of the care team should be provided with on-going role-specific training and scripting, and involved in encouraging patients to ask questions and to promote a “question-friendly” environment.

▶ Staff training is essential to successful implementation and use of Choosing Wisely at the point of care.

“I want somebody that’s going to get in depth, really find out what’s going on with me and give me the best possible solution for it, even if it’s going to be something I don’t want to hear. I don’t want them to sugarcoat anything. I want them to be straight up, to the point, tell me to my face. Truth hurts, but I’ll get over it.”

– Consumer focus group feedback on the ideal clinician

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For healthcare clinicians who want to successfully incorporate Choosing Wisely into their practice, we’ve compiled a set of recommendations based on input from patients and staff, as well as observations made by project team members.

•Create a “Question-Friendly Practice” environment that encourages patients and families to feel comfortable asking questions at any point during their visit.

•Explain the context of the “5 Questions” when giving them to patients, so they understand their purpose and how to use them.

Incorporating Choosing Wisely into care settings

Future Recommendations

Improving Choosing Wisely materials

•Involve staff in determining the best placement of Choosing Wisely materials and signage, and offer on-going role-specific training.

•Start using Choosing Wisely in a single-site department or care team, to incorporate it as seamlessly as possible into clinic workflows before adding additional departments and care teams.

•Seek engagement from supervisory staff to ensure buy-in and participation from all staff.

•Identify in advance, how the practice will respond to questions about costs, which are a top concern for patients but challenging for clinicians and care teams to address.

Consumer Reports and its partners should continue refining Choosing Wisely materials to address issues of language, health literacy, and cultural competency. Specifically:

•Refine Spanish-language translations for literacy level, conversational quality, and cultural competency.

•Create materials with both English and Spanish text on the same document so patients can use the language they prefer without having to ask. Staff appreciated that they didn’t have to make an assumption about their patient’s language proficiency or preference.

•Consider alternative messaging focused on patient empowerment, especially since engaged patients have better health outcomes.

» Suggestions from health center staff included “Knowledge is Healthy!” or “You’re in charge!” or “Make sure you talk about these questions with your clinician before you leave today.”

» Perhaps include a “tagline” to explain in simple terms how Choosing Wisely is related to Consumer Reports.

•Continue to adapt materials for lower literacy levels and consider adding more pictures or graphics. Words and concepts such as “risk” are not always understood and should be addressed.

•Several suggested changing Question 1 from “Do I really need this test or procedure?” to “Why do I need this test or procedure?”

•Reinforce that the “5 Questions” can be used specifically for conversations about medications, which practitioners see as a good way to start conversations about care choices. Practitioners recommended the creation of a fold-out wallet card with room for a medication list along with the “5 Questions.”

•Implementation guides need to identify and highlight information most helpful to underserved populations, including how to recognize and address the specific contextual factors that impact patients’ comfort and willingness to engage with these questions.

•Use graphics and images of patients, families, and health professionals that are racially and ethnically diverse and inclusive.

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Conclusions and next steps

We conclude that the “5 Questions” and the Choosing Wisely campaign hold great potential to support achieving health equity, promoting high-quality care for patients, and motivating underserved consumers to ask questions of their clinicians and be more engaged in their care. Care teams included administrative and clinical staff. We have seen that the interest in and use of Choosing Wisely in safety-net healthcare settings across the country is growing. Because of that, there is an opportunity and a need to further develop pragmatic tools and approaches, and share the lessons learned. This will help local and national partners looking to incorporate Choosing Wisely into practice do so in ways that directly address health equity concerns.

To facilitate this, we recommend:

•The inclusion of tips tailored to the needs of underserved populations who commonly seek care at safety-net health centers as a part of Choosing Wisely implementation guides and toolkits.

•Further tailoring materials to populations with low health literacy, especially those materials developed in Spanish.

•Addressing contextual factors surrounding patient-clinician conversations, such as micro-aggressions, in future initiatives to empower patients.

In February 2017, the CCWC was awarded an additional grant from the Connecticut Health Foundation to support further communication of this work. We plan to convene our partners and others in 2017 to review and discuss the results and implications of our grant project, and to recommend directions for future work that will promote and enhance the effectiveness of Choosing Wisely as a tool for achieving health equity.

For more information, access to background materials and references, and for permission to distribute this document, please contact: Nancy Yedlin, MPH, at the Donaghue Foundation or Lauren Vo, APRN, at the Connecticut Center for Primary Care.

We appreciate the Connecticut Health Foundation for supporting this work and thank the participants in our focus groups and point-of-care pilots for sharing their opinions and insights with us. Special thanks to our partners and key collaborators.

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Key Collaborators

The project team sought the expertise of local and national partners with deep knowledge of the issues confronting underserved populations.

The focus group protocols and materials were developed by Rachel Grob, PhD, from the Center for Patient Partnerships and University of Wisconsin-Madison, and Mark Schlesinger, PhD, of Yale University, who have a specific research interest in the way decisions on value in healthcare are perceived by and addressed for low-income consumers2.

Dr. Grob and Dr. Schlesinger facilitated the English-language focus groups. Reverend Marcus McKinney and Lawrence Young of The Curtis D. Robinson Center for Health Equity partnered with us to recruit participants for and host the consumer and community health worker groups.

For the Spanish-language focus group, our partners Grace Damio of the Hispanic Health Council and consultant Rafael Perez-Escamilla, PhD, of Yale University adapted protocols and materials and conducted the session. These partners have strong connections to our local communities and provided us with rich perspectives on the context surrounding conversations about healthcare with underserved consumers.

2. Schlesinger, M. and Grob, R. (2017). “Treating, Fast and Slow: Americans’ Understanding of and Responses to Low-Value Care”. The Milbank Quarterly, 95: 70–116. doi:10.1111/1468-0009.12246.

Dominic Lorusso, Director of Health Partnerships at Consumer Reports, was also a consultant on this grant and helped us design and print customized materials for each pilot site.

Our pilots in FQHCs were designed and implemented in partnership with the Community Health Center Association of Connecticut (CHCACT). CHCACT‘s Clinical Excellence Quality Improvement Advisors Heather Adams and Russell Dexter worked closely with us on all aspects of the pilots.

Project management and oversight for the grant was the responsibility of Nancy Yedlin, MPH, Vice President at the Donaghue Foundation and past Chair of the CCWC Leadership Council; Karen Pasquale, MPH of ProHealth Physicians; and Lauren Vo, APRN, of the Connecticut Center for Primary Care. The project team included the Leadership Council of the Connecticut Choosing Wisely CCWC, of which Ms. Yedlin and Ms. Vo are members.

This brief was completed in July 2017.

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