Author: Building Trust

Senior Investigator Michael Parchman, MD, MPH, of the MacColl Center for Health Care Innovation, part of Kaiser Permanente Washington, is a nationally recognized expert on applying implementation science to primary care. As both a family practitioner and health services researcher, he has more than 25 years of experience as a clinician and medical educator.

Building Trust team: Can you tell me why you think trust is important in improving health care and what interests you in the topic?

Dr. Parchman: This work began several years ago, when the Robert Wood Johnson Foundation approached us about the issue of engaging clinicians and other health care professionals in addressing overuse and promoting high value care. The more we explored this issue, the more we became aware of how trust is woven deeply into the fabric of every aspect of delivering high value care. It came up over and over again, and also came up repeatedly in our opioid work, where we are supporting primary care clinics in redesigning their care systems for patients who are on long-term opioids for chronic pain.

BT: You’re now working on a project that’s focused on medical management for dementia patients in ACOs. Can you tell us more about that project and how trust factors into the work?

Dr. Parchman: We’re currently funded by the IMPACT Collaboratory, which is a National Institute of Aging-funded initiative, to work with ACOs on prescribing potentially inappropriate medications for patients with dementia. This raises clear issues of trust with both patients and their family members or caregivers. For example, they may ask, “Why was I started on this medicine in the first place?” So, there’s a trust in the medical profession issue that arises.

Clinicians may also not trust data that’s presented to them about how often they prescribe these medications. Clinicians may not trust patients to follow through on replacement services that might be safer and sometimes more effective than some of the medications. And then there’s the issue of clinician and patient trust in the evidence behind the potential harm from these medications. Many clinicians say, “I know these studies show there’s potential for harm from these medications but they’re not like my patients.” Finally, as a clinician there’s trust in  your organization to support you in decreasing the use of a service for which the potential for harm is greater than the benefit, and trusting your peers not to prescribe these potentially inappropriate medications.

BT: What do you hope to measure around trust with this project?

Dr. Parchman: We’re training 30 clinicians across two ACOs to become clinician champions. Through a curriculum and a project workbook, we’re going to partner with these clinicians to look at how they implement this work in their own setting and use the data they enter in the project workbook to discover how often issues of trust come up, what kinds of trust issues come up, and how they address them. (Find the workbook and curriculum at Taking Action on Overuse.)

BT: What have you learned about trust from your work on de-prescribing opioids and older adults?

Dr. Parchman: Our work focuses on six building blocks for opiate medication management. When clinics engage with our team, coaches or facilitators help them look at how they are managing opioid medications. Clinics sometimes come to us when they unexpectedly find themselves inheriting patients who have legacy opioid prescription from a retiring provider. When those patients come in for refills, there’s that difficult conversation about why they are on the medication and the potential for harm. Then they ask why they were started on the medication in the first place. It entails having what I call a “sense-making conversation” with patients, and we worked to develop scripts for those conversations. We suggest saying things like, “Well you know we used to think these medications were safe. We now know they are not. There’s new evidence that these medications probably are not as safe as we thought.” So, you blame the medication and don’t blame the retiring provider.

BT: Historically, older patients are reluctant to have these shared decision-making conversations. Do you have any tips on engaging older adults in such conversations?

Dr. Parchman: It usually requires several visits. You have to build a relationship and frequently you find yourself in a position of saying, “OK, let’s not upset the apple cart today. We will give you enough to last you for another month or two. But, I need to see you back, and we need to continue this conversation. In the meantime, I want to give you some materials for you to read and think about and then we can talk about some options for your care.” The number one message is “I am never going to abandon you as a patient. I just want to make sure that you’re safe.”

BT: Can you share any insights from your practice facilitators, who need to convince clinicians to take the time to have those conversations?

Dr. Parchman: To have a conversation with the patient, you don’t have to go into a 20-minute long conversation. The other thing is, not to put it all on the shoulder of the prescriber. We train medical assistants and nurses on how to have these conversations with patients so everybody on the team is on the same page. (Find these tools here.)

BT: Is there any additional advice you’d like to offer?

Dr. Parchman: Be patient. This work takes time.

