Family Medicine Clerkship QI

and Population Health Toolkit

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TABLE OF CONTENTS

INTRODUCTION ___________________________________________________________ 3
Benefits of Population Health Management in Health Care Delivery _________________ 4
A Note on Teamwork in Health Care Delivery ___________________________________ 4
CHRONIC DISEASE ________________________________________________________ 6
Chronic Disease Management_______________________________________________ 7
Diabetes ________________________________________________________________ 7
Hypertension ___________________________________________________________ 12
CANCER SCREENING _____________________________________________________ 16
Shared Decision Making in Cancer Care ______________________________________ 18
ANNUAL WELLNESS VISITS ________________________________________________ 21
PEDIATRIC IMMUNIZATIONS _______________________________________________ 22
MOTIVATIONAL INTERVIEWING ____________________________________________ 23
Principles and Practice of Motivational Interviewing _____________________________ 23
Motivational Interviewing Techniques ________________________________________ 24
MEDICAL STUDENT PATIENT ENGAGEMENT PLAN _______ Error! Bookmark not defined.
Care Gap Scripting_______________________________________________________ 27
Pediatric Immunizations Scripting ___________________________________________ 28
Script for Talking with Challenging Patients ___________________________________ 29
Messaging Templates ____________________________________________________ 30

CONTACTS _____________________________________________________________ 322

FAQS __________________________________________________________________ 333
REFERENCES __________________________________________________________ 334
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INTRODUCTION
Population health management has become increasingly central to the practice of primary
care as health care systems strive to eliminate growing and persistent health disparities.
Population health, defined as “the health outcomes of a group of individuals, including the
distribution of such outcomes within the group,”1 is an “interdisciplinary, customizable
approach that allows health departments to connect practice to policy for change to happen
locally. This approach utilizes non-traditional partnerships among different sectors of the
community – public health, industry, academia, health care, local government entities, etc. – to
achieve positive health outcomes.”2

To this end, population health management “refers to the process of improving clinical health
outcomes of a defined group of individuals through improved care coordination and patient
engagement supported by appropriate financial and care models.”3 Improving population
health necessitates collaboration among different groups and organizations. In the context of
primary care, coordinated teamwork amongst physicians, nurses, case managers,
pharmacists, behavioral health, social workers, residents, and students is critical to improving
the health of communities.
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Benefits of Population Health Management in Health Care

Delivery

The population health approach helps by:4

• Focusing on wellness instead of sick care

• Using data more effectively to improve care
• Engaging patients in their care
• Coordinating care that was previously siloed and fragmented, something that is easier
to do as accountable care organizations and patient-centered medical homes have
evolved

Areas of focus in population health management can include a focus on chronic disease
management, cancer screening rates, annual wellness visits (AWV), and health maintenance.
Working together, the team can help identify and contact patients who are missing a critical
care need or require additional education or assistance.

The goal of this activity is to further learn about population health management and teamwork
in health care delivery, where students will work together to contact patients who have been
identified as having a chronic disease or a health maintenance gap in their care. Students will
have an opportunity to learn about chronic disease management, discuss shared decision
making for cancer screening, perform medication reconciliation, and provide patient
education and counseling.

Objective

• Demonstrate skills needed for cost-effective delivery of care, including teamwork,

population health management, quality improvement (QI), and use of the electronic
medical record.

A Note on Teamwork in Health Care Delivery

Effective teamwork in health care delivery is important in providing quality, patient-centered
health care, ensuring patient safety, and improving population health.5 The importance of
effective teams in health care is particularly important because of factors such as: (i) the
increasing complexity and specialization of care; (ii) increasing co-morbidities; (iii) increasing
chronic disease; (iv) global workforce shortages.6

Principles of Team-Based Health Care7

1. Shared goals
2. Clear roles
3. Mutual Trust
 5

4. Effective Communication
5. Measurable processes and outcomes

Benefits of Effective Teamwork8

Organizational Individual Benefits

Team Benefits
Benefits Patients Team Members
Reduced
Improved coordination Enhanced job
hospitalization time Enhanced satisfaction
of care satisfaction
and costs

Reduced unanticipated Efficient use of health Acceptance of

Greater role clarity
admissions care services treatment

Enhanced
Better accessibility for Improved health
communication and Enhanced well-being
patients outcomes
professional diversity

As you move through this toolkit, think about how you can apply your knowledge of population
health management to enhance your understanding of chronic disease management, shared
decision making for cancer screening, medication reconciliation, and patient education and
counseling.

Additional resource on population health management:

Medicaid and Public Health Partnership Learning Series | Public Health and Population
Health 101

Shared Effective
goals & comm.
clear
roles

Mutual
trust

Effective Teamwork
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CHRONIC DISEASE
Chronic diseases impose an enormous burden on the economy with significant financial,
societal, and health implications. According to the Centers for Disease Control and
Prevention (CDC), six in ten adults in the US have at least one chronic disease, and four in
ten adults have two or more.9 Additionally, chronic and mental health conditions accounted
for about 90% of the nation’s 3.5 trillion in annual health care expenditures.10 The burden of
chronic disease is not only concerning for patients but also the health care system. Those
with multiple chronic conditions have poorer health, use more health services, and spend
more on health care — trends that have been stable since 2008.11 Therefore, chronic disease
management is an important task for health care systems.

