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FAMILY HEALTH HISTORY

TOOLKIT PROJECT: FINAL REPORT

Comprehensive Community Health Centers, Inc.

Danielle Smith Brigitte Lamberson

July 31, 2012

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Comprehensive Community Health Centers, Inc.

FAMILY HEALTH HISTORY

TOOLKIT PROJECT: FINAL REPORT

Table of Contents

Agency Contact Information ......................................................................................................................... 3

Overview ....................................................................................................................................................... 4

Project Implementation ................................................................................................................................ 5

Project Evaluation ......................................................................................................................................... 8

Sustainability ............................................................................................................................................... 12

Lessons Learned .......................................................................................................................................... 12

Recommendations ...................................................................................................................................... 13

Budget ......................................................................................................................................................... 14

Appendix A .................................................................................................................................................. 16

Appendix B .................................................................................................................................................. 20

Appendix C .................................................................................................................................................. 21

Appendix D .................................................................................................................................................. 22

Appendix E .................................................................................................................................................. 23

Appendix F .................................................................................................................................................. 24

Appendix G .................................................................................................................................................. 25

Appendix H .................................................................................................................................................. 26

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Agency Contact Information Agency Name: Comprehensive Community Health Centers, Inc. Address: 801 South Chevy Chase Drive, Suite 20. Glendale, CA 91205 Website: www.cchccenters.org Contact Persons: Danielle Smith Health Education Program Manager Direct Line: (818) 265-2267 Fax: (818) 265-2228 Email: danielles@cchcenters.org Brigitte Lamberson Health Educator Direct Line: (818) 265-2269 Fax: (818) 265-2268 Email: brigittel@cchccenters.org

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I. Overview Organizational Background and Community Description Comprehensive Community Health Centers, Inc. (CCHC) is located within five to ten miles north of downtown Los Angeles and operates four community health clinics in the cities of Glendale, Eagle Rock, Highland Park, and North Hollywood. Across its four locations, CCHC provides medical, dental, mental health, social, and health education services to address the needs of its communities. CCHC provided 108,038 encounters to 36,889 patients in 2011. CCHC has a significantly diverse patient base. Fifty-eight percent are Latino, 29% are White, and 13% report as Asian/Pacific Islander, Black, Native American, or Other. CCHC serves a significant number of Eastern Europeans (Armenian, Russian, and Iranian) that are frequently overlooked because they are counted as “Whites”. Fifty-two percent of CCHC patients are foreign-born, and of those over 5 years of age, 70% speak a language other than English at home. Collection and Use of FHH before the Project CCHC would collect an individual and Family Health History (FHH) at every visit where a patient was receiving a complete physical exam. A review of Past, Family, and Social History (PFSH) was conducted by a Medical Assistant (MA). PFSH questions relevant to FHH included those surrounding acute and chronic conditions including anemia, bleeding disorders, congenital problems, depression, diabetes, epilepsy, hepatitis, hypertension, stroke, tuberculosis, and different cancers. The MA would record any history of the conditions/disorders mentioned above if the patient themself had a history, or if their parent or sibling had a history. There was also an option for “other” which would include extended second and third degree relatives such as grandparents, aunts, uncles, and cousins. The provider would review the PFSH, including FHH, and asked any additional questions as needed. The provider would also provide appropriate feedback, education, and referrals for the client surrounding the condition. Educational materials were readily available to patients with more common conditions/disorders. Before project implementation, CCHC was currently in transition between paper medical records to electronic health records (EHR). There were only two of CCHC’s four clinics who were completely paperless utilizing the EHR system and two who were still utilizing paper chart records. PFSH and FHH questions are the same on both the paper and electronic documents. CCHC previously emphasized the importance of FHH in health education classes. Monthly classes on diabetes and healthy living have been offered at each clinic since July 2010. Discussion included chronic disease risk factors and patients were encouraged to discuss FHH with their families. Although the specific FHH information was not recorded in the patient’s health record at the time of the class, class attendance was encouraged for all chronic disease patients. Assessment of Provider and Patient Need Before project implementation, CCHC staff and patients both revealed a high need for increased FHH education and awareness. In preparation for the funding application, key CCHC staff were interviewed to assess their opinions regarding prior FHH collection practices. Many MAs admitted to primarily focusing on individual health history, and did not always collect a thorough FHH. Providers indicated that if the FHH had reflected information that required further education, lab work, or referral they were sure to explain that to the patient. A comment made by one of the Family Practice Physicians was that it was unfortunate that physicals were the only time that a FHH was conducted at CCHC; however she also felt that time did not permit a thorough FHH to be completed at every visit. She expressed that

