The first part of this toolkit focused on the mechanics of the referral process, the nuts and bolts of setting up a structure within a primary care practice. The success of the referral process is dependent upon the practice and the community partner. The success of the next step, linking with the patient, depends on the receptivity and response of the targeted patients.
Midway through the AHRQ pilot project it became clear that practices were establishing functional, bidirectional referral systems, and clinicians were remembering to refer eligible patients to the targeted community program. However, the majority of referrals were not converting to enrollments. Eight months after consistent program referral by the four practices in the AHRQ pilot project, results showed that only about 1 in 10 patients who were referred actually enrolled. Physicians and other team members were disappointed that their work to establish a referral system wasn't paying off with improvements in patient health. The community representative was frustrated by the sheer volume of follow-up calls to referred patients who had not enrolled in the program, and sometimes were surprised, angry, or befuddled when the partner called. At this point, the project shifted to a much stronger focus on the patient engagement aspect of the referral process.
Through an ongoing series of interviews, one-on-one meetings, and a cross-practice learning collaborative, the practices and community partner developed strategies to improve patient enrollment. Several clinicians with the highest "conversion" rates shared their methods for selecting patients for the program. "We all know our patients, and you just know when they're ready. They might still need a push, but you know when they're ready. You have to trust your instincts," one physician explained. Another physician commented that community program referral is different than referring a patient to a specialist. While the mechanics might be the same on the practice side, it presents a new scenario for the patient who is not just putting another medical appointment on the calendar. By committing to enroll in a community program, like the YDPP, they are committing to a lifestyle change. This is why clinician and patient interaction during the referral process cannot be overemphasized.
During a cross-practice learning collaborative, participants mutually agreed that referring a patient based on physiologic criteria alone was not a successful method. There was a collective sense that clinicians needed to consider another equally important criteria—the patient's readiness to change. This second consideration spurred the development of the patient engagement tools described below.
Nine tools for increasing patient engagement.
|Tool 12||Motivational Interviewing Approach||Reviews fundamentals of motivational interview and gives examples of how to use OARS||Clinician|
|Tool 13||Videos on Motivational Interviewing Strategies||Synopsis and links to several high-quality demonstration videos||Clinician|
|Tool 14||Decisional Balance Worksheet||Instructions on how to use worksheet with patient; includes example and handout||Clinician; Patient Handout|
|Tool 15||Patient Videos on Healthy Lifestyles||Synopsis and links to several patient videos; clinician could mark personal favorites||Patient Handout|
|Tool 16||Patient Testimonials from Community Program||Testimonials from individuals who attended the YMCA Diabetes Prevention Program; template could be modified for other community programs||Patient Handout|
|Tool 17||"Weighing the Cost"||Instructions on how to explain graph to patient; graph to give patients||Clinician; Patient Handout Use|
|Tool 18||"The Time Game"||Clinician instructions on how to use worksheet with patient; includes example and patient worksheet||Clinician; Patient Handout|
|Tool 19||"Turn off the Oven"—Prediabetes Awareness||Information about diabetes development||Patient Handout|
|Tool 20||"Shedding Light"—Prediabetes Awareness||Information about diabetes development||Patient Handout|