Leading Causes of Death and Disability and Leading Drivers of the

Nation’s in Annual Health Care Costs12

• Heart Disease
• Cancer
• Chronic Lung Disease
• Stroke
• Alzheimer’s Disease
• Diabetes
• Chronic Kidney Disease
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Chronic Disease Management

Chronic disease management is “an integrated care approach to managing illness which
includes screenings, check-ups, monitoring and coordinating treatment, and patient
education. It can improve your quality of life while reducing your health care costs if you have
a chronic disease by preventing or minimizing the effects of a disease.”13

Helping patients manage their chronic disease(s) effectively is an important task for primary
care providers. However, barriers in healthcare delivery can lead to ineffective management
of chronic conditions and subpar care. Recall, the six core elements of the Chronic Care
Model (CCM), which aims to optimize the care of patients with chronic disease include:14,15

1. Delivery system design (moving from a reactive to a proactive care delivery system
where planned visits are coordinated through a team-based approach)
2. Self-management support
3. Decision support (basing care on evidence-based, effective care guidelines)
4. Clinical information systems (using registries that can provide patient-specific and
population-based support to the care team)
5. Community resources and policies (identifying or developing resources to support
healthy lifestyles)
6. Health systems (to create a quality-oriented culture)

Diabetes
Diabetes, a chronic condition affecting how your body turns food into energy, has significant
health and economic consequences. According to a 2018 report by the American Diabetes
Association, the total costs of diagnosed diabetes was $327 billion in 2017 of which $237
billion accounts for direct medical costs and $90 billion in reduced productivity.16

Diabetes by the Numbers17,18

34.2 million

U.S. adults have diabetes More than 1 in 3 U.S. adults 1 in 5 U.S. adults don’t know
have prediabetes they have diabetes
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No. 1
Diabetes is the No.1 cause
of kidney failure, lower-limb
amputations, and adult
blindness
7th $1 in $4
Diabetes is the 7th Leading Healthcare dollars is spent
cause of death in the U.S. caring for people with
diagnosed diabetes

As with other chronic conditions, racial and ethnic minorities shoulder a disproportionate
burden of morbidity and mortality for diabetes. Findings from a recent CDC report show that
the prevalence of diabetes varies across different racial and ethnic groups.

Prevalence of diagnosed diabetes was highest among American Indians/Alaska Natives

(14.7%), people of Hispanic origin (12.5%), and non-Hispanic blacks (11.7%), followed by
non-Hispanic Asians (9.2%) and non-Hispanic whites (7.5%). American Indians/Alaska
Natives had the highest prevalence of diagnosed diabetes for women (14.8%) and men
(14.5%). Among adults, prevalence varied significantly by education level, which is an
indicator of socioeconomic status. Specifically, 13.3% of adults with less than a high school
education had diagnosed diabetes versus 9.7% of those with a high school education and
7.5% of those with more than a high school education.19

Diabetes Care Guidelines

Each year, the American Diabetes Association publishes the “Standards of Medical Care in
Diabetes,” which includes current clinical practice recommendations. It also provides
information and guidance on the components of diabetes care, general treatment goals and
guidelines, and tools to evaluate the quality of care. These guidelines will be very
instrumental as you provide diabetes education and counseling to patients.

If you have not done so already, familiarize yourself with the diabetes guidelines and
recommendations using the links below.

• Standards of Medical Care in Diabetes - 2020

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Lipid Management

Recommendations
• Lifestyle modification focusing on weight loss (if indicated); application of a
Mediterranean style or Dietary Approaches to Stop Hypertension (DASH) eating
pattern; reduction of saturated fat and trans fat; increase of dietary n-3 fatty acids,
viscous fiber, and plant stanols/sterols intake; and increased physical activity should
be recommended to improve the lipid profile and reduce the risk of developing
atherosclerotic cardiovascular disease in patients with diabetes. A
• In adults not taking statins or other lipid-lowering therapy, it is reasonable to obtain a
lipid profile at the time of diabetes diagnosis, at an initial medical evaluation, and every
5 years thereafter if under the age of 40 years, or more frequently if indicated. E
• Obtain a lipid profile at initiation of statins or other lipid-lowering therapy, 4–12 weeks
after initiation or a change in dose, and annually thereafter as it may help to monitor
the response to therapy and inform medication adherence. E
• For patients with diabetes aged 40–75 years without atherosclerotic cardiovascular
disease, use moderate-intensity statin therapy in addition to lifestyle therapy. A
• For patients with diabetes aged 20–39 years with additional atherosclerotic
cardiovascular disease risk factors, it may be reasonable to initiate statin therapy in
addition to lifestyle therapy. C
• In patients with diabetes at higher risk, especially those with multiple atherosclerotic
cardiovascular disease risk factors or aged 50–70 years, it is reasonable to use high-
intensity statin therapy. B
• In adults with diabetes and 10-year atherosclerotic cardiovascular disease risk of 20%
or higher, it may be reasonable to add ezetimibe to maximally tolerated statin therapy
to reduce LDL cholesterol levels by 50% or more. C

