The Rochester Regional Health System is an example of a health care organization that is committed to advancing primary care in its community. It has 42 physician practices that are recognized as a patient-centered medical home (PCMH), which is a promising model for transforming the organization and delivery of primary health care. To become a PCMH, an individual or organization must meet certain standards, such as incorporating shared decisionmaking into practice to promote patient-centered, coordinated care.
Rochester General Hospital, in coordination with the Agency for Healthcare Research and Quality (AHRQ), hosted a SHARE Approach train-the-trainer workshop in June 2015 to train providers in shared decisionmaking. Shared decisionmaking helps providers engage patients in their health care decisions, which can help improve care coordination and communication, a shared goal of a PCMH.
Since the SHARE Approach workshop, Rochester General Hospital has developed and completed three of its own abbreviated shared-decisionmaking trainings for residents. Primary care practices within the Rochester Regional Health System, such as the Bay Creek Medical Group, have also conducted shared-decisionmaking trainings based on the SHARE Approach curriculum with their physicians, nurses, and clinical staff. As a result, providers across the health system are using shared decisionmaking to improve patient care.
The Rochester Regional Health System is an integrated network of nationally recognized, community-focused services, including a hospital and more than 80 primary and specialty medical practices.
Implementing Shared Decisionmaking
Dr. Kathleen McGrail, a physician at Bay Creek Medical Group, attended the AHRQ SHARE Approach workshop to learn ways to systematically incorporate shared decisionmaking in her internal care practice. At the workshop, Dr. McGrail made valuable connections with others, who mutually supported one another's efforts to introduce shared decisionmaking into practice across the health system.
Meanwhile, at Rochester General Hospital, Dr. Rachel Karmally, Ambulatory Chief Resident in the Internal Medicine Residency Program, was planning a shared-decisionmaking training for residents as part of PCMH recertification. Dr. Karmally teamed up with Dr. McGrail to create the training, based on the SHARE Approach curriculum, for the hospital residents as well as Bay Creek Medical Group staff.
Training for Bay Creek Medical Group Staff
At Bay Creek Medical Group, 22 staff members, including nurses, physicians, physician assistants, and clerical staff, participated in a one-hour training session during which they:
- Reviewed SHARE Approach materials and tools.
- Performed role-playing exercises.
- Engaged in conversation about shared decisionmaking best practices.
It was important that all staff participated in the training so everyone understood shared decisionmaking and how to use decision aids and other tools with patients.
Training for Residents
At Rochester General Hospital, Dr. Karmally carried out three separate shared-decisionmaking trainings for residents. Each training included a short didactic lecture from Dr. McGrail followed by small break-out sessions.
During the break-out sessions, residents participated in role-playing exercises to practice shared decisionmaking. The role-play exercises were facilitated by Dr. McGrail, Dr. Henderson, and Dr. Deshommes, preceptors in the residents' continuity clinics. The role-playing scenarios focused on three categories:
- Cardiovascular health and statins.
"The idea in the beginning was that we needed to pick something that would be relatively easy—something we do many times a day or a week and something that's relatively clear cut." —Dr. McGrail
Dr. McGrail and Dr. Karmally chose these three topics because they wanted the scenarios to be relatable. "The idea in the beginning was that we needed to pick something that would be relatively easy—something we do many times a day or a week and something that's relatively clear cut," explained Dr. McGrail. This would make it easier to explain how to put shared-decisionmaking into practice with patients.
Following the role-playing exercises, Dr. Karmally conducted a debrief on the training and provided residents with feedback cards. A total of 50 residents completed the shared-decisionmaking training, and most reported they that enjoyed their experiences. All were provided with a double-pocket folder with SHARE Approach materials that they could take home and use for future reference.
Shared Decisionmaking in Practice
The providers trained at the Rochester General Hospital and Bay Creek Medical Group SHARE Approach workshops were inspired to incorporate shared decisionmaking into their practice. For example, a direct link within the electronic medical record was created so that clinicians in all primary and specialty practices across the health system could seamlessly access shared decision aids during a patient visit. The links chosen were for decisions commonly addressed in an internal medicine visit: use of statins, anticoagulation in patients with atrial fibrillation, treatment of osteoporosis and knee osteoarthritis, and management of urinary incontinence. The shared decision aids come from AHRQ, Mayo Clinic, and Option Grids.
Dr. Karmally had residents approach her immediately following the first training to report that they had already used one of the decision aid tools from the workshop. Second-year residents who participated in the trainings included share decisionmaking in some of their "senior talks" where they present on a topic of their choice. Finally, another group of residents presented an original research project on quality improvement, recommending shared decisionmaking as one way to encourage the use of statins for patients with high cholesterol.
"The SHARE training really got them motivated, which to me, is the greatest thing that came out of this. I find with some of these things, the motivation is there for a couple of months after you do it and then it dies down. But it's really nice to know that its [shared decisionmaking] continued 6 to 8 months after," exclaimed Karmally.
One resident, Dr. Sonam Kiwalker, was even inspired to create her own digital decision aid to help patients quit smoking. She has used this decision aid with a couple of patients and has received positive feedback so far. As a next step, Dr. Kiwalker plans to submit to the hospital's institutional review board a proposal to measure the utility of the tool with patients.
Dr. Kiwalker is also the incoming Ambulatory Chief Resident in the Internal Medicine Residency Program, and is going to continue to introduce shared-decisionmaking concepts and tools to residents, as well as conduct additional SHARE Approach trainings.
What is the SHARE Approach?
The SHARE Approach is a five-step process for implementing shared decisionmaking, which offers physicians and other health care professionals the training and tools to help patients compare the potential benefit, harm, and risk of various treatment options for their conditions through meaningful dialogue about what matters most to the patient. The five steps are:
Benefits of Shared Decisionmaking
When asked if shared decisionmaking has been valuable, Dr. McGrail responded "I would say in my experience…when you're in the exam room, there's a bidirectional experience when using those decision aids. Patients stand up, they come over to the [computer] screen and engage with you." Dr. McGrail feels that patients like these tools, and providers are energized by having a rewarding two-way conversation with patients.