Author: Building Trust

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.

In May, the ABIM Foundation and AcademyHealth convened 75 researchers, clinicians, patients and funders to chart the course of research on trust and health care for the next several years. The meeting, which also kicked off AcademyHealth’s new research community on trust and health care, covered a scan of existing research and identified areas where more is needed. Through guided conversation, participants discussed opportunities and methods to broaden and deepen the field of trust research.

Jodyn Platt, PhD from the University of Michigan and Lauren Taylor, PhD from the Hasting Center grounded the conversation with an overview of their literature review and their initial findings. The scan included looking at research on patient trust in clinicians, clinician trust in other clinicians, patient and clinician trust in organizations and patient and clinician trust in the system. In addition, the review paid particular attention to health equity, confidence in science and building and repairing trust.

Participants went on to have a rich conversation about potential areas of research, and voted on the top 10 areas to explore moving forward:  

Advancing Trust at the Organizational Level

1. How can trust be defined and measured at an organizational level (e.g., between patients and organization, community and organization, employees and organization, and clinicians and organization)?
2. What can organizations do to address influential structural determinants of distrust, such as partisanship and politicization, structural racism, and systems of privilege in order to improve trust with patients and within their systems?
3. Perform an analysis of positive deviance to identify fundamental drivers of optimal trust within organizations with diverse populations, studying signals at different levels (e.g., patient-clinician, system-clinician, and system-community).
4. What are the policies, partnerships, and practices that constitute the trustworthiness of organizations?
   • What is the impact of new organizations in new communities? Mergers? Workforce-community concordance? Patient-clinician concordance? A pipeline of trainees?
5. When organizational policies and values prevent clinicians from providing the care they think they should provide, how does that affect their trust in organizations?
   • What are the downstream effects of the loss of organizational trust on patient and clinician outcomes?

Advancing Trust at the Clinician Level

6. Why is trust in nurses consistently high vs. less consistent trust estimates in physicians—why the disparate scores and consistency? (correlate: why is trust in nurses more global and trust in physicians more personal?)
7. One of the drivers of patient trust is the perception that their doctor cares about them. How does a clinician convey that they care about a patient? What are the things they do or don’t do?
   • What are the behaviors, language, attributes?
   • What makes patients trust their clinician or health care organization more, and what would diminish or threaten that trust?
   • What underlies trust? Where is the locus of trust, mistrust, confidence?
8. What is the level of trust clinicians have in patients and their caregivers, and what interventions might most meaningfully increase that trust?

Advancing Trust at the Patient and Community Level

9. What are longitudinal trends in trust at the population level, and what factors affect change in trust?
10. What are the frames (e.g., patients, communities, institutions, or policies) for advancing trust that would have the biggest impact on health equity?
    • How can we center the community and their needs?

Additionally, participants discussed the importance of the study setting, populations of focus, measurement, methods, potential partners, and possible interventions and outcomes applicable to the research topic.

AcademyHealth and the ABIM Foundation plan to build on these topics by fostering a community built around research on trust and advocate for these issues to receive attention and funding. To learn more or join the community, contact Kelly Rand at krand@abim.org.

Janice Tufte resides in Seattle and is a patient collaborator involved with health systems research, evidence production, clinical practice quality improvement and human readable digital informed knowledge generation. She recently co-authored a paper currently under review with the Journal of Health Design that discusses the importance of collectively designing research and is working with AcademyHealth’s Paradigm Project in developing a new research prototype.  Learn more about Janice at www.janicetufte.com.

Susan Perez’s research focuses on understanding consumers’ decision-making processes in order to develop healthcare policies, information, and resources to promote high value decisions. Dr. Perez has conducted studies that classified approaches to processing Internet health information among vulnerable populations; addressed statewide overuse of healthcare services; identified approaches for patients and providers to discuss the cost of care; developed a statewide campaign to address variation in C-section rates by working with both patients and hospitals; and illuminated consumers’ views of cost sharing, quality and network choice. Prior to joining the faculty at the California State University, Sacramento Department of Public Health, Dr. Perez completed a postdoctoral fellowship in quality, safety, and comparative effectiveness research and earned a doctorate in Nursing Science and Health-Care Leadership program at the University of California, Davis. 

Gwen Darien is a longtime patient advocate who has played leadership roles in some of the country’s preeminent nonprofit organizations. As executive vice president for patient advocacy, engagement and education at the National Patient Advocate Foundation and the Patient Advocate Foundation, Gwen leads programs that link PAF’s direct patient services to NPAF initiatives to help ensure access to equitable, affordable, quality health care.

A three-time cancer survivor, Gwen came into cancer advocacy to change the experiences and outcomes for the patients who came after her and to change the public dialogue about cancer and other life-threatening illnesses.

Gwen serves on a wide range of program committees and workshop faculties. She is the Chair of PCORI’s Patient Engagement Advisory Panel and serves on the Board of Trustees of the USP. Gwen also writes about her experiences as an advocate and cancer survivor.