Read more on lipid management

A1C

Recommendations
 An A1C goal for many nonpregnant adults of <7% is appropriate. A
 On the basis of provider judgement and patient preference, achievement of lower A1C
levels (such as <6.5%) may be acceptable if this can be achieved safely without
significant hypoglycemia or other adverse effects of treatment. C
 Less stringent A1C goals (such as <8%) may be appropriate for patients with a history
of severe hypoglycemia, limited life expectancy, advanced microvascular or
macrovascular complications, extensive comorbid conditions, or long-standing
diabetes in whom the goal is difficult to achieve despite diabetes self-management
education, appropriate glucose monitoring, and effective doses of multiple glucose-
lowering agents including insulin. B
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 Reassess glycemic targets over time based on criteria [i.e. in older adults] E

Read more on A1C

Retinopathy

Recommendations
• Optimize glycemic control to reduce the risk or slow the progression of diabetic
retinopathy. A
• Optimize blood pressure and serum lipid control to reduce the risk or slow the
progression of diabetic retinopathy. A
• Adults with type 1 diabetes should have an initial dilated and comprehensive eye
examination by an ophthalmologist or optometrist within 5 years after the onset of
diabetes. B
• Patients with type 2 diabetes should have an initial dilated and comprehensive eye
examination by an ophthalmologist or optometrist at the time of the diabetes
diagnosis. B
• If there is no evidence of retinopathy for one or more annual eye exams and glycemia
is well controlled, then screening every 1–2 years may be considered. If any level of
diabetic retinopathy is present, subsequent dilated retinal examinations should be
repeated at least annually by an ophthalmologist or optometrist. If retinopathy is
progressing or sight-threatening, then examinations will be required more frequently. B

Read more on diabetic retinopathy

Nephropathy

Recommendations
• Blood pressure should be measured at every visit. A
• Blood pressure should be optimized to reduce risk and/or slow the progression of
diabetic kidney disease. A
• Urine albumin-to-creatinine ratio should be obtained at the time of diagnosis and
annually thereafter. An elevated urine albumin-to-creatinine ratio (>30 mg/g creatinine)
should be confirmed on two of three samples. B
• Estimated glomerular filtration rate should be determined at the time of diagnosis and
annually thereafter. E
• In nonpregnant patients with diabetes and hypertension, either an ACE inhibitor or an
angiotensin receptor blocker is recommended for those with modestly elevated urinary
albumin-to-creatinine ratio (30–299 mg/g creatinine) and is strongly recommended for
 11

those with urinary albumin-to-creatinine ratio >300 mg/g creatinine and/or estimated
glomerular filtration rate <60 mL/min/1.73 m2. E
• For those with nephropathy, continued monitoring (yearly urinary albumin-to-creatinine
ratio, estimated glomerular filtration rate, and serum potassium) may aid in assessing
adherence and detecting progression of disease. E
• Referral to nephrology is recommended in case of uncertainty of etiology, worsening
urinary albumin-to-creatinine ratio, or decrease in estimated glomerular filtration rate. E

Pharmacologic Interventions

Recommendations for Type 2 DM

 Metformin is the preferred initial pharmacologic agent for the treatment of type 2
diabetes. A
 Once initiated, metformin should be continued as long as it is tolerated and not
contraindicated; other agents, including insulin, should be added to metformin. A
 The early introduction of insulin should be considered if there is evidence of ongoing
catabolism (weight loss), if symptoms of hyperglycemia are present, or when A1C
levels (>10%) or blood glucose levels (≥300 mg/dL) are very high. E
 Among patients with type 2 diabetes who have established atherosclerotic
cardiovascular disease or indicators of high risk, established kidney disease, or heart
failure, a sodium–glucose cotransporter 2 inhibitor or glucagon-like peptide 1 receptor
agonist with demonstrated cardiovascular disease benefit is recommended as part of
the glucose-lowering regimen independent of A1C and in consideration of patient-
specific factors. A
 In patients with type 2 diabetes who need greater glucose lowering than can be
obtained with oral agents, glucagon-like peptide 1 receptor agonists are preferred to
insulin when possible. B

Read more on pharmacologic interventions

Immunizations

Recommendations
• Provide routinely recommended vaccinations for children and adults with diabetes as
indicated by age. C
• Annual vaccination against influenza is recommended for all people ≥6 months of
age, especially those with diabetes. C
• Vaccination against pneumococcal disease, including pneumococcal pneumonia, with
13-valent pneumococcal conjugate vaccine (PCV13) is recommended for children
before age 2 years. People with diabetes ages 2 through 64 years should also receive
23-valent pneumococcal polysaccharide vaccine (PPSV23). At age ≥65 years,
regardless of vaccination history, additional PPSV23 vaccination is necessary. C
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• Administer a 2- or 3-dose series of hepatitis B vaccine, depending on the vaccine, to

unvaccinated adults with diabetes ages 18 through 59 years. C
• Consider administering a 3-dose series of hepatitis B vaccine to unvaccinated adults
with diabetes ≥60 years of age. C

Read more on immunizations

Resources on creating a diabetes diet

Eat Well

Diabetes diet: Create your healthy-eating plan

The Diabetes Diet

Local resources for diabetes support

Diabetes Education and Research Center

Food Fit Philly

Hypertension
Hypertension, also known as high blood pressure (BP), is a chronic condition affecting nearly
half of adults (approx. 108 million) in the U.S.20 Patients with hypertension are at elevated risk
for heart disease and stroke, which are leading causes of death.

