title: Coaching patients in the use of decision and communication aids: RE-AIM evaluation of a patient support program.
abstract: BACKGROUND
  Decision aids educate patients about treatment options and outcomes. Communication aids include question lists, consultation summaries, and audio-recordings. In efficacy studies, decision aids increased patient knowledge, while communication aids increased patient question-asking and information recall. Starting in 2004, we trained successive cohorts of post-baccalaureate, pre-medical interns to coach patients in the use of decision and communication aids at our university-based breast cancer clinic.
  
  
  METHODS
  From July 2005 through June 2012, we used the RE-AIM framework to measure Reach, Effectiveness, Adoption, Implementation and Maintenance of our interventions.
  
  
  RESULTS
  1. Reach: Over the study period, our program sent a total of 5,153 decision aids and directly administered 2,004 communication aids. In the most recent program year (2012), out of 1,524 eligible patient appointments, we successfully contacted 1,212 (80%); coached 1,110 (73%) in the self-administered use of decision and communication aids; sent 958 (63%) decision aids; and directly administered communication aids for 419 (27%) patients. In a 2010 survey, coached patients reported self-administering one or more communication aids in 81% of visits 2. Effectiveness: In our pre-post comparisons, decision aids were associated with increased patient knowledge and decreased decisional conflict. Communication aids were associated with increased self-efficacy and number of questions; and with high ratings of patient preparedness and satisfaction 3. Adoption: Among visitors sent decision aids, 82% of survey respondents reviewed some or all; among those administered communication aids, 86% reviewed one or more after the visit 4.
  
  
  METHODS
  Through continuous quality adaptations, we increased the proportion of available staff time used for patient support (i.e. exploitation of workforce capacity) from 29% in 2005 to 84% in 2012 5. Maintenance: The main barrier to sustainability was the cost of paid intern labor. We addressed this by testing a service learning model in which student interns work as program coaches in exchange for academic credit rather than salary. The feasibility test succeeded, and we are now expanding the use of unpaid interns.
  
  
  CONCLUSIONS
  We have sustained a clinic-wide implementation of decision and communication aids through a novel staffing model that uses paid and unpaid student interns as coaches.
authors.affiliation: Philip R. Lee Institute For Health Policy Studies, University of California, San Francisco, 3333, California St, Suite 265, San Francisco, CA, 94118, USA. Jeff.belkora@ucsf.edu.
authors.forename: Jeff
authors.initials: J
authors.lastname: Belkora
authors.affiliation: Philip R. Lee Institute For Health Policy Studies, University of California, San Francisco, 3333, California St, Suite 265, San Francisco, CA, 94118, USA. Shelley.volz@ucsf.edu.
authors.forename: Shelley
authors.initials: S
authors.lastname: Volz
authors.affiliation: Philip R. Lee Institute For Health Policy Studies, University of California, San Francisco, 3333, California St, Suite 265, San Francisco, CA, 94118, USA. Meredith.Loth@gmail.com.
authors.forename: Meredith
authors.initials: M
authors.lastname: Loth
authors.affiliation: Philip R. Lee Institute For Health Policy Studies, University of California, San Francisco, 3333, California St, Suite 265, San Francisco, CA, 94118, USA. Alexandra.Teng@ucsf.edu.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Teng
authors.affiliation: Philip R. Lee Institute For Health Policy Studies, University of California, San Francisco, 3333, California St, Suite 265, San Francisco, CA, 94118, USA. Margot.Zarin-Pass@ucsf.edu.
authors.forename: Margot
authors.initials: M
authors.lastname: Zarin-Pass
authors.affiliation: Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, 1600 Divisadero Street, San Francisco, CA, 94115, USA. dmoore@cc.ucsf.edu.
authors.forename: Dan
authors.initials: D
authors.lastname: Moore
authors.affiliation: Carol Franc Buck Breast Care Center, University of California, San Francisco, 1600 Divisadero Street, 2nd Floor, San Francisco, CA, 94115, USA. Laura.Esserman@ucsf.edu.
authors.forename: Laura
authors.initials: L
authors.lastname: Esserman
mesh_terms: D000328:Adult; D001943:Breast Neoplasms / Q000628:therapy*; D002140:California; D003142:Communication; D003657:Decision Making; D003661:Decision Support Techniques; D005260:Female; D006282:Health Personnel / Q000193:education*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010353:Patient Education as Topic / Q000379:methods*; D015397:Program Evaluation; D011795:Surveys and Questionnaires