Kathleen Noonan, CEO of the Camden Coalition of Healthcare Providers, and Daniel Wolfson, MHSA, executive vice president and COO of the ABIM Foundation, discuss trust and its relationship to trauma and healing in the context of the COVID-19 pandemic.

PHILADELPHIA, November 1, 2021 – The Alliance for Academic Internal Medicine (AAIM), the American Board of Internal Medicine (ABIM), the ABIM Foundation, the American College of Physicians (ACP) and the Josiah Macy Jr. Foundation have announced a second round of grants for internal medicine residents and faculty members, designed to improve the quality of education and training and create a more trustworthy health system that serves everyone.

The first round of grants in 2020 brought in 170 applications, from which 32 projects at medical schools and training programs were selected. The grants, which totaled $287,500, include projects such as expanding community-focused health curriculum for primary care residents at Magnolia Regional Health Center/University of Mississippi Medical Center and developing a training program for medical residents to work directly with the Hispanic community at UT Southwestern Medical Center, among others.

For this second round of grants, sponsors are devoting a total of $400,000 to support new or existing programs that promote trust and create a more equitable health system by incorporating diversity, equity and inclusion (DEI) into the fabric of internal medicine and training. Inter-professional programs that incorporate members from across the care team will be preferred.

Specifically, sponsors are seeking proposals that (a) focus on providing training, skill and competency acquisition with the goal of promoting trustworthiness through equitable outcomes, or (b) focus on engineering care processes to promote trustworthiness through equity.

Examples of successful projects could include:

• Training programs that incorporate DEI, and in particular those that employ inter-professional education best practices.
• Quality improvement programs and program evaluations that advance trustworthiness through health equity.
• Ideas on building trustworthiness and psychological safety among teams, including an intentional focus on recognizing bias, lack of diversity and the barriers to being heard due to hierarchical structures.
• Innovative approaches to create collaborative partnerships between health systems and community-based service organizations in under-resourced communities.
• Approaches that foster and support diverse and equitable pathways into medicine and faculty and leadership positions.

Letters of intent for the second round of grants will be accepted through December 1, 2021 and selected applicants will be invited to submit full proposals early next year. Grants of $20,000 and $10,000 will be awarded in Spring 2022.

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About the Alliance for Academic Internal Medicine
AAIM represents over 11,000 academic internal medicine faculty and administrators at medical schools and community-based teaching hospitals in the US and Canada. Its mission is to promote the advancement and professional development of its members, who prepare the next generation of internal medicine physicians and leaders through education, research, engagement, and collaboration. Follow AAIM on Twitter @AAIMOnline.

About the American Board of Internal Medicine
Since its founding in 1936 to answer a public call to establish more uniform standards for physicians, certification by the ABIM has stood for the highest standard in internal medicine and its 21 subspecialties. Certification has meant that internists have demonstrated – to their peers and to the public – that they have the clinical judgment, skills and attitudes essential for the delivery of excellent patient care. ABIM is not a membership society, but a physician-led, non-profit, independent evaluation organization. Our accountability is both to the profession of medicine and to the public.

About the ABIM Foundation
The ABIM Foundation’s mission is to advance medical professionalism to improve the health care system by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org, connect on Facebook or follow on Twitter.

About the American College of Physicians
The American College of Physicians is the largest medical specialty organization in the United States with members in more than 145 countries worldwide. ACP membership includes 161,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. Follow ACP on Twitter, Facebook and Instagram.

About the Josiah Macy Jr. Foundation
Since 1930, the Josiah Macy Jr. Foundation has worked to improve health care in the United States. Founded by Kate Macy Ladd in memory of her father, prominent businessman Josiah Macy Jr., the Foundation supports projects that broaden and improve health professional education. It is the only national foundation solely dedicated to this mission. Visit the Macy Foundation at macyfoundation.org and follow on Twitter at @macyfoundation.

Tara Montgomery is a trusted change leadership advisor and strategist who strives to connect the dots between healthy people and healthy democracies, bringing consumer and citizen perspectives to conversations about culture change in health care and other complex systems. Tara is driven by optimism about the power of collaboration to solve the world’s most challenging problems, having spent over two decades convening and partnering with US, UK, and international academic, cultural, scientific, and nonprofit institutions and leading strategic initiatives to advance public health, education, corporate social responsibility, and social change.