Only about 1 in 4 adults with hypertension have their condition under control, and nearly half
of adults (45%) with uncontrolled hypertension have a BP of 140/90 mm Hg or higher. This
includes 37 million U.S. adults. Additionally, half of adults (30 million) with BP ≥140/90 mm
Hg who should be taking medication to control their BP aren’t prescribed or aren’t taking
medication.20

From 2003 to 2014, the average costs of high BP to the U.S. was about $131 billion each
year.20

Similar to diabetes, gender, geographic, and racial/ethnic disparities in hypertension exist.20

• A greater percentage of men (47%) have high BP than women (43%).

• High BP is more common in non-Hispanic black adults (54%) than in non-Hispanic
white adults (46%), non-Hispanic Asian adults (39%), or Hispanic adults (36%).
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• Among those recommended to take BP medication, BP control is higher among non-

Hispanic white adults (32%) than in non-Hispanic black adults (25%), non-Hispanic
Asian adults (19%), or Hispanic adults (25%).
• States in the eastern and southeastern parts of the U.S. have a higher percentage of
people self-reporting they have been diagnosed with hypertension.

Teaching Patients How to Monitor Blood Pressure at Home21

Provide background and purpose. Patients should be trained by health professionals to

accurately monitor their BP at home.

Assist in device use. A significant portion of the patient training consists of teaching how to
properly use the BP monitor. The health professional should ensure the patient has a cuff that
fits, knows what to do if it does not fit and knows how to position the cuff correctly on their arm
over bare skin. For further guidance, health care teams should refer to the manufacturer’s
user manual.

Next, show the patient how to turn the device on and begin measuring their BP. After the cuff
has deflated, the BP reading will be displayed. Explain to the patient which numbers
represent the systolic and diastolic BP.

Help the patient prepare to measure BP. Patients should be instructed to use the
bathroom, if needed, and to rest sitting in a chair for five minutes prior to taking their BP.
Patients should also be informed not to talk, use the phone, text, email or watch TV during
their measurement.
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Others in the room should refrain from talking during the patient’s reading. Remind patients to
wait at least 30 minutes after exercising or using caffeine or tobacco before they take their BP
measurements.

Guide the patient to correct posture. Accurate readings require proper body positioning,
as shown in this helpful Target: BP infographic. Proper positioning means patients must
remain seated in a chair with back support, legs uncrossed and feet placed flat on the ground
or supported by a stool. The patient should have the cuff positioned just above the elbow with
the arm supported so the cuff is at the same level as their heart, which is about mid- chest.

Let the patient know how often to measure. Patients should take two readings, one
minute apart. Between readings, patients should not remove the cuff. Patients should
measure their BP in the mornings and evenings.

Prepare the patient for dealing with errors or problems. Show the patient how to start
over if something goes wrong. Provide the patient with instructions on what to do if their
readings show an abnormal BP. Share a phone number to call, if possible.

Show the patient how to document blood pressure data. Patients should document their
readings in the BP log. They can record an average of their two readings or list each
individually. Depending on the device used, there might be memory storage for their
measurements.

Ensure the patient understands how to correctly measure BP. To ensure comprehension,
ask patients to “teach back” what they have learned. Correct any mistakes they might make
and provide a second demonstration if needed. Printed reminders or tips can also help the
patient remember the steps to take at home.

Below you will find two a sample BP logs you can share with patients.

Sample blood pressure log

Recording log

Patients can get a BP cuff at these following locations:

• Walgreens
• CVS
• Rite Aid
• Target

Hypertension Guidelines
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The American College of Cardiology (ACC)/American Heart Association (AHA) have

developed blood pressure guidelines geared towards addressing the prevention, detection,
evaluation, and management of high blood pressure in adults.

Familiarize yourself with the hypertension guidelines and recommendations for hypertension
management using the links below.

ACC/AHA 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High
Blood Pressure in Adults

ACC/AHA versus European Society of Cardiology (ESC)/European Society of Hypertension

(ESH) on Hypertension Guidelines: JACC Guideline Comparison

US Hypertension Management Guidelines: A Review of the Recent Past and

Recommendations for the Future
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CANCER SCREENING
Cancer, a genetic disease, is the second leading cause of death 17 in the U.S. Common risk
factors of cancer include alcohol consumption, HPV, tobacco use, and having a family history
of cancer.22 The financial costs of cancer are high for both the person with cancer and for
society as a whole.23 The estimated national expenditures for cancer care in the U.S. in 2018
were $147.3 billion.24

Quick Facts23

The number of new cases of cancer

(cancer incidence) is 439.2 per 100,000 men and
women per year (based on 2011–2015 cases).

The number of cancer deaths (cancer mortality) is

163.5 per 100,000 men and women per year (based
on 2011–2015 deaths).

Cancer mortality is higher among men than

women (196.8 per 100,000 men and 139.6 per
100,000 women). When comparing groups
based on race/ethnicity and sex, cancer mortality
is highest in African American men (239.9 per
100,000) and lowest in Asian/Pacific Islander
women (88.3 per 100,000).