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a resource such as the Does It Run In the Family? Toolkit would help patients see the importance of disclosing more information regarding FHH during their visits. MAs had also indicated that patients often did not know their FHH, or if they did, they did not express high interest in how that information could have affected them and their lifestyle choices. One example shared by an MA was that of a 26 year old male patient who had strong family history of diabetes. The patient had a body mass index of 35 as well as hypertension. He was unaware that his obesity and hypertension coupled with strong family history of diabetes put him at high risk for developing diabetes himself and possibly high-risk complications in the future. At the time, the provider was able to perform a point-of-care Hemoglobin A1c test during the visit and the results had indicated that he was pre-diabetic. The patient was counseled on the condition and attended a diabetes class offered by CCHC’s Health Education Department. II. Project Implementation Prior to Implementation EHR Revisions CCHC revised the History and Subjective tab of the EHR template. Revisions included a drop down box for both FHH toolkits given (Highland Park Clinic use only) and FHH toolkits returned (All Clinics); a checklist of possible illnesses and diseases that run in the family was transformed to include a free text portion for a more thorough FHH collection; all patient notes were modified to allow for FHH collection (not just physicals); and a system was created to streamline reporting. All clinic staff were trained by EMR and Health Education staff on changes made to EMR templates prior to implementation. Toolkit Customization Health Education staff recruited participants willing to share their own FHH stories to be featured in CCHC’s toolkit. Health Education staff recruited four participants at weekly health education classes and via telephone interview calls. Participants were given a consent form to be filled out and signed allowing CCHC to publish, print and distribute their own FHH stories, along with their first name and best picture (see Appendix A). Participation was completely voluntary and included a $10 grocery gift card as compensation for participation. Final customization of the toolkit included a brief message from the Health Educator of the importance of FHH. Customization and design of the toolkit was successful in representing our patient and community population. Implementation Initial CCHC goals were to implement the Does It Run in the Family? Toolkit from May 1, 2011 through July 31, 2012. Unfortunately due to a delay in toolkit customization and printing, the project was postponed and instead implemented on November 7, 2011 with the original objectives to implement in three ways: implementing the toolkit at every annual physical for every patient at the Highland Park clinic; implementing the toolkit at all health education classes at all four clinic sites; dispensing the toolkit during outreach in the surrounding communities. Highland Park Clinic The Highland Park clinic was selected to utilize the toolkit within their current FHH practices. The toolkit was initially to be given to all patients visiting for complete physicals, and the workflow was then modified to include all patients, regardless of reason for visit. This was in part due to the revision of all templates being inclusive of FHH fields, but also because of the delay in the start date, which would negatively affect project goals in terms of number of participants reached. Both booklets are given to

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each patient. MAs go through the toolkit with the patient, collect FHH information, and record all findings in the EMR. MAs suggest that the patient takes the toolkit home and review it with their family. At their next medical visit, patients are asked to return with the toolkit and update their FHH. Patients who do so are rewarded with a $10 grocery gift card. MAs are responsible for dispensing the incentive. The Clinic Manger is responsible for keeping an up-to-date manual log of all patients receiving the incentive (see Appendix B). Health Education Classes The Health Education Program at CCHC has been successful in the implementation of classes for patients and their families, and the toolkit has been a fantastic way to emphasize FHH as a possible risk factor for many conditions and diseases. Classes are presented each week across all four sites and have an average attendance of 15 to 20 participants. Topics discussed during the presentation include diabetes, hypertension, cholesterol, obesity, nutrition, physical activity, and smoking cessation. All newly diagnosed and uncontrolled chronic disease patients are referred to the class by providers and patients are also recruited by the Health Educator based on abnormal lab findings. Many patients also attend based on self-referral. Since project implementation, the toolkit has reached approximately 660 participants to date and has the opportunity to reach approximately another 400 participants. The Health Education classes have incorporated the toolkit during the discussion regarding risk factors and genetic predisposition for chronic diseases. This has been a great opportunity to initiate family discussions as family members are already encouraged to come to classes to support the patient. Overall, participants have had a positive response to provide thorough family health history at their next provider visit. All class participants recognize this is an engaging tool to initiate conversations with their families and “play detective” for the benefit of their own health. In one occasion, a class participant shared that she was diagnosed with gestational diabetes during her first pregnancy. She was aware that this would put her at high risk for developing diabetes in the future and if left untreated, but she was not aware that her baby would also be at high risk for developing diabetes and obesity in the future. Patients and family members alike are encouraged to return to their next medical appointment with the toolkit and update their FHH where they also receive a $10 grocery gift card as an incentive. The $10 grocery gift card has demonstrated to be a very good incentive to participate. Outreach and Education Program CCHC has also implemented the toolkit while doing outreach in the surrounding communities. CCHC’s Outreach and Education program reaches approximately 2,000 community members annually. The toolkit has been a great addition to our outreach efforts which focus on improving the overall health of an individual. CCHC’s Outreach and Education program sets up informational booths throughout the community and also provides short presentations on clinic services. The toolkits assist in improving the health of our community and also serve as an agency-wide marketing tool. Community members in need of clinic services are encouraged to come to the clinic and if they bring the toolkit they will get the same $10 grocery gift card, even if it is their first visit. Modifications to Implementation Plan Marketing Tools To better market and promote both health education classes and the FHH project, labels with Highland Park’s health education class schedule were added to Book 1 of the set of toolkits (see Figure 1). Also,

