THE SHARED DECISION MAKING MODEL:PROVIDERS’ AND PATIENTS’ KNOWLEDGE

AND UNDERSTANDING IN CLINICAL PRACTICE

Debbie Baca-Dietz, DNP, AGNP-BCDanuta Wojnar, PhD, RN, MED, IBCLC, FAAN

Christine R. Espina, DNP, MN, RN

NPO 2019

I do not have any financial or other conflicts of interest to disclose

Disclosures

DNP Project Site and Stakeholders:

Site: Federally Qualified Health Centers• Research Council and Clinical Director • Chief Executive Officer and Clinical Director

Washington State Health Care Authority’sChief Medical Officer, Daniel LesslerPractice Transformation Mgr, Laura Pennington

Acknowledgments

ACKNOWLEDGEMENTS

DNP Project Committee Members• Dr. Danuta Wojnar, Committee Chair and Advisor

• Dr. Christine Espina, Committee Member, Reader

• Family and friends whose constant support and reassurance allowed me to achieve my goals.

SHARED DECISION MAKING – WHAT IS IT?

• The definition, focus and elements of SDM are continually evolving making it difficult to assess “what clinicians know.”

• In the literature, SDM has been referred to as patient-centered care, patient-focused care, and informed-patient care.

• In addition to these related terms, some authors use the term [SDM] inconsistently which can be problematic for providers who wish to implement SDM in clinical practice. (Moumjid et al., 2007)

SHARED DECISION MAKING: A FRAMEWORK FOR CLINICAL PRACTICE (AHRQ, 2016)

SHARED DECISION MAKING DEFINED

The five steps of the SHARE Approach are:S: Seek your patient’s participation: Discuss the benefits and

harms of each option.H: Help your patient explore and compare treatment options: Take

into account what matters most to your patient.A: Assess your patient’s values and preferences: Take into account

what matters most to your patient. R: Reach a decision with your patient: Decide together on the best

option and arrange for a following appointment.E: Evaluate your patient’s decision: Plan to revisit decision and

monitor its implementation (AHRQ, 2016).

There is a widespread need to redesign American healthcare to reduce health disparities, improve patient access to care, and decrease the ever growing cost of healthcare. (U.S. Department of Health and Human Services’ Healthy People 2020 report, 2017)

Problem Statement

HEALTHY PEOPLE 2020

RACEETHNICITYSEXSEXUAL IDENTITIYAGEDISABILITYSOCIOECONOMIC STATUSGEOGRAPHIC LOCATION IMMIGRATION STATUS(HealthyPeople 2020, 2017)

Health disparities among underserved populations:• Increased rate of hospital admission• Increased number of emergency department (ED) visits• Increased Morbidity• Increased Mortality

(U.S. Department of Health and Human Services’ Healthy People 2020 report, 2017)

Health Disparities

Redesigning of the healthcare system is critical to address the primary care healthcare crisis and worsening population health (Smolowitz, Speakman, Wojnar, Whelan, Ulrich, Hayes & Wood, 2015)

Patient satisfaction with care and active engagement in the care are essential to improve care outcomes and provider satisfaction (Bodenheimer et al., 2009; Reeves et al., 2012)

Collaboration between the provider and patient using shared-decision making (SDM) can improve care outcomes (DeMeester et al., 2016)

State of the Science

SDM helps patients to comply with a treatment plan, when they understand the diagnostic tests, and the risks and benefits associated with treatment (AHRQ, 2016)

WDOH (2017), Robert Wood Johnson Foundation (2015), and Agency for Heathcare Research and Quality (2015) have identified SDM as a critical component of excellent healthcare

Affordable Care Act encourages use of SDM by paying physicians based on value not volume (Affordable care Act, 2010)

State of the Science

• There is much evidence providers understand and value SDM, but SDM is not used consistently (HealthIT, 2013)

• Well educated, empowered individuals engage in SDM across all levels of care far more than less educated individuals (Durand et al., 2014)

• It is important to explore the engagement in SDM for underserved populations, and identify facilitators and barriers to SDM to discuss implications for primary care providers’

Research-Practice Gap

The purpose of the study was threefold:

1. To assess providers’ knowledge and understanding of SDM with underserved populations in an FQHC

2. To explore underserved patients’ knowledge and understanding of SDM when receiving care in an FQHC

3. To discuss implications for primary care providers’ working with the underserved.

Project Aims

FEDERALLY QUALIFIED HEALTH CENTERS

• Federally Qualified Health Centers (FQHC) are community-based organizations that offer underserved areas and marginalized populations access to quality primary healthcare services