In 2016, there were an estimated 15.5 million

cancer survivors in the United States. The
number of cancer survivors is expected to
increase to 20.3 million by 2026.
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Screening Tests

According to the CDC, “screening means checking your body for cancer before you have
symptoms. Getting screening tests regularly may find breast, cervical, and colorectal (colon)
cancers early when treatment is likely to work best.”25 Recommended screening tests include:

Breast Cancer Lung Cancer

Mammograms are the best way to find breast
cancer early, when it is easier to treat.
Learn more about screening for breast cancer
Cervical Cancer
The Pap test can find abnormal cells in the
cervix, which may turn into cancer. The HPV
test looks for the virus (human papillomavirus)
that can cause these cell changes. Pap tests
also can find cervical cancer early, when the
chance of being cured is very high.
Learn more about screening for cervical
cancer
Colorectal (Colon) Cancer
Colorectal cancer almost always develops
from precancerous polyps (abnormal growths)
in the colon or rectum. Screening tests can
find precancerous polyps, so they can be
removed before they turn into cancer.
Screening tests also can find colorectal cancer
early, when treatment works best.
The U.S. Preventative Services Task Force
(USPSTF) recommends yearly lung cancer
screening with low-dose computed
tomography (LDCT) for people who have a
history of heavy smoking and smoke now or
have quit within the past 15 years, and are
between 55 and 80 years old.
Learn more about screening for lung cancer
Screening for Other Kinds of Cancer
Screening for ovarian, pancreatic,
prostate, testicular, and thyroid cancers has
not been shown to reduce deaths from those
cancers. The USPSTF found insufficient
evidence to assess the balance of benefits
and harms of screening for bladder
cancer and oral cancer in adults without
symptoms, and of visual skin examination by a
doctor to screen for skin cancer in adults.

Learn more about screening for

colorectal cancer

USPSTF Recommendations for Cancer Screening

Read more on the different recommendations for cancer screening on the USPTSF website.
 18

Shared Decision Making in Cancer Care

“Shared decision making is simply a process that aids a physician and patient in selecting the
optimal test or treatment for the patient. It involves a bidirectional flow of information.”26

Diagram obtained from the research article: A Simple Approach to Shared Decision Making in Cancer Screening

“Shared decision making is particularly beneficial in situations where more than one treatment
or screening decision is valid. With cancer screening, there are many options for primary care
patients and good evidence that early detection can lead to decreased mortality and
morbidity. But most of the screening methods also have possible harmful effects, including
over-diagnosis or over-treatment, anxiety related to false-positive results, and discomfort or
harmful effects from diagnostic procedures. Patients should understand all of this information
and consider their personal needs and values in order to make a wise decision about
screening.”26

Six Steps to Shared Decision Making

Six key steps that all shared decision-making conversations should include:26

1. Invite the patient to participate. This key first step informs patients that they have
options in cancer screening, and their values and preferences are an important part of
the decision whether to get a particular screening test.

2. Present the options. For example, there are multitudes of ways to screen for colon
cancer. For breast cancer screening, women 40 years and older can choose to get a
mammogram or not.
 19

3. Provide information on benefits and risks. A man considering a PSA test needs to
know what a positive result means, what the risks of prostate biopsy are, and the
effects of overdiagnosis (i.e., detection of low-grade cancer that would never have
affected his life). He should also know that catching an aggressive cancer early may
save his life.

4. Assist patients in evaluating options based on their goals and concerns. For
example, if an elderly man does not want to have surgery in any situation because of a
bad reaction he had in the past, then maybe lung cancer screening is not a good
choice for him.

5. Facilitate deliberation and decision making. The primary care physician can help
patients make decisions based on their ongoing relationship and experiences treating
other illnesses. Cancer screening decisions do not need to be made urgently but can
be discussed during a series of visits.

6. Assist patients in following through on their screening decisions. Members of the

primary care team can aid patients in setting up appointments, provide information
about tests, and help address any barriers to getting the desired screening.
 20

Numerous models of shared decision making are available to primary care physicians to use
in cancer screening. All of the models incorporate the six key areas of shared decision
making described above. 26 Two of these models are described below: the Agency for
Healthcare Research and Quality’s SHARE method,27 and the 5 As method described by the
USPSTF.28

TWO MODELS OF SHARED DECISION MAKING

SHARE model:

Seek your patient’s participation.

Help your patient explore and compare treatment options.

Assess your patient’s values and preferences.

Reach a decision with your patient.

Evaluate your patient’s decision.

5 As model:

Assess the patient’s health needs, including acute issues and eligibility for
preventive services, and desired role in decision making.

Advise the patient about recommended screening, providing balanced information –

benefits, harms, alternatives, scientific uncertainties - about the service. If
appropriate (for A, B, and D recommendations), provide a recommendation.

Agree on a decision by eliciting the patient’s values, determining preferences, and

negotiating a course of action.

Assist the patient by ordering services.

Arrange a follow-up visit to review screening services in the future.