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posters were created for all clinic sites to serve as an invitation for patients to attend a health education class, participate in the project, and return their toolkits for an incentive (see Appendix B). Figure 1. Label added to Book 1

During the health education classes and outreach events many participants expressed confusion about how to utilize the toolkit. In order to eliminate such challenges, flyers were created with step-by-step instructions for participants. Flyers were added to toolkits being dispensed at health education classes and during outreach events (see Appendix C). EHR Documentation Due to frequent data entry errors, accurate tracking of toolkits given and returned were found. Occurrence of data entry errors lead to limited data. As a result, the total number of toolkits returned via EHR reports did not reconcile with Clinic Managers manual incentive logs. Suggestions were made by Clinic Managers to have a structured tracking system for toolkits distributed at health education classes and at outreach events. Revisions have been made to both the health education class and outreach sign in sheets to manually track toolkits given to all participants who have not yet participated in the FHH project, in this way, leaving little room for tracking errors (see Appendix D). In addition, Health Education staff met with support staff at all sites to review appropriate EHR documentation steps. Project Awareness and Staff Buy-In CCHC’s Health Education Department held in-service trainings in August 2011 for clinic support staff at all sites on the significance of thorough FHH collection, appropriate interview techniques, documentation of FHH in the EHR, utilizing the toolkit, and administering incentives. Due to high employee turnover rates, “make-up” sessions were held to capture those who had not yet been trained. Over time, one of the greatest challenges the Health Education Department found was making sure all new hires were up to date with the project and re-trained if necessary. Clinic Managers recommended trainings be held before lunch hour and without impacting patient care. This proved to be yet another challenge and accommodations were made. FHH project was often viewed as “another” training and/or project. A total of over 60 staff were trained. Because of the delay in getting the toolkits, staff would not receive a toolkit at their initial training and have a chance to participate in the project with their own FHH as planned in the initial objective. Instead this was done at the project mid-point evaluation. As a result, staff buy-in was a factor. Provider buy in was also a challenge. Initially CCHC had a champion provider for this project, but before implementation began, she had left the agency. It took time to replace her in the Highland Park clinic and new providers were still getting settled well into implementation. Not having a provider champion for this project as planned was a huge barrier in regards to improving FHH interpretation and streamlining referrals and community partnerships as needed.

