Purpose: It is widely recognized that use of decision aids (DAs) and decision support in clinical practice results in greater knowledge, participation in decision making, and decision comfort for patients. To increase patient engagement and effective self-care at MMC Medical Clinic, which serves a vulnerable multicultural, multilingual population (49% Medicaid, 9% Medicare, 16% dual eligible, 16% free care; >30% refugee/ESL), we implemented a collaborative shared decision making (SDM) program.
Method: Primary care providers partnered with an onsite Learning Resource Center (LRC) health educator to order DVD-based decision aids (DAs) in an effort to: (1) inform patients regarding screening, treatment, and self-care options for selected conditions; and (2) create a structured SDM process to elicit patient values and preferences regarding these options. Following referral of patients to the LRC, the SDM-trained health educator provided one-on-one encounters for DA viewing and decision support regarding diabetes, prostate and colorectal cancer screening, back pain, and depression. The SDM process included identification of eligible patients; creation of an electronic DA order enabling the health educator to contact consenting patients; an approximately one-hour DA viewing consult with the educator and sometimes an interpreter; completion of DA pretests and posttests; and documentation of the LRC encounter. Pretest and posttest data were gathered beginning in July 2010, and were used to identify key follow-up issues and assess patient satisfaction with the SDM process.
Result:
| MMC Clinic (n=45 patients) | All SDM pilot practices (n=154 patients) | |
| Less than HS education | 27% | 12% |
| Watched all of DA DVD | 87% | 62% |
| DA perceived as “very/extremely useful” for clarifying values | 73% | 54% |
| Change in certainty about health care decisions: before and after SDM | 18% → 59% | 26% → 47% |
| “Very/extremely important” for providers to give DAs to patients | 87% | 64% |
Conclusion: Our experience shows that primary care providers, health educators, and interpreters can work together to engage “hard to reach” multicultural, multilingual populations in shared decision making. Despite challenges to integrating SDM into routine clinical practice including systematic identification of patients to use DAs, efficient tracking and sharing of SDM process data, and limited provider time for quality improvement activities, we recommend that providers who care for multicultural populations adopt innovative SDM strategies to ensure that patients’ values and preferences are central to health care decision making.