Links to additional resources on shared decision making in cancer care are provided below:

Shared Decision-Making for Cancer Care among Racial and Ethnic Minorities: A Systematic
Review

Association of Actual and Preferred Decision Roles with Patient-Reported Quality of Care:
Shared Decision Making in Cancer Care
 21

ANNUAL WELLNESS VISITS

Annual wellness visits (AWV) allow patients to get regular health exams and tests that can
help find problems before they start. AWV also can help find problems early, when chances
for treatment and cure are better. By getting the right health services, screenings, and
treatments, patients take meaningful steps that improve their chances of living a longer,
healthier life.29 The USPSTF has several recommendations for preventative care, which
varies by age and gender. Some of these recommendations include:

• 1-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men
aged 65 to 75 years who have ever smoked
• Screening for abnormal blood glucose as part of cardiovascular risk assessment in
adults aged 40 to 70 years who are overweight or obese
• Primary care clinicians assess women with a personal or family history of breast,
ovarian, tubal, or peritoneal cancer or who have an ancestry associated with breast
cancer susceptibility 1 and 2 (BRCA1/2) gene mutations with an appropriate brief
familial risk assessment tool
• Biennial screening mammography for women aged 50 to 74 years
• Offering or referring adults who are overweight or obese and have additional
cardiovascular disease (CVD) risk factors to intensive behavioral counseling
interventions to promote a healthful diet and physical activity for CVD prevention

For a full list of recommendations, visit the USPTSF website

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PEDIATRIC IMMUNIZATIONS
Maintaining childhood immunizations and well-child care during the COVID-19 pandemic can
be challenging. According to the CDC, stay-at-home and shelter-in-place orders have
resulted in declines in outpatient pediatric visits and fewer vaccine doses being administered,
leaving children at risk for vaccine-preventable diseases. 30 Therefore, encouraging parents to
bring their child in for vaccination is important.

Below you will find a few helpful resources for providers on vaccine conversations with
parents:

Talking with Parents about Vaccines for Infants

Talking to Patients about Vaccine Safety

Information for Pediatric Healthcare Providers

 23

MOTIVATIONAL INTERVIEWING
Motivational interviewing is defined as “a directive, client-centered counseling style for
eliciting behavior change by helping clients explore and resolve ambivalence.”31 The goal of
motivational interviewing is to “help patients identify and change behaviors that place them at
risk of developing health problems or that may be preventing optimal management of a
chronic condition.”32 Understanding the different factors that may influence an individual
patient’s readiness to change behavior is integral to this approach.33 The goal of using
motivational interviewing is to help patients move through the stages of readiness for change
in dealing with risky or unhealthy behavior.

Stages of Readiness for Change

• Precontemplation —The patient does not believe a problem exists. (“I won’t get
pregnant!”)

• Contemplation — The patient recognizes a problem exists and is considering

treatment or behavior change. (“Maybe I could get pregnant, and there are things I
could do to prevent this.”)

• Action — The patient begins treatment or behavior change. (“I’ll take that prescription
for birth control pills.”)

• Maintenance — The patient incorporates new behavior into daily life. (“I’m taking the
pill every day.”)

• Relapse —The patient returns to the undesired behavior. (“The pill makes me sick, I
think I’ll stop.”)

Principles and Practice of Motivational Interviewing34

Motivational interviewing helps the patient identify thoughts and feelings that influence
“unhealthy” behaviors and can help the patient develop new thought patterns to aid in
behavior change. This technique is implemented most effectively after the physician has
established a trusting rapport with the patient. Once the desired outcome (e.g., weight loss,
better compliance with contraception, smoking cessation) is set, the health care provider then
uses the following principles during the interview:

• Express empathy and avoid arguments — For example, as part of a discussion

about weight loss in a patient with diabetes mellitus, the physician can state, “I
understand that is has been difficult for you to exercise and lose weight in the past.
Many of my patients find this to be difficult. I think it is still important for us to try to find
ways for you to work on this. What do you think you can do to exercise more and eat
less?”
 24

• Develop discrepancies — The physician can help the patient understand the
difference between their behavior and their goals. For example, consider stating, “You
have told me that you would like to feel better and cut down on your medication. I think
you know that losing weight would help with this. Why do you think it is hard for you to
find more time to exercise?”
• Roll with resistance and provide personalized feedback — When patients express
reasons for not achieving goals, the physician can help them find ways to succeed. For
example, consider stating, “I know you are tired when you get home from work, but do
you think you could try walking up the stairs at work instead of taking the elevator?”
• Support self-efficacy, elicit self-motivation — For example, the physician can state,
“Let’s talk about what you can do to be more physically active.”

Motivational Interviewing Techniques

One approach to motivational interviewing is the FRAMES acronym.

F Feedback — Compare the patient’s risk behavior with nonrisk behavior patterns. She may
not be aware that what she considers normal is risky.

R Responsibility — Stress that it is her responsibility to make the change.

A Advice — Give direct advice (not insistence) to change the behavior.

M Menu — Identify “risk situations” and offer options for coping.

E Empathy — Use a style of interaction that is understanding and involved.

S Self-efficacy — Elicit and reinforce self-motivating statements such as “I am confident that I

can stop drinking.” Help the patient to develop strategies, implement them, and commit to
change.
 25

Additional Resources for Motivational Interviewing

Motivational Interviewing for Medical Students

Encouraging Patients to Change Unhealthy Behaviors With Motivational Interviewing

Implementing motivational interviewing in primary care: the role of provider characteristics

Motivational Interviewing: Talking with Someone Struggling with Opioid Addiction

 26

WHAT TO LOOK AT BEFORE YOU CALL

EPIC SCREENSHOTS FIND PATIENT IN EPIC AND CONFIRM
PROVIDED IN THE EPIC PATIENT IS CORRECT BY:
SCREENSHOTS – STORY 1. MRN
BOARD VIEW 2. NAME
DOCUMENT 3. DOB