Dave Ellis is a national leader in providing trainings and facilitating conversations on the lasting impacts of ACEs and generational trauma. He shares his expertise with the State of New Jersey and coordinates statewide work related to ACE’s.

The University of Mississippi Medical Center (UMMC) and Magnolia Regional Health Center (MRHC) both share the mission of decreasing the shortage of primary care physicians, reducing health disparities, and improving health outcomes throughout Mississippi.

In an effort to increase the number of residents and fellows training in primary care programs, Internal Medicine residencies at UMMC and MRHC have developed a partnership to expose trainees to both traditional academic and rural community-based graduate medical education. The intent is to expand the curriculum to strengthen patient-centered relationships as a core feature through a focused emphasis on didactic and clinical activities. This project strives to eliminate health disparities among Mississippians based on race, geography, income or social status.

Project initiatives include:

• Creating new educational activities and partnerships   with both non-profit and privately funded organizations to enrich learner exposure to patients.
• Expanding primary care resident curriculum, including a series of community-focused educational health topics and interactive lecture series, with input from various stakeholders from the community and other health care workers.
• Educating students, residents and nursing leaders at local neighborhood centers, clinics and health fairs. The collaboration will focus on patient mistrust and physician bias, presented through a series of lectures, reflective narratives and community engagement activities.

Program quality and efficacy will be assessed by comparing patient assessments between residents actively involved in the program and those who are not. “Mississippi is the state known for having some of the worst health outcomes. We thought it would be great to have residents out in the community [in patients’ homes and at community events] to see if there are improved health outcomes. Getting residents out into communities where patients live will help to restore trust,” said Margaret Hayes Baker, MD, Program Director, Internal Medicine, MRHC and Director, Magnolia Hospitalist Group.

This project aims to strengthen the doctor-patient relationship by building trust with patients and decreasing bias in trainees. Project leaders will also measure the program’s impact on retaining primary care physicians to practice in Mississippi after training.

“By accomplishing each of these outcomes, we will impact the health care of Mississippians by increasing the number of primary care physicians who are well-trained in delivering safe, equitable care to our diverse patient population,” said Baker.

Dr. Reshma Gupta and September Wallingford from Costs of Care shared information about the Patient Affordability Framework. This framework helps health systems and care teams develop strategies to make care more affordable for patients and avoid financial harm. Renee Firato, a patient affiliated with Family Reach, a nonprofit organization that provides financial support for families facing cancer, was our patient reactor.

Dr. Reshma Gupta, MD, MSHPM is a practicing internist, the Chief of Population Health and Accountable Care at University of California Davis Health in Sacramento, CA, and part of the Population Health Leadership Team for strategy across all UC Health campuses.

Dr. Gupta’s work focuses on innovation in policy and care redesign to improve the delivery of high-quality, affordable, equitable healthcare for patients and healthcare systems.

September Wallingford, RN, MSN is the Operations Director for Costs of Care. She oversees Costs of Care’s vast portfolio of programs dedicated to improving the value and affordability of healthcare and has led multiple grants and subcontracts from various organizations, as well as developed partnerships with leading healthcare organizations such as The Leapfrog Group, Institute for Healthcare Improvement (IHI), and the ABIM Foundation. Ms. Wallingford is a practicing medical/surgical oncology nurse at a large academic medical center in Boston, Massachusetts and brings significant interprofessional insights to the Costs of Care team.

Renee Firato,  Young Adult Leukemia survivor,  current Adult Breast Cancer patient, Single supermom to 8 year old Ava.  Preschool Teacher, Writer, Artist, Warrior, Advocate, Passionate about making the cancer experience better for all patients.

Parkland Health & Hospital System is one of the largest public hospital systems in the country, averaging more than one million patient visits annually. The system also includes 20 community-based clinics, 12 school-based clinics, numerous outreach and education programs, and is the primary teaching hospital for the University of Texas-Southwestern Medical Center.

In collaboration with the ABIM Foundation and America’s Essential Hospitals, Parkland conducted an inaugural Building Trust Challenge from January – March 2020. The challenge was hosted by Parkland’s Center for Innovation and Value and Patient Relations departments and was designed to identify who was building trust within and outside of the institution.

