Patient-Centered Reproductive Goals and Contraception

Patient-Centered Reproductive Goals and Contraception Counseling; Shared Decision-Making in Action Patty Cason MS, FNP-BC UCLA School of Nursing Envision Sexual and Reproductive Health

Disclosures Advisory Board/Consultant Teva, Medicines 360, Allergan, Merck, Bayer, ContraMed, Evofem, Trainer/speaker Merck, Medicines360, Teva, ContraMed

Objectives Demonstrate patient-centered language in patient education Describe use of appropriate questions when giving patient information. Identify questions that foster patient-centered contraceptive care

U.S. Medical Eligibility for Contraceptive Use U.S. Selected Practice Recommendations Providing Quality Family Planning Services

US Medical Eligibility Criteria: Categories 2 No restriction for the use of the contraceptive method for a woman with that condition Advantages of using the method generally outweigh the theoretical or proven risks 3 Theoretical or proven risks of the method usually outweigh the advantages – not usually recommended unless more appropriate methods are not available or acceptable 4 Unacceptable health risk if the contraceptive method is used by a woman with that condition 1 https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6503.pdf

U.S. Selected Practice Recommendations Provides recommendations on optimal use of contraceptive methods for persons of all ages, including adolescents.

Population level

Population-Level Goals Public health considerations Cost: benefit ratios Costs, risks, benefits to society or government Epidemiology

Individual level

Individual-Level Goals Impact on a particular person Non-contraceptive benefits of a method Consequences of pregnancy Side effects or complications from a method

Satisfaction Mirrors Continuation 75-90% of users satisfied with LARC All populations studied report high levels of satisfaction Adolescents, Adults All demographics All SES Diedrich, J. T. (2015). Am J Obstet Gynecol Rosenstock, J. R. (2012). Obstetrics and Gynecology Peipert, J. F. (2011). Obstet Gynecol Kavanaugh ML. (2013) J Pediatr Adolesc Gynecol

LARC Policy Insure full access: No cost for placement or removal All methods/no restrictions by length of use Same day placement (operationalized) Copper IUD as EC Competent counseling (with reimbursement)

Patient Education Access to: Information about the full range of methods Accessible, medically correct information Culturally appropriate information Comparative effectiveness data in understandable terms

Training Providers trained in placement and removal Primary, pediatrics, family Providers/staff trained in client-centered counseling Providers/staff trained in responding to objections and managing complications

Language for LARC “This method is good for up to years but if you want to get pregnant before then or you would like it removed for any reason, come in, we will remove it and your ability to get pregnant will return to whatever is normal for you immediately.”

Ask more questions & Talk less

Patient-centered care “Patient-centered care is care that is respectful of and responsive to individual patient preferences, needs, and values.” - Institute of Medicine Recognized by IOM as a dimension of quality Associated with improved outcomes

Shared Decision-Making “Clinicians provide patients with information about options and help them to identify their preferences in the context of their values.” Fried (2016) N Engl J Med

Shared Decision-Making in Family Planning Consistent with patient’s desires for family planning counseling Focus on patient’s preferences Provision of decision support, without pressure Associated with improved satisfaction with counseling and with choice of method Dehlendorf C, (2013) Contraception

Efficient Patient-Centered Questions

Reproductive Intention/Goals PATH Questions 1.Do you think you would like to have (more) children some day? 2.When do you think that might be? 3.How important is it to you to prevent pregnancy (until then)?

Reproductive Goals Clarifies motivation and degree of acceptability regarding pregnancy so we discuss appropriate interventions /Contraception /Preconception Care Basic Infertility Services

Preconception Care “Since would you like to discuss ways to be prepared for a healthy pregnancy?” For example you have said “if it happens, it happens” many women using this method of contraception get pregnant

Best Question When the Answer is “No time soon ” Not, “What method are you interested in?”

Characteristics of Contraceptive Methods Do you have a sense of what is important to you about your method? Do you have a sense of what you are looking for in a contraceptive method? Dehlendorf C, (2016)

Attitude about Effectiveness Hormones Menstrual cycle and bleeding profile Length of use Control over removal Object in her body Return to fertility Non-contraceptive benefits Side effects

Counseling Skills

Re-phrasing “So I hear you saying (you really like the idea of using a method without hormones) do I have that right?” “It sounds like.(It’s very important to you not to get pregnant until you are out of school and you would love a method that you don’t have to think about) does that sound right?”

Alternate “Many of my patients say (that they worry about gaining weight with contraception) is that what you mean?”

Establish Rapport, Show Empathy

Positive Feedback (THEIR Values) Condom use, adherence to a method, exercise, quit smoking, or a good question You are both on the same side -theirs! Builds trust Encourages them coming from their “best self”

Positive Feedback “It’s great that you were so strong in standing up for yourself (asking your partner to use condoms.)” “You’ve clearly thought about this a lot so what do you make of this situation?” “Not many people (your age) act so responsibly about using a condom every time.”

Empathy Without Labeling Rather than: “You sound angry” (or anxious) Not: “I know how you feel.” Use neutral words: “It sounds like is concerning to you” “Anyone would find hard to deal with”

Try NOT to Disagree “Find the yes” Find something in what they are saying to agree with .and then add your scientific or medical information. “Yes! . and ” Instead of “No” or “But”

Find the “Yes” Rather than: “No, that’s not true! Don’t trust “Dr. Google” Try: “I can see you like to inform yourself!” “I have a great resource for you that I think you will love ” (Bedsider)

Addressing Patient’s Concerns “That’s too bad your friend had that experience. I haven’t heard of that before, and I can tell you it definitely doesn’t happen frequently.” Christine Dehlendorf 2016

Health Literacy

“The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Healthy People 2010

How does it feel reading this? If you have any of the fjposu symptoms, call the loskslh immediately: Aslfhip pain Sudden lknsoe Any lasj in your lskneo

Consequences---Clues Frequently missed appointments Lack of follow through with tests or referrals Adherence issues Unable to name medications, purpose or dose Ask fewer questions

Provide Quality Patient Education

Mismatched Communication

Limit the Amount of Information Humans do not integrate much of the information provided More information less retention Focus on specific needs and knowledge gaps

Information Sandwich Sandwich the one piece of information you want to give between questions Following information with a question requires the patient to interact with the information Understand remember integrate

A small amount of information Information Sandwich With questions on each side

Questions How would that be for you? Knowing that, how would it be for you ? Has it ever happened before? How did you manage it? Do you have a sense of how you would manage it?

Q: “How would it be for you if you didn’t get your period while you are using the implant?” A: “That would not be good” Q: “What is it about not getting your period that concerns you?” A: “My mom said it’s not healthy not to get my period”

The YES: “Your mother is completely right, when you are not on contraceptive hormones it is important to get you period every month, it’s great that you know that. The Science: Interestingly, if a woman is using contraceptive hormones it keeps her uterus very healthy and thin. It actually prevents cancer of the uterus” Question: “Knowing that, how would it be for you not getting periods?”

Visual and Tactile Aids Demonstrate/draw pictures Clearly written education materials Illustrations 3-D models

Demo Unit IUDs and Implant Give them the unit to hold, feel and play with while discussing the method how to feel the threads what the plastic feels like if it is expelling

Second Tier Combined Hormonal Contraceptives

Language for Patient Education

Examples of Plain Language Annually Topically Eligible Fertility Hypertension Dermatologist Yearly or every year On the skin Able to get Ability to get pregnant High blood pressure Skin doctor The Plain Language Thesaurus for Health Communications http://depts.washington.edu/respcare/public/info/Plain Language Thesaurus for Health Communications.pdf

Misconceptions All contraception is equally effective Underestimate their fertility Pregnancy confirms fertility No need for effective contraception Pregnancy is safer than contraception

Use Natural Frequencies And Common Denominators “If a woman switches from the pill to an IUD her chance of unintended pregnancy is reduced from 9 in 100 to 1 in 100”

Teach Back “I’ve just gone over a ton of information and I’m not always as clear as I would like to be or “Just to be sure I didn’t forget to tell you something Do you understand? AND Do you have any questions? “What questions do you have?”

Obstacles

On one hand Goal Behavior On the other hand

Find the Obstacle Goal Obstacle

Ask more questions & Talk less

Thank you!

Questions?

https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/qualitypatient-safety/quality-resources/tools/literacy-toolkit/ healthlittoolkit2.pdf Brega AG, et al. AHRQ Health Literacy Universal Precautions Toolkit, Second Edition 2015.

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