Implementing Shared Decision Making in a multicultural practice: A collaborative primary care provider-health educator approach

Issues: There are significant logistical challenges associated with provider distribution and patient use of decision aids (DAs). Such challenges may include practice-based resource constraints, patients' language barriers, and limited literacy skills. Our clinic serves a population comprised of MaineCare, Maine's Medicaid program, (30%), dual Medicare, Medicaid (16%); free care (24%), self pay (14%), Medicare (13%), and insured (3%) patients. At least 30% of patients are part of Maine's growing refugee community and do not speak English as a first language. Many patients have limited literacy skills.

Description: Primary care providers collaborated with the onsite Learning Resource Center (LRC) to implement use of DVD-based decision aids (DAs) in order to (1) improve patient access to information about multiple screening, treatment, and self-care options for selected conditions; and (2) engage patients in a structured SDM process to improve decision quality.

The LRC-based health educator, with advanced training in SDM, partnered with practice-based clinicians to provide patients with a one-on-one encounter for DA viewing and decision support. Selected DAs included diabetes, prostate cancer screening, colorectal cancer screening, low back pain, and depression. The SDM team developed a workflow that includes: identification of patients to view selected DAs; recommendation of DAs to patients by providers; creation of a DA order in the electronic medical record that results in patient contact by the health educator; patient viewing of DAs onsite with the health educator, often with a foreign language interpreter, or at home; patient completion of DA pre- and posttests to measure and document patients understanding, values and preferences.

Lessons Learned: Barriers to making SDM a routine part of primary care practice include: (1) standardizing methods for providers to identify eligible patients and order DAs; (2) creating time for SDM teams to meet regularly to review workflows and engage in quality improvement activities; and (3) gathering and sharing SDM process data efficiently. Despite these challenges, preliminary review of the data suggests that engagement of providers, health educators, and interpreters to develop customized “patient centered” decision support yields positive patient outcomes.

Recommendations: (1) Primary care providers who care for multicultural populations should explore adoption of structured SDM processes, including use of DAs, to ensure that patients' values and preferences are key factors in health care decision-making. (2) Primary care practices should explore innovative models of providing culturally competent health education, decision support, and care coordination services to complement clinical care that improve outcomes for “hard-to-reach” patients.