• Health Resource and Service Administration (HRSA) is responsible for designating FQHCs as health professional shortage areas, medically underserved areas and medically underserved populations

• HRSA identifies facilities with shortages of primary care, dental care, and mental health providers in areas of low socioeconomic status, geographic location, or language barriers that limit access to affordable health care services (HRSA, 2016)

Descriptive phenomenology approach• Widely used in qualitative research• Helps to understand phenomena that are not well understood

and are essential for designing supportive interventions• Helps with understanding of an individual’s perspective on a

particular phenomenon (Matua, 2015)• Seeks to answer the question, “what is it like to have a certain

experience? (Crabtree & Miller, 1999, p.28)• The ultimate goal is to understand “the meaning of lived

experiences, from the first-person point of view” (Wojnar & Swanson, 2007)

Theoretical Framework

Study Design• Descriptive phenomenological inquiry • Colaizzi’s (1978) 7 step method to guide the analysis

Desired Sample • Approximately 6-8 providers and 6-8 patients meeting the

inclusion criteria • Consistent with the phenomenological approach data was

collected until no new conceptual information emerged (Morse, 1994; Wojnar & Swanson, 2007)

METHODS

Inclusion Criteria - Providers: Employed at the FQHC ≥ 2 years; self identified as serving people

from underserved populations in their practice; English proficiency; willing to share their story

Inclusion Criteria - Patients ≥18 y/o; self-identified as member of underserved population; user of

FQHC for ≥ two years; at least 4 medical visits in the last year for the mgmt. of a chronic condition; English proficiency; willing to share their story

Prior understanding or experience of SDM was not a requirement to participate.

Setting: The sole criterion for site selection was FQHC designation

METHODS

INTERVIEW PROCESS

Recruitment: flyers posted in the clinic. Participants called or directly spoke with PI in response to study advertisements

Semi–structured interviews. Primarily in person. Interviews took place in a providers offices, exam room or conference room Open ended questions. Additional questions asked to

explore themes/explanations All interviews were audio recorded and transcribed verbatim Brief demographic survey completed

Data Collection and Analysis process:(a) Bracketing(b) Analyzing – Coliazzi’s 7 steps(c) Intuiting (d) Describing

(Swanson-Kauffman & Schonwald, 1988)

Methods

• Bracketing - researcher attempts to set aside assumptions about the phenomenon under investigation (Wojnar & Swanson, 2007)

- used a self-reflective diary - used to clarify with the study participants when unsure of responses. To present a true description of the phenomenon

• Analyzing – Colaizzi’s (1978) 7 steps method to identify meaningful information and organize it into categories, themes and sub-themes

Data Analysis

Analyzing – Colaizzi’s (1978) 7 steps method1. Reading all transcripts for the general understanding2. Extracting significant statements3. Formulating meanings for these statements4. Categorizing the formulated meanings into the clusters of

themes, sub-themes, processes & counting occurrences5. Integrating the analyzed data into an exhaustive description of

the phenomenon under study6. Checking with some participants to validate their individual

experiences with the general description of the phenomenon7. Incorporating the insights & suggestions from the participants

into the final report

Data Analysis

• Intuitingconscious effort by the researcher to engage in active listening and learning the participant’s experience while refraining from premature conclusions about the phenomenon

• Describing coding the text for topics, identifying themes, sub-themes,

and processes to create a theoretical model that represents the universal essences of the phenomenon (Wojnar & Swanson, 2007)

Data Analysis

PROVIDER DEMOGRAPHIC FINDINGS

Demographic profile of providers by gender, age, race, training and income

• Providers (n=13): six males and seven females• Ages ranged from 30 to 60+ years. 62% (n=8) were b/t 30-39 y/o• Twelve providers were Caucasian and one Asian• Medical Doctors (n=5); Physician Assistants (n=5): and Nurse

Practitioners (n=3)• Six earned $100,000 - $150,000/year• Seven earned > $150,000/year

PATIENT DEMOGRAPHIC FINDINGS

Demographic profile of patient participants by gender, age, race, education and income

• Patients (n=6): 2 males and 4 females• Ages ranged from 30 to 60+ years. Three were >60 y/o; two between

40-49 y/o and one 30-39 y/o• Four were Caucasians, 1 Hispanic and 1 first generation immigrant

from Ukraine• Annual income: 67% less than $10,000/year and 33% earned

$10,000 to $19,000/year• Employment status: 83% disabled and 17% retired

OUTCOMES OF PROVIDERS EXPERIENCES

Overarching Theme: “SDM is the cornerstone of patient centered approach to care”“SDM is a fundamental doctor-patient relationship, and if done well,

you create people who are active participants in their care”Sub-themes1. Engaging the patient2. Using individual approach to care for and educate3. Include patients in decision making and what’s best for the patient4. Feeling great. “makes you feel great,” “it gives you joy,” and “there is no

better feeling than to know the patient understands, will participate in the plan and maybe have some improved health outcomes.”