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Partnerships CCHC did not establish partnerships with outside agencies other than with Genetic Alliance and other health centers involved in the FHH project. Performance Satisfaction and Value Project outcomes have met many original objectives, but there have been shortcomings. As anticipated, existing staff that received initial training and are still involved in the project are performing to expectation. Collection and documentation of FHH is more thorough and patient interaction has improved. The toolkits have not reached as many patients or community participants as anticipated due to a delay in project implementation. The FHH project has brought great value in terms of collection, however little focus has been on interpretation by providers. Current Status of FHH Project CCHC is currently in the implementation phase of the project and will continue its efforts as previously described. III. Project Evaluation Methods CCHC’s Health Education Department staff worked together to evaluate the effectiveness and likeability of the FHH project. Project evaluation methods included support staff training conducted in August 2011 and mid-point evaluation surveys conducted in March 2012. Measures from EMR/Chart Audits CCHC local evaluation measures from EMR and chart audits included: the number of patients receiving the toolkit in the clinic; the number of patients returning the toolkit in the clinic; the number of patients receiving AND returning the toolkit in the clinic. From November 7, 2012 to July 6, 2012, CCHC dispensed 1672 toolkits at the Highland Park clinic (excludes total number of toolkits given at outreach activities and Health Education classes). During this same time, the total number of toolkits returned across all clinics was 85, and total number of toolkits given and returned in the Highland Park clinic was 75. This infers that 10 toolkits returned were dispensed during Health Education classes across all sites and/or during outreach activities. Initially, the evaluation plan included randomly selecting 40% of Highland Park’s complete physical exam visits for chart reviews to ensure that FHH documentation in the patient’s record was accurate and that providers were reviewing it. CCHC has excluded this measure as toolkits were distributed during all provider visits, including sequential visits, at the Highland Park Clinic. Therefore, CCHC reviewed 100% of patient records who returned with their toolkit to see if their FHH was updated at their next visit. Sample findings suggest that there was a change when comparing data reported at toolkit given versus data reported at toolkit returned. Overall, a more thorough FHH collection is observed (see Table 1).

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Table 1. Sample of change in documentation

Measures from Staff Mid-Point Evaluation CCHC’s local evaluation strategies included pre/post surveys (before and after initial training) (Appendix E), satisfaction surveys (post training) (Appendix F), and surveying providers, support staff, and administrators relevant to the project midway through the project (Appendix G). Surveys collected the following information: number of staff who attended FHH training; number of staff satisfied with the FHH training; confidence and skills in collecting FHH; knowledge of FHH; and perceived usefulness and value of FHH. CCHC developed and conducted a five-point Likert scale survey to collect data from support staff. The survey included questions from the pre-/post-training survey at the beginning of the project provided by HRSA’s National Evaluators. The five-point Likert scale included the following options: 1=Strongly Agree; 2=Agree; 3=Not Sure; 4=Disagree; 5=Strongly Disagree. Ten questions were asked to participating respondents utilizing the Likert scale coupled with two open-ended questions to gain qualitative feedback. The mid-point evaluation survey included the following questions:

1. I learned important information from the Family Health History training held in August 2011. (Leave this question blank if you were not trained);

2. I feel confident to list at least three benefits of collecting family health history in a clinical setting;

3. I feel confident to initiate discussions about family health history with patients; 4. I feel confident in collecting family health history information from patients; 5. Family health history is very useful in preventing, detecting, and managing disease; 6. Family Health History is very useful in building a relationship with patients; 7. Overall, the Does It Run In the Family? Toolkit made our conversations with patients in the clinic

better; 8. The Does It Run In the Family? Toolkit enhanced our current family health history collection

procedures; 9. The Does It Run In the Family? Toolkit has encouraged patients to talk to their own families

about family health history; 10. The Does It Run In the Family? Toolkit changed the amount of family health history information

patients bring to their visit; 11. What did you like most of the FHH toolkit project? 12. What did you like least of the FHH toolkit project?

Sample Findings

Patient ID Number Date Toolkit Given Family History Date Toolkit Returned Family History

1/13/12 No family medical hx reported.

3/29/12 Asthma: sister and children; Diabetes: mother and aunts on mom's side, sister

12/22/11 Cancer: breast (mom) 2009 age 42; Diabetes: paternal grandma

1/16/12 Cancer: breast (mom) 2009 age 42; Diabetes: paternal grandma; Cancer mother stage 4 lung cancer

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There were a total number of 66 respondents to the mid-point evaluation survey. Among the respondents were: Clinic Managers (3); EHR Project Manager (1); Health Education Program Manager (1); Health Educators (2); Medical Assistants (37); Medical Records staff (2); Outreach Worker (1); Patient Care Coordinators (18); and Quality Improvement Manager (1). Respondents by site included: administration (6); Highland Park clinic (9); Eagle Rock clinic (13); Glendale clinic (12); and North Hollywood clinic (26). Findings suggest that: 77% of respondents Strongly Agreed or Agreed that they learned important information from the FHH training; 14% did not attend the initial FHH training provided by Health Education Department staff held in August 2011; 95% of respondents Strongly Agreed or Agreed that they were confident in their skills when collecting FHH; 95% of respondents Strongly Agreed or Agreed that FHH is useful and valuable (for all mid-point evaluation results see Appendix A). Qualitative data of staff feedback at mid-point evaluation included comments of what staff liked most and least about the FHH Toolkit project. The common facilitators discussed were the effectiveness of the toolkit among patients, community members, and staff alike. Among similar comments, respondents reported that the toolkit was very informative and in increasing awareness and communication. The common barriers reported were staff buy-in, high staff turnover rates and low patient response to the FHH project (see Tables 2 and 3). Table 2. Staff Feedback: What did you like most about the FHH Toolkit Project?

