Upstream’s Approach to Patient-Centered Counseling

Core to our mission at Upstream is true patient choice. We believe that helping patients identify and achieve their goals related to pregnancy planning and prevention should be considered standard primary care. We also believe that if patients choose a method of contraception, they should be able to receive it that same day.

At many health centers there are barriers that prevent patients from accessing the full range of contraceptive options in a single visit, leading to inequities in access across the US. These barriers can stem from structural factors like a method being too expensive or not in stock, gaps in provider knowledge, or training gaps. They can also be created by provider bias based on race, age, ethnicity, gender identity, sexual orientation, ability, and socioeconomic status. Our interventions are designed to eliminate these structural and provider-level barriers and as a result, helps to ensure that the reproductive autonomy of all patients is enhanced and valued.

During Upstream’s training and ongoing technical assistance, staff and providers learn how to provide medically accurate, patient-centered contraceptive counseling and care that is free from coercion. But what does that mean in practice?

  • It means training that includes all methods of contraception, and working to ensure that any patient who enters a health center has access to their desired method on the day they want it – for some patients, this means same-day, for others it means easily scheduling a return visit. This also includes training and guidance on removing methods whenever a patient requests a removal.
  • It means we train staff and providers to offer contraceptive counseