UCSF's Dr. Urmimala Sarkar, MD, speaks about the challenges of delivering high-quality healthcare to socioeconomically vulnerable patients and highlights the efficacy of several communication tactics especially pertaining to medication adherence.

1. Urmimala Sarkar
Assistant
Professor
Division of
General Internal
Medicine
Center for
Vulnerable
Populations
Health-IT-Enabled Self-
management Support For
Vulnerable Patients With
Diabetes

2.  Invited by Dr. Zayas-Caban to discuss my AHRQ-funded work
 Primary care physician
 Underserved patients
 Low income
 Limited English proficiency
 Limited health literacy
 Huge potential to leverage technology to improve health
 Reduce/ eliminate health disparities
 Medical innovation and technological advancement should
start with diverse populations
WHY I AM AT MEDICINE X

3.  7 out of 10 deaths among Americans each year are
from chronic diseases
 75% of our health care dollars go to treatment of
chronic diseases
 Profound disparities by educational attainment and
race/ ethnicity for incidence and for outcomes
 Compared to non-Hispanic whites, the risk of
diagnosed diabetes is
 18% higher among Asian Americans
 66% higher among Latinos
 77% higher among non-Hispanic African-Americans
BURDEN OF CHRONIC DISEASES

4. COMPLEXITY OF MANAGING
CHRONIC CONDITIONS
Diabetes daily tasks
Taking medications
Timing and planning of meals and exercise
Checking blood sugar
Adjustment of medications in response to numbers
Being vigilant for problems (checking feet)
Regular trips to doctors’ office, pharmacy, and lab
Benazapril 5mg

5. ADHERING TO MEDICATIONS IS
CHALLENGING

6. Automated telephone self-management
(ATSM)
Engage patients between visits
Remotely
Literacy and language appropriate
Tailor with “rules”
Screen for those who need live telephone
follow-up
CAN TECHNOLOGY HELP?

7.  Patients respond via touch-tone commands, and based on
their answers, patients hear automated health education
messages in the form of narratives
 Example response
 Example Exercise Narrative
IMPROVING DIABETES EFFORTS ACROSS
LANGUAGE AND LITERACY (IDEALL)

8.  ATSM: weekly automated calls
 English, Cantonese, or Spanish
 Triggers for live telephone follow-up from NP
 Topics rotated
 Self-care (diet, exercise, medication adherence)
 Psychosocial issues (such as depressive symptoms)
 Access to preventive services (such as eye care)
 ATSM vs. group visits vs. usual care
 ATSM group vs usual care
 improvements in self-management behavior (P < 0.05)
 fewer bed days/month (-1.7 days, P = 0.05)
 less interference with daily activities (OR 0.37, P = 0.02)
IMPROVING DIABETES EFFORTS ACROSS
LANGUAGE AND LITERACY (IDEALL)

9. 9
SMART STEPS: PARTNERING TO
PUT RESEARCH INTO PRACTICE
San Francisco Health Plan (SFHP): nonprofit
Medicaid managed-care plan
Recruitment and implementation
Evaluation by UCSF CVP, funded by AHRQ
Wait-list randomized trial

10. “out of range” responses
Live call within 3 days
Care managers
not licensed nurse practitioners
Language-concordant
Provide education
Trained to generate patient-
centered action plans
Safety or access issues
PCP notification tailored by
clinic site
SMART Steps
Patient
Case
Manager
ATSM PCP

11. Engagement in ATSM
% completing calls
Differences by language
Compare intervention (combined) vs. waitlist
in change from baseline to 6-month:
Summary of Diabetes Self-Care Activities
Quality of life (SF-12)
OUTCOMES
Toobert 2000, Ware 1996

12. PARTICIPANTS WITH 6-MONTH F/U
(N=249)
Characteristic Intervention (n=125) Wait-List (n=124)
Age in years, mean (SD) 56.6 (7.9) 54.9 (8.6)
Women, % 77 72
Latino, %
Black / African-American, %
Asian / Pacific Islander, %
White / Caucasian, %
26
6
60
6
20
10
62
7
Born Outside the U.S., % 86 85
Cantonese-speaking, %
Spanish-speaking, %
54
20
55
19
8th grade education or less, % 39 47
Limited health literacy, % 47 40
Income ≤ $20,000 / Yr, % 61 60
Hgb A1c >8.0%, % 30 24

14. CHANGE IN QUALITY OF LIFE AT 6 MOS
(N=249)
Adjusted*
Difference
(95% CI)
Standardized
Effect Size*
p-value
Physical
Component
SF-12
2.0
(0.1,3.9)
0.25 0.04
Mental
Component
SF-12
1.3
(-1.0,3.6)
0.14 0.26

15. CHANGE IN SELF-CARE AT 6 MOS
(N=249)
Adjusted*
Difference
(95% CI)
Standardized
Effect Size*
p-value
Overall Self-
Care
0.2 (0.1, 0.04) 0.29 <0.01
Glucose
monitoring
0.7 (0.2, 1.3) 0.30 <0.01
Foot
care
0.6 (0.2, 0.9) 0.32 <0.01
Medication
Adherence
0.0 (-0.2, 0.2) 0.02 0.82

16. Partnering with LHL / LEP patients:
Bicultural and bilingual content
Unmet need for language-concordant support
Practice-based research:
Innovate and create from within
Invest in the safety net providers
 Partnership with Medicaid managed care plan
Population-based implementation
Long-term relationships
SUCCESSFUL ENGAGEMENT

17. Phone-based population recruitment
Health coaches
Tailoring, training, and turnover
Bicultural as well as bilingual staff
Assessing fidelity: data collection &
feedback
Quasi-experimental designs beyond RCT
LEARNING OPPORTUNITIES

18. Scope: apply to other chronic conditions
Platform: mHealth beyond telephone
Linkages to patient-centered medical
home, electronic health records
Fidelity to mission
Reach and sustainability:
Within our health system
Medicaid and other insurers
FUTURE DIRECTIONS

19. QUESTIONS?
Project Team: Dean Schillinger, Neda Ratanawongsa ,
Margaret Handley, Judy Quan
Acknowledgements: San Francisco Health Plan Team,
Andrea Lopez