Engaging Low-Income Urban Patients in Their Own Health Management

Ade Olomu (center) and project manager Annette Sokolnicki (right) review medications with a patient.

Obtaining quality health care is a challenge for many Americans. For homeless and low-income patients who have a history of coronary artery disease or diabetes, the barriers can be almost insurmountable. For one thing, they may encounter logistical problems in following dietary and other lifestyle recommendations. For another, assuring continuity of care is especially difficult in urban areas where services may be fragmented.

Tricia Ware of Sparrow Health Center discusses a case with Dr. Olomu.

But what concerns Dr. Ade Olomu is the lack of adequate means to engage these poor and under- or uninsured patients in their own health care. "Self management of chronic conditions is so important," she said. "If all we do is get them to take their medications and stop smoking—those are the biggies. We have to do a better job of connecting with these patients."

When she began to look for ways to address the problem, Olomu and her co-investigator Dr. Margaret Holmes- Rovner, professor of medicine in the College of Human Medicine, found willing collaborators at Ingham County Health Department (Drs. Dean Sienko and Jaeson Fournier) and Sparrow Health Center (Drs. Sugandha Lowhim, Jeffery Meier, and Dana Balander). The partners agreed that the key to closing the gap might be giving patients more opportunities and encouragement to discuss their issues. "These folks don't ask questions," said Olomu. "They don't want to make waves."

The partners' solution pulls together a number of elements that are not entirely new in themselves, but which together target the needs of the clinic's patients. With funding from the Blue Cross Blue Shield of Michigan Foundation, Dr. Olomu and her co-investigators are testing the implementation of an outpatient program for cardiovascular and diabetic patients called the "Office Guideline Applied in Practice" (Office-GAP).

The core of the program is the use of a one-page "GAP Contract," or agreement form, during every office visit. The GAP Contract lists all the recommended medications and life style changes for the patient. After the doctor and the patient have reviewed this document together, both of them sign the form. "It's very powerful," said Dr. Olomu. "The patients take it home and put it on the refrigerator. We want them to know what they have to do to help prevent a heart attack."

Before starting the program, every patient attends a 90-minute group meeting in the clinic's conference room. The aim is to have about six patients in each group. Project manager Annette Sokolnicki, a research assistant in the Department of Medicine, found a wealth of existing patient education tools available for use in the group meeting. For example, "There's an American College of Physicians publication, Living with Diabetes¹, that's very visual," she said. "It has pictures of what a serving size should be, so it's useful for nonreaders." The team shows a self-help video, Living with Coronary Heart Disease², and then goes over each patient's medications individually. According to Holmes-Rovner, "The patients love the group visits and the video. It's about shared decision making. They often don't know they can negotiate issues with their doctor."

For example, said Sokolnicki, "One guy was given a medication to take at night. He was having trouble because he works a night shift and the medicine was making him too sleepy to work. But his doctor didn't know about the night shift, and the patient didn't realize it was OK to ask about taking his medication in the morning. We help them formulate questions for their physician. They also learn from each other in the groups."

Receptionist Angela Smith, foreground, with staff of Sparrow Health Center. Dr. Lowhim and Dr. Meier are second and third from left.

Olomu's team has been seeing positive changes in patients' behavior. "Some patients have already quit smoking and started losing weight and taking appropriate medications," she said. Holmes-Rovner added, "We've got 80-85 people in the program. Over half have done their follow-up appointment and updated their GAP Contract, and about 20 patients have completed the program. They're staying with us."

Feedback from doctors using the program has also been positive. "The Office-GAP program shared similar goals and objectives with the Ingham County Health Department's Sparrow Health Center in providing quality health care and improving health outcomes, especially in the area of chronic diseases such as diabetes mellitus and heart disease," said Sugandha Lowhim, who is chief deputy medical director for Ingham County Health Department and a physician at the Sparrow clinic. "By adhering to the GAP Contract patients were constantly reminded of how to improve the management of their conditions—a crucial element in delivering comprehensive care through multiple interventions such as smoking cessation, diet, regular exercise, and taking their medications as prescribed."

Although anecdotal evidence is encouraging, the next step for the research team is to decide whether there's enough data to support long-term, larger scale trials. "It's easier to track patients over time now that electronic records are being mandated," said Holmes-Rovner. Also, said Olomu, "We do have some preliminary data suggesting that patient knowledge about heart attacks has increased tremendously. But the first question we have to answer is: Can it be done in every outpatient clinic?"

Annette Sokolnicki leads a group meeting with patients who are starting the Office-GAP program.

1. American College of Physicians Foundation. (2006). Living with diabetes: An everyday guide for you and your family.. Philadelphia, PA: Author.
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2. Foundation for Informed Medical Decision Making. (2007). Living with coronary heart disease [booklet and video].. Boston, MA: Health Dialog.
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