What did you like most about the FHH Toolkit Project?

Easy. Family history patient just comes turn it in and I document

How important it is to know patient’s family history

Knowing patient’s family history is an important tool to treat patients

How to communicate better with the patients

Gives a lot of educational information

That it will help us with family health history. Some patients have no idea about it

Correct family health history info

You find out what family history you have

It provides you good information

People were not shy to tell their story

They give patients an idea on how to start a conversation with their family members

The importance of patient information

Learn about family health history and eat well

Learn more about family history

All the information and detail it has

Has a lot of health information

How it influenced our Mas on the importance of capturing family health history

The FHH toolkits gave our patients and community members the opportunity to learn how FHH can affect our health while promoting conversations with their own families.

Increased communication and awareness

I liked the fact that it allowed our patients to talk and discuss their health history with their family members

The brochure was very professional & eye-catching

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Table 3: Staff Feedback: What did you like least about the FHH Toolkit Project?

What did you like least about the FHH Toolkit Project?

Not all patients actually bring them in. I haven’t had a patient bring me one.

I haven’t seen any patient bring this back

I liked everything

If we can do twice a month for classes

Response from patients was low, staff buy-in may have been a factor

Training staff w/ our high turnover

Post-project Evaluation To measure perceived impact on clinic workflow, Health Education Department staff interviewed four key support staff. Respondents included: Patient Care Coordinator (1); Medical Assistant (1); Licensed Vocational Nurse (1); and Clinic Manager (1). Interviews took place at the Highland Park clinic. The following questions were asked:

1. How has the FHH project enhanced the patient workflow? 2. How has the FHH project interrupt the patient workflow? 3. Do you have any additional comments regarding the FHH project? 4. Do you have any recommendations for future use of the FHH toolkits in a clinic setting?

When interviewees were asked if the FHH project enhanced workflow, nearly all respondents reported that the project has made FHH collection more efficient. Respondents shared that the toolkits have impacted patients’ knowledge of FHH and patients have a better understanding of the link between FHH and current health status. As a result, patients are more open to sharing their FHH with their provider and Medial Assistant. They stated that patients are providing more accurate and thorough information, which makes it easier to input and/or update the patient’s health record. When interviewees were asked if the FHH project interrupted workflow, nearly all respondents stated that interruptions were most noticeable during the initial medical visit when toolkits were given. They report not having enough time during the medical visit to speak with the patient regarding the project and still complete all other tasks necessary before the patient could see the Provider. Back office support staff conveyed that the 15 or 30 minute medical visit coupled with the FHH project could have been more efficient if there was a designated key staff explaining the project and importance of FHH to patient before they were seen by the Medical Assistant. All interviewees reported that in-service staff trainings in general are beneficial and are not perceived by staff as an interruption. Respondents reported that staff buy-in was mostly gained through the initial FHH in-service training and additional meetings. As a result, Medical Assistants have learned the value of FHH collection, as well as additional interview techniques to collect the most accurate information from the patient while building rapport. Staff did report that the initial FHH in-service training should have been delayed to just before project implementation. They suggested that a refresher “re-training” prior to project implementation or postponing the in-service staff training to a later date closest to project implementation date would have been favorable. Respondents reported that high employee turnover rates were a great interruption to patient flow. The Highland Park Clinic Manager suggested that FHH project overview should be reviewed after newly hired back office staff demonstrates efficiency in all other clinical tasks that are more of a priority.

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Additional comments and future recommendations by respondents included the following: debrief FHH project instructions when toolkit is given to the patient separate from the medical visit by assigning a designated key staff to do this as patient orientation; eliminate the paper version of the health history form patients fill out in the waiting room and only ask patients face-to-face in the exam room; provide an area within the toolkit for patients to notate their FHH and bring it to their next medical visit; and to simplify the toolkits in length. CCHC also intends to measure the number of staff who used the toolkit with their own family but staff were instructed that they had until August 15, 2012 to participate. Using current data for staff returning toolkits to update their FHH would be inaccurate. IV. Sustainability CCHC will continue to distribute the toolkits beyond the grant period, until inventory of gift cards and toolkits are obsolete. CCHC will continue to sustain promotion of FHH during all medical visits, health education classes, and community outreach events, as well as with clinic staff. In order to continue use of the Does It Run In the Family? Toolkit and/or incentives, it is necessary to find other funding sources. V. Lessons Learned Training CCHC learned that in order to make this project successful, continuous, on-going staff trainings should be readily available for staff. CCHC did not ascertain a way to incorporate this successfully without overwhelming the staff or disrupting patient care. It is important to note that this does not only apply to this project. CCHC has struggled with incorporating other new projects that require initial and ongoing training as well. Workflow In a very busy clinical setting, designated key staff should be assigned to debrief the FHH project in a one-on-one session with the patient. CCHC found that Medical Assistants do not have enough time to go over the importance of a thorough FHH collection with the patient while still providing quality education/counseling. An education/counseling session on FHH should be separate from the actual medical visit. Language/Literacy Barriers During Health Education classes and outreach events the large Armenian population CCHC serves proved to be less responsive and to the FHH project due to the language barrier. CCHC opted not to translate the toolkits into Armenian because most of the patient population identifies and Hispanic/Latino, especially at the Highland Park clinic. Still, the large Armenian population reached during classes and outreach activities was challenging. This could have been done differently by our agency, only printing a small number of Armenian language toolkits for distribution during the FHH project, but this would have impacted time and funding negatively. Patient Incentives CCHC’s initial and continuous plan to incentivize participants returning with their toolkits proved to be successful. Patients were more willing to elicit FHH from their families and return to the clinic with a thorough FHH compared to data prior to project implementation. During the project, CCHC learned that there are laws regarding monetary incentives in California where patients can only receive up to $50

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annually. Since CCHC utilizes the gift card incentives with other programs, patients who had participated in those programs and had already received gift cards totaling $50 could not be incentivized for participation of the FHH project because they had reached their limit. CCHC, or other health centers with similar barriers, could consider incentives other than gift cards since this only applies to monetary gifts. Marketing Materials CCHC utilized materials marketing the FHH project including fliers and posters. Patients were more eager to learn and share their FHH and participate in health education classes and the FHH project. CCHC received great support and feedback regarding the FHH project from Genetic Alliance and the other health centers involved in the FHH project. VI. Recommendations Toolkit Although content and common language currently utilized within the toolkits is appropriate, booklets should be more simplified and shorter in length. Toolkits should include a customizable note section for patients to write in their family health history and be able to take this with them to their next medical visit or next provider office. Toolkit Integration For the integration of the Does It Run In the Family? Toolkit in federally-funded health centers, CCHC foresees that organizational facilitators will include: standardized questions collecting FHH; incentives for completing the toolkit; print materials readily available to providers for patient education and/or a resource list of outside referrals specializing in genetics; health education classes to include FHH in class curricula; and marketing and/or outreach materials, such as, posters and fliers. Organizational barriers to integrating the toolkit may include: insufficient time for FHH education during the patient’s medical visit; increase staff turnover rates; and changes due to EMR implementation and data entry errors leading to inaccurate data. Collection and Use of FHH For thorough collection and use of FHH information in federally-funded health centers, CCHC foresees that facilitators will include: staff/provider buy-in; promotion of FHH collection; team approach to FHH collection and use within the agency; having a champion or key staff to introduce the FHH toolkit to patients; providers to take the time to interpret FHH data and follow-up with care; and patient and/or family understanding of being a proactive patient in their role of collecting their own FHH. Staff Training Provider and support staff training was a major barrier. Establishing provider/staff buy-in is critical and minimizing staff turnover and or establishing a plan for on-going training is crucial. Patients A lack of understanding and knowledge of the linkage between FHH and their own health is needed for successful collection and use of FHH. Appointment no-show rates, non-compliancy, reluctance to collecting and/or discussing FHH, and lack of health insurance or financial coverage need to be addressed.

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APPENDIX A: FHH Consent Form

Consent Form for Participants

Comprehensive Community Health Centers, Inc. (CCHC) would like to invite you to participate in a

project we are conducting with Genetic Alliance, a non-profit health advocacy organization. We want to

know more about how family health history can affect our own personal health. The goal of this project

is to help CCHC patients understand how having knowledge of family health history may be able to help

prevent illness and disease, and hopefully encourage patients make healthy choices. We will distribute

the Does it Run in the Family? Toolkit to CCHC patients and community members interested in

participating.

How You Can Help

CCHC would like to add a brief story of your family health history along with your best picture! The story

we collect from you may include the disease that runs in your family and who has it. It may also include

how it was diagnosed, how the disease affects your family and the changes you made in your daily life to

stay healthy. Your information will be published in CCHC’s Does it Run in the Family? Toolkit that will be

distributed to our patients and the communities we serve. Please read the sample story and how it will

be featured.

Your first name and picture will be printed with your story. You can tell us if you do not want your name

or picture printed with your story. We will not print your name or picture if you do not want us to.

Participation in this project is completely voluntary. Compensation will include a $10 Grocery Gift Card

upon completion of your participation.

Please Complete the Following Section:

I voluntarily grant Comprehensive Community Health Centers, Inc. permission to publish my family

health history story and picture (if I choose to) in CCHC’s Does it Run in the Family? Toolkit. I understand

that I am doing this voluntarily and will receive a $10 Grocery Gift Card upon completion.

Signature: ____________________________ Date: ____________________________

Print Name: __________________________

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Sample Story

Please review and read the sample story below to help write your own story:

Mary’s Story

I've been overweight for as long as I can remember. I never thought it was a big problem because

everyone else in my family is overweight, too. At the end of one of my regular checkups my doctor told

me about the risk for disease I would carry if I continued to be overweight as I got older. I found out that

being overweight increased the risk of high blood pressure and cholesterol as well as my risk for

coronary artery disease. My doctor also told me that I could lower these risks if I changed my lifestyle.

It is not easy, but I started eating healthier foods, and I go for a short walk every day. I've lost some

weight and hope to get down to the recommended weight for my height. My blood pressure is lower

now, and so is my cholesterol. I'm setting an example for the rest of my family, and many of them are

now working on losing weight as well.

Sample of how your story and picture will be featured in CCHC’s Family Health History Toolkit.

Please call, mail or email your brief family health history story and best picture to:

Comprehensive Community Health Centers, Inc.

Attn: Brigitte Lamberson

801 S. Chevy Chase Drive Suite 20

Glendale, CA 91205

Direct Line: (818) 265-2269

Email: brigittel@cchccenters.org

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Formulario de Consentimiento para Participantes

Comprehensive Community Health Centers, Inc. (CCHC) quisiera invitarlo a participar en un proyecto

que estamos conduciendo con la Alianza Genética, una organización sin fines de lucro de defensa de

salud. Queremos saber más sobre como el historial de salud familiar puede afectar nuestra salud

personal. La meta de este proyecto es para ayudar a pacientes de CCHC a entender mejor como

teniendo el conocimiento del historial de salud familiar puede prevenir enfermedades, y cómo tal vez

animar a pacientes hacer decisiones saludables. La herramienta ¿Nos Vendrá de Familia? se distribuirá a

los pacientes de CCHC y también a miembros de la comunidad interesada en participar.

Como Usted Puede Ayudar

¡CCHC quisiera agregar un breve relato de su historial de salud familiar junto con su mejor foto! La

historia que vamos a colectar de usted puede incluir la enfermedad que corre en su familia y quien la

tiene. También puede incluir como fue diagnosticado, como la enfermedad afecta a su familia y los

cambios que usted ha hecho en su vida diaria para estar saludable. Su información será publicada en la

herramienta ¿Nos Vendrá de Familia? y será distribuida a nuestros pacientes y todas las comunidades

que servimos. Por favor lea la muestra de un relato breve y como se presentara.

Su primer nombre y foto será imprimido con su historia. Usted nos puede decir si no quiere que su

nombre o foto sea imprimido con su historia. Nosotros no vamos a imprimir su nombre o foto si usted

no quiere que lo hagamos. Su participación en este proyecto es completamente voluntaria.

Compensación incluirá una tarjeta de regalo al súper mercado de $10 al finalizar su participación.

Por Favor Complete la Siguiente Sección:

Yo voluntariamente concedo permiso a Comprehensive Community Health Centers, Inc. que publique mi

relato de mi historial de salud familiar y foto (si deseo) en la herramienta de CCHC ¿Nos Vendrá de

Familia? Yo entiendo que estoy haciendo esto voluntariamente y recibiré una tarjeta de regalo al súper

mercado de $10 al finalizar mi participación.

Firma: ____________________________ Fecha: ____________________________

Nombre: ___________________________

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Muestra de un Relato

Historia de Mary

Yo he sido una persona con sobrepeso por largo tiempo de lo que me acuerdo. Nunca pensé que fuera

un problema grave porque todos en mi familia son personas con sobrepeso también. Al final de uno de

mis chequeos regulares, mi doctor me dijo sobre el riesgo de enfermedades que puedo tener si continuo

ser persona con sobrepeso a medida que avance de edad. Descubrí que siendo persona con sobrepeso

aumenta el riesgo de alta presión de la sangre y colesterol igual que mi riesgo para enfermedad de la

arteria coronaria. Mi doctor también me dijo que puedo reducir estos riesgos si cambio mi estilo de vida.

No es fácil, pero comencé a comer comidas más saludables, y hago caminatas cortas todos los días. He

bajado de peso y espero bajar al peso recomendado para mi altura. Mi presión de la sangre está bajo

ahora, y también mi colesterol. Estoy entablando un ejemplo para el resto de mi familia, y muchos de

ellos están ahora trabajando para bajar de peso también.

Muestra de cómo su relato y foto se presentara en la herramienta de CCHC Historial de Salud Familiar.

Por favor envié su relato de su historial de salud familiar y foto por correo postal o correo electrónico o llame al:

Comprehensive Community Health Centers, Inc.

Atn: Brigitte Lamberson

801 S. Chevy Chase Drive Suite 20

Glendale, CA 91205

Línea directa: (818) 265-2265

Correo Electrónico: brigittel@cchccenters.org

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APPENDIX B: Manual Incentive Log

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APPENDIX C: FHH Project Poster/Flyer

Notes: Poster is 11” x 14”

Flyer is 5 1/2” x 7”

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APPENDIX D: Health Education Class Sign-In Sheet

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APPENDIX E: Pre/Post Survey

Staff Name: __________________________________ Clinic: ___________________________ Date: ___/___/_____

1. The Family Health History toolkit was designed to_____.a. Be a whole new program b. Be included in CCHC’s current FHH

collection procedure

c. Additional to the clinical workflow d. None of the above

2. Family Health History will ______.

a. Identify trends and patterns of disease that can lead to treatment and prevention

b. Promote conversations about health in the family and community

c. Increase knowledge of health and genetics d. All of the above

3. The goal of communication is to promote_____ with the patient.

a. Silence b. Dishonesty

c. Effective interaction d. Non-verbal cues

4. Non-verbal communication _____.

a. Does not involve the use of words b. Involves spoken words

c. Involves written words d. Both b and c

5. Active listening is_____.

a. Judging b. Using open-ended questions

c. Condemning d. Criticizing

6. Asking a series of questions, one at a time is an example of what interviewing technique?

a. Guided Questions b. Active Listening

c. Transitions d. Cultural Awareness

7. What is appropriate body language?

a. Establish eye contact b. Minimize the distance between you and

the patient

c. Limit note-taking as much as possible d. All of the above

8. Using the verbal statement: “What else is bothering you?” is an example of which interviewing technique _____.

a. Summarization b. Transitions

c. Guided Questions d. Active Listening

9. Transitions tell the patient that _____.

a. The interview has ended b. You are organizing your thoughts

c. You are changing directions during the interview

d. Validating their emotional experience

10. When dealing with sensitive topics _____. a. Be non-judgmental b. Don’t make assumptions c. Be open-minded d. All of the above

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APPENDIX F: In-service Training Satisfaction Survey

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APPENDIX G: Mid-point Evaluation Survey

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APPENDIX H: Midpoint Evaluation Survey Results

Question 1: I learned important information from the Family Health History training held in August 2011. (Leave this question blank if you were not trained).

Question 2: I feel confident to list at least three benefits of collecting family health history in a clinical setting.

Notes: 77% Strongly Agreed or Agreed 14% did not attend the training

Notes: 92% Strongly Agreed or Agreed

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Question 3: I feel confident to initiate discussions about family health history with patients.

Question 4: I feel confident in collecting family health history information from patients.

Notes: 94% Strongly Agreed or

Agreed

Notes: 95% Strongly Agreed or

Agreed

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Question 5: Family health history is very useful in preventing, detecting, and managing disease.

Question 6: Family health history is very useful in building a relationship with patients.

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Question 7: Overall, the Does It Run In the Family? Toolkit made our conversations with patients in the clinic better

Question 8: The Does It Run In the Family? Toolkit enhanced our current family health history collection procedures

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Question 9: The Does It Run In the Family? Toolkit has encouraged patients to talk to their own families about family health history

Question 10: The Does It Run In the Family? Toolkit changed the amount of family health history information patients bring to their visit