LOOK AT CARE GAPS AND/OR

COMPLETE EXCEL DOCUMENT USING IF NO CARE GAPS LISTED
HEALTH MAINTENANCE RECORDS TO
UP TO DATE FROM DROP DOWN CONFIRM WHAT CARE GAPS SHOULD
BE DISCUSSED

IF CARE GAPS EXIST

CHECK ENCOUNTERS TAB FOR MOST

IF NO CONTACT RECENT OFFICE ENCOUNTER
WITHIN LAST MONTH IF PATIENT HAS HAD
CONTACT IN LAST MONTH

COMPLETE EXCEL DOCUMENT USING

COMPLETE OUTREACH CALL TO RECENT CONTACT FROM DROP
PATIENT DOWN MENU AND DESCRIBE
CONTACT IN NOTES COLUMN

COMPLETE EXCEL DOCUMENT USING

THE APPROPRIATE CHOICE FROM
THE DROP DOWN MENU
 27

Care Gap Scripting

Good Morning/Afternoon/Evening

May I speak with ________?

My name is _____ and I am a (Medical Student/Medical Assistant) calling from Jefferson

Family Medicine, and “PCP name”. We hope that you are staying safe and healthy during this
time. Despite these stressful times, we are striving to meet all of your healthcare needs, which
is why we are reaching out today.

We currently have in person visits available as well as telemedicine visits.

If you have time right now, I would like to review your health maintenance records and help
you schedule any needed services. I see that you are currently due for:

Mammogram
- Jefferson’s Breast Cancer is currently seeing patients for breast cancer screenings. To
schedule an appointment please call 215-955-5400.

Cervical Cancer Screening

- Cervical Cancer Screening: Have you had a pap recently? If yes, and not in Jefferson
(Center City) system – ask patient to send records to the office.
o Medical Students: If no, I can have someone from the office contact you to set
up an appointment – what is the best number to reach you?

Colon Cancer Screening

- Colon Cancer Screening: We have 2 options for colon cancer screenings. You may get
a colonoscopy or a Fecal Immunochemical Test also known as a FIT Test. A
colonoscopy done at Jefferson will mean you are good for 10 years as long as
everything comes back normal. With the FIT test, we can mail you the order and
specimen collection kit for you to drop off. If everything comes back normal, you will be
good for 1 year. If there is an abnormality or it is inconclusive, further testing will be
needed. Which one would you prefer?
o If FIT test is chosen: Send message to team pool to have FIT test ordered and
sent to patient
o If colonoscopy is chosen: Please allow 72 hours for the order to be placed and
then call 215-955-5400 to schedule your appointment.
 28

Diabetes Check-in
- Diabetes check-in: It is important to touch base regularly with your doctor regarding
your diabetes, have routine blood tests done to monitor your status, and complete a
retinal eye exam annually. I want to help you schedule your appointment and order any
labs that you need.
o Do you have the supplies you need to check your blood sugar regularly? Do you
keep a log of those blood sugar readings?

Hypertension Check-in
- Hypertension check-in: It is important to touch base regularly with your doctor
regarding your blood pressure, and have routine tests done to monitor your health. I
am going to assist you with that today if you are interested? If yes, what is the best
number to reach you at to schedule a visit? Additional questions you can ask:
o Do you have a blood pressure cuff that you use to monitor your blood pressure?
Annual Wellness Visit
- Annual Wellness Visit: This visit replaces the head-to-toe physical that is not covered
by Medicare. During this visit, you and your provider develop a personalized
prevention plan based on your current health and risk factors – this visit is at no cost to
you. We are currently doing these visits in office.
o Med Students: I am going to have someone from the office contact you to
schedule your appointment – what is the best number to reach you?

Pediatric Immunizations Scripting

Good Morning/Afternoon/Evening

May I speak with ________ (guardian of pediatric patient)?

My name is _____ and I am (Medical Student/ Medical Assistant) calling from Jefferson
Family Medicine and PCP NAME. We hope that you are staying safe and healthy during this
time. Despite these stressful times, we are striving to meet all of your healthcare needs, which
is why we are reaching out today. We have taken great steps to make visits to the office safe.
We want to make sure that children come to the office and receive all vaccinations to protect
them against future infection. We are currently offering a limited number of in person visits
and would like to have your child come in to check-in with their primary care provider and
receive his/her vaccinations that are due.
- Medical Students: I am going to have someone from the office reach out to schedule
the appointment – what is the best number to reach you?
 29

Notes
- Patient must have been seen in the office in the last year – if not let the patient know
that someone will be reaching out to schedule an appointment and confirm best
number to reach the patient
- Hypertension patients: should have an appointment every six months; you can address
care gaps, but if they have not been seen inform them that you will be having someone
contact them to schedule an appointment
- Diabetes patients: uncontrolled (most recent A1c >8%) should be seen in the office
every 3 months; controlled (most recent A1c <8%) should be seen in the office every
six months; you can address care gaps, but if they have not been seen inform them
that you will be having someone contact them to schedule an appointment
- Encourage the patients to schedule the appointment and follow the steps for sending
messages to the pools

Voicemail Script:

Hello, my name is ________ and I am calling from Jefferson Family Medicine and PCP
NAME. We are reaching out to our patients regarding their care. Please call the office back at
215-955-7190, so that we can set up an appointment.

Script for handling difficult patients:

Sometimes patients can be difficult on the phone and these can range from mildly annoyed to
extremely rude. Below are some things to keep in mind about handling these types of phone
calls.

