Patient-Centered Reproductive Goals and Contraception Counseling

1. 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

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

3. 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

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

6. US Medical Eligibility Criteria: Categories https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6503.pdf

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

10. Population level

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

12. Individual level

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

14. 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 ObstetGynecolRosenstock, J. R. (2012). Obstetrics and Gynecology Peipert, J. F. (2011). ObstetGynecol Kavanaugh ML. (2013) J PediatrAdolescGynecol

15. 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)

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

17. 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

18. 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.”

19. Ask more questions &Talk less

20. 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

21. 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

22. 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

23. Efficient Patient-Centered Questions

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

25. Reproductive Goals

26. 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…

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

28. 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)

29. 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

30. CounselingSkills

31. 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?”

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

33. Establish Rapport, Show Empathy

34. 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”

35. 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.”

36. 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______hardto deal with”

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

38. 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)

39. 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

40. Health Literacy

41. “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

42. How does it feel reading this? If you have any of the fjposu symptoms, call the loskslhimmediately: • Aslfhippain • Sudden lknsoe • Any lasj in your lskneo

43. 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

44. Provide Quality Patient Education

45. Mismatched Communication

46. 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

47. 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

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

49. 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?

50. 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”