To encourage challenge submissions, Parkland launched an organization-wide survey comprised of questions ranging from ‘What does building trust mean to you?’ to ‘Are you building trust in your area?’ This survey was first shared at the executive level, and then through various Parkland platforms, including a letter from the CEO, the staff newsletter, and through discussion at various meetings, including a population health forum. The challenge received 36 submissions; surpassing initial expectations.

Addiction Psychiatry Services was the challenge winner. Honorable mentions were awarded to The Village Project and Supporting Parkland Staff (SPARKS).

• Addiction Psychiatry Services: Historically, acute care hospital settings have done a poor job of identifying and treating substance use disorders. The Addiction Psychiatry Services team is building trust by engaging patients during acute hospitalization to provide an opportunity for patients to obtain a substance use disorder diagnosis, participate in initial treatment and become engaged with ongoing outpatient treatments. The team has also built trust with community-based organizations to ensure patients have access to resources they need immediately after being discharged from the hospital.
• The Village Project: In 2017, the Centers for Disease Control reported that Black people accounted for 13% of the U.S. population but represented 43% of new HIV diagnoses. The HIV Services Department identified that there was a health care delivery gap for HIV+ Black men ages 17-34 who have sex with men (BMSM) in the Dallas area and implemented a nine-month intervention program. Participants receive weekly visits from a dedicated case manager and peer patient navigator for the first six months, followed by monthly contact for the remaining three months. A customized care plan is created with the patient and a comprehensive acuity assessment is re-evaluated every 90 days. This initiative helps young BMSM access HIV care to achieve viral suppression and expands access to behavioral health in an outpatient care setting.
• SPARKS: Supporting Parkland Staff (SPARKS) is a peer support program comprised of employee volunteers who receive psychological first aid training and provide confidential support to Parkland employees who experience a stressful patient-related event. In this peer-based support program, trust in implicitly built into the model because volunteers understand experiences at Parkland first hand. In the first 10 months of the program, 230 employees received peer support, showing significantly higher utilization than similar initiatives.

Keys to successful implementation included, yet were not limited to, gaining verbal support from organizational leaders, engaging in 1:1 communication with departments, streamlining the submission process, and ensuring a multidisciplinary effort, explained Sheryl Mathew, LCSW, ACM-SW, Grants & Research Program Manager at the Center for Innovation and Value at Parkland (CIVP).

“Establishing and maintaining trust is essential if we are to provide the best possible care for our patients, our employees, and the community. We saw the opportunity to take advantage of the creative thinking from the ABIM Foundation to highlight the importance of trust and recognize the types of behaviors and activities that will promote greater trust within our institution and between Parkland and the community we serve,” said Fred Cerise, MD, MPH, President and CEO of Parkland Health & Hospital System.

You can read more about Parkland’s Building Trust Challenge here.

Claire is a federal policy analyst and patient advocacy blogger whose health history goes back to the early 1980s. Since then, she has managed a raft of serious conditions, both acute and chronic. She has also been a caregiver for both chronically ill and terminally ill family members. A few years ago, she realized that her experience with healthcare could be used to help patients, so she started a blog and started looking for ways to use her skills to make positive changes to the healthcare ecosystem. Claire has a BA in Government from Smith College and an MA in Political Management from George Washington University.

You can reach Claire Sach’s blog here.

Alma McCormick is a member of the Crow Nation and the Executive Director of Messengers for Health, a Crow Indian 501 (c) (3) nonprofit organization located on the Crow reservation in Montana.  Alma is a leader and a community activist for improved health and wellness amongst her people.  Her educational background is in Community Health and she furthered her education receiving a Bachelor’s of Science in Health and Wellness at the Montana State University-Billings. She has been actively involved in cancer awareness outreach and advocacy amongst Native American women in Montana since 1996. She has extensive experience in conducting community-based participatory research projects addressing various health needs of the Crow people while working in partnership with Montana State University-Bozeman. She has traveled nationwide to present at health conferences to share the program’s successes. She has also co-authored numerous peer reviewed journal articles. Alma’s passion for her work in community outreach stems from her personal experience of losing a young twin daughter to neuroblastoma cancer in 1985.