Some steps you can take:

1. Be empathetic and nonjudgmental – taking a mindful pause and deep breath can be
helpful when trying not to judge or discount their feelings even if you don’t
necessarily understand them or feel comfortable with them
2. Be mindful of your emotions – these phone calls can be very sensitive, try your best to
not get caught up in the patient’s reaction to your call
3. Ignore Challenging Questions – stay focused on why you called; Example: patient
states they are still waiting for their refill - “I understand, my call today is regarding your
health maintenance; however, when we finish our phone call I will send a message to the
team to address your request”
4. Set Limits – no matter how calm you stay on the phone there are some situations
that you cannot talk through; if this is the case it is appropriate to hang-up the phone once
you have explained what you are going to do. For instance, “Sir/ma’am thank you for
taking the time to talk with me; however, I understand that you are upset and I have been
 30

instructed to end the call at this time.” If after this warning they continue in the same
manner, hang up the phone and complete your note. Send an email to Jennifer Langley
and Wydera Stubbs with a description of the situation.
5. Finally, don’t take these types of phone calls personally. Although this is not easy to
do, keep in mind the patients are not angry at you, but rather the situation or something
else entirely.

Staff Messaging Templates

STAFF MESSAGE FOR APPOINTMENT REQUEST

POOL: FAM 33 S 9TH ST SCHEGISTRATION

Good Morning/Afternoon,

I spoke with INSERT PATIENT NAME and he/she requested an in-

person/telemedicine appointment. Please reach out to the patient to schedule
the appointment. Once the appointment is scheduled please send a staff
message to Jennifer Langley with the date and time of the appointment.

Thank you,

INSERT YOUR NAME

STAFF MESSAGE FOR ORDERS REQUEST

POOLS: FAM 33 S 9TH ST TEAM 1, FAM 33 S 9TH ST TEAM 2, FAM 33 S 9TH
ST TEAM 3

AFTER CHOOSING THE APPOPRIATE TEAM POOL FROM THE LIST

ABOVE

Good Morning/Afternoon,
I spoke with INSERT PATIENT NAME and he/she is due for a LIST
SCREENINGS NEEDED HERE and has agreed to get them done. Please place
the orders for LIST ORDERS NEEDED and send them to the patient. Once
orders have been placed please send a staff message to Jennifer Langley with
the date the orders were placed and when they were sent to the patient.

Thank you,

INSERT YOUR NAME

 31

STAFF MESSAGE FOR APPOINTMENT AND ORDERS REQUEST

POOLS: FAM 33 S 9TH ST SCHEGISTRATION, FAM 33 S 9TH ST TEAM 1,
FAM 33 S 9TH ST TEAM 2, FAM 33 S 9TH TEAM 3

AFTER CHOOSING THE APPOPRIATE TEAM POOL FROM THE LIST

ABOVE

Good Morning/Afternoon,

I spoke with INSERT PATIENT NAME and he/she requested an in-

person/telemedicine appointment. Please reach out to the patient to schedule
the appointment. Once the appointment is scheduled please send a staff
message to Jennifer Langley with the date and time of the appointment.

The patient also needs the following orders placed to address current care gaps:
INSERT LIST OF ORDERS NEEDED. Please place the orders and send them
to the patient. Once orders have been placed please send a staff message to
Jennifer Langley with the date the orders were placed and when they were sent
to the patient.

Thank you,

INSERT YOUR NAME

 32

CONTACTS
If you have any questions regarding the outreach activity, please use the contact information
below:

Jefferson Family Medicine Contact Info.

Office Address:33 S 9th Street, Suite 301, Philadelphia, PA 19107

Phone Number: 215-955-7190
Fax Number: 215-923-9186

Contacts:
Jennifer Langley, Population Health Specialist: 215-503-3748; Jennifer.langley@jefferson.edu
Wydera Stubbs, Population Health Medical Assistant: 215-955-4525; Wydera.stubbs@jefferson.edu
Jackie Raab, Director, Clinical Operations: 215-955-5878; Jackie.raab@jefferson.edu
Krissten Appenzeller, Administrative Assistant: 215-955-1330; Krissten.appenzeller@jefferson.edu

Pools:
Schegistration: JUP FAM MED 833 CHES SCHEGISTRATION
Team 1: JUP FAM MED 833 TEAM 1
Team 2: JUP FAM MED 833 TEAM 2
Team 3: JUP FAM MED 833 TEAM 3
 33

FAQS
1. Will I be provided with a phone to contact patients?

No. You will not be provided with a phone from the clinic. Please download the
Doximity app on your personal phone. This app will allow you to use your cell phone to
call patients without revealing your private number. When their phone rings, patients
will see the JFMA number. After you download the app, please fill out the “Add Caller
ID” portion on Dialer using the information below.

Nickname: Jefferson Family Medicine

Number: 215-955-7190

2. What should I do if patients have questions that I cannot answer?

If you are unable to find the answer to the question during the call, collect patients
preferred contact method and make a note for follow-up in the outreach document with
the patient’s questions.

3. Who should I contact for more information?

Refer to page 32 of this document for a list of individuals that you can contact.

4. Do I have to complete the outreach activity?

Yes, you are required to complete this activity. It is an integral part of your clerkship
experience.
 34

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