OUTCOMES OF PROVIDER EXPERIENCES

Experiences of lapses to practicing SDM“Being in the driver seat is not a comfortable role to be in but may

be necessary”

Sub-themes1. Deciding about situations “unfit” for SDM2. Taking charge without patient buy-in3. Working to overcome barriers to SDM

EXPERIENCES OF PATIENTS

Theme: “they tell you [explain] what to do and we do it together” Six sub-themes emerged as common understanding of care thatuses SDM1. SDM makes you feel like a person not just a patient2. We don’t feel judged and feeling safe to ask questions3. Trusting that questions will be answered4. Providers can be trusted5. Providers genuinely listen6. When we are listened to and are given choices you feel validated

and valued.

EXPERIENCES OF PATIENTS

“When someone [provider] asks me for my opinion it makes me feel not belittled, like my opinion matters. What I’m actually saying matters to the doctor, you know, but some doctors, they just see you, tell you what’s up but they don’t really care what you are saying because they are the doctor, and just tell you take these pills and just push you out the door, I wouldn’t listen and that’s not been my experience here at all, which is good.”

EXPERIENCES OF PATIENTS

The care home in which she lived would not walk with her, despite her persistent requests; she stood outside her room and waited. Her provider sent written orders to the care home allowing the patient to walk alone from point A to point B. Not only is she walking, she proudly reports recently getting her driving permit.

DISCUSSION

• Providers and patients saw the value in SDM and understood that trust, respect, and equal power dynamic are necessary for open communication

• The majority of providers use SDM most of the time• Providers were familiar with the term SDM and recognized it as a

very important aspect of the care process. • Patients engaged in SDM are likely to follow the treatment plan and

be more invested. Consistent with prior reports (Durand et al., 2014; Malloy-Weir et al., 2015) that SDM encourages patients to participate in self care

• Findings provide insight into the scope of using SDM in FQHCs in contrast to prior research which focused on the providers satisfaction with care (Bodenheimer et al., 2009; Reeves et al., 2012)

DISCUSSION

Consistent with the established definitions of SDM (Malloy-Weir et all, 2015) providers in the current study consistently used the following principles to provide care:

• Provide individualized care that carefully recognizes different ethnic groups, education levels, mental health, and health literacy

• Explain and explore the positive and negative risks associated with different tx courses. Making sure patients understand the different treatment options

• Take into account patients’ personal preferences; involve family and caregivers

• Involve ancillary staff to help patient succeed in accomplishing their plan

• Present treatment options, ask for their input then make the decisions together

DISCUSSION

Although patients were unfamiliar with the definition of “shared decision making,” they were able to describe what was special in the care they received:

• Patients regarded themselves as active participants and felt comfortable asking questions of their providers

• Patients perceived their providers were listening and had a genuine concern for their well being

• Patients felt their provider would ask questions, explained purpose of labs and medications then work together to accomplish a common goal

CONCLUSION

Thirteen providers reported implementing shared decision making daily into their clinical practice (primary care, internal medicine and psychiatry) except in a few rare cases that warranted other approaches.

All providers rejected the paternalistic approach to care; it’s ineffective and fails to consider the patients preferences, values, and life context.

Time pressure was noted by all providers (except one) as a major barrier to SDM.

Provider participants expressed desires to have more time to have in- depth conversations with their patients, to explain conditions and procedures and respond to questions and concerns.

IMPLICATIONS FOR RESEARCH AND CLINICAL PRACTICE

The vast majority of providers in the FQHC use SDM systemically and there were no adverse effects from use to the patients

Unlike prior reports suggesting SDM may be harmful to the underserved, this study shows all the patients interviewed, had only positive things to say about it; thus contributing to the body of knowledge SDM is beneficial to everyone

The major barrier to SDM, according to providers and patients interviewed, is lack of time.

Findings suggest that use of SDM in FQHC contributes to provider and patient satisfaction and improved patient engagement in self-care. Providers should therefore strongly consider using SDM when working with the underserved

IMPLICATIONS FOR RESEARCH AND CLINICAL PRACTICE

Further research is needed and SDM evaluated broadly to address the varied understandings of SDM to improve provider and patient satisfaction, to improve health outcomes, for all but most importantly, the underserved whose health is generally far worse than the general population.

LIMITATIONS• Participants were actively recruited from two clinics in one geographic

region. Wider representation of perspectives of providers and patients from similar settings might have produced different findings.

• It is noteworthy that patient volunteers all came from one location, suggesting that findings regarding patients’ experiences should be used cautiously.

REFERENCESAgency for Healthcare Research and Quality. (2015). National healthcare quality and

disparities report and 5th anniversary update on the national quality strategy. Retrieved from http://www.ahrq.gov/research/findings/nhqrdr/nhqdr15/index.html

Agency for Healthcare Research and Quality. (2016). The SHARE Approach.

Retrieved from http://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.html

Bodenheimer, T., Chen, E., & Bennett, H.D. (2009). Confrontingt he groeing burden of chronic disease. Can the uS health care workplace dot he job? Health Affairs, 28, 64-74.

Crabtree, B.F., & Miller, W.L. (1999). Doing qualitative research (2nd ed.). B.F Crabtree & W.L Miller (Eds.). London: Sage Publications, Inc.

Colaizzi, P.F. (1978). Psychological research as the phenomenologist views it. In R.S. Valle & M. King (Eds.), Existential phenomenolgical alternative for psychology (pp. 48-71). New York: Plenum.

DeMeester, R. H., Lopez, F. Y., Moore, J. E., Cook, S. C., & Chin, M. H. (2016). A Model of Organizational Context and Shared Decision Making: Application to LGBT Racial and Ethnic Minority Patients. Journal of General Internal Medicine, pp. 1–12. http://doi.org/10.1007/s11606-016-3608-3

Durand, M.-A., Carpenter, L., Dolan, H., Bravo, P., Mann, M., Bunn, F., & Elwyn, G. (2014). Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis. PloS One, 9(4), e94670. http://doi.org/10.1371/journal.pone.0094670

Health Information Technology. (2013). Shared decision making. Retrieved from https://www.healthit.gov/sites/default/files/nlc_shared_decision_making_fact_sheet.pdf

REFERENCESMalloy-Weir, L. J., Charles, C., Gafni, A., & Entwistle, V. A. (2015). Empirical relationships between health literacy and

treatment decision making: A scoping review of the literature. Patient Education and Counseling. http://doi.org/10.1016/j.pec.2014.11.004

Matua, G.A. (2015). Choosing phenomenology as a guiding philosophy for nursing research. Nurs Researcher, 22(4), 30-34.

Morse, J.M. (1994). Designing funded qualitative research. In Denizin, N.K. & Lincoln, Y.S., (Eds.), Handbook of qualitative research (2nd ed.). Thousand Oaks, CA: Sage.

Reeves, S., Tassone, M., Parker, K., Wagner, S.J., & Simmons, B. (2012). Interprofessional Education: An overview of key developemnts in the past few decades. Work, 41 (3), 233-245.

Robert Wood Johnson Foundation. (2015). When physicians and patients share decision-making. Retrieved from https://www.rwjf.org/content/dam/farm/reports/program_results_reports/2015/rwjf420207

Smolowitz, J., Speakman, E., Wojnar, D., Whelan, E.M., Ulrich, S., Hayes, C., & Wood. L. (2015). Role of the registered nurse in primary care: Meeting health care needs in the 21st century. Nursing Outlook, 63(2), 130-136.

Swanson-Kauffman, K.M., & Schonwald, E. (1988). Phenomenology. In B. Sarter (Ed.), Paths to knowledge: Innovative research methods for nursing (pp. 97-105). New York: National League for Nursing.

REFERENCESU.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2017). Healthy People

2020 social determinents of health. Retrieved from https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Social-Determinants

Washington State Department of Health. (2017). Medical quality assurance commission strategic plan. Retrieved from https://www.doh.wa.gov/Portals/1/Documents/3000/2017-2019StrategicPlanFinal.pdf

Wojnar, D., & Swanson, K. (2007). Phenomenology: An exploration. J Holistic Nursing, 25(3), 172-180.

END PRODUCTS

This DNP capstone was prepared for manuscript and submitted to the Journal of the American Association of Nurse Practitioners and is currently under peer review

Special invite from Health Care Authority’s Laura Pennington to present findings to nursing leadership

Thank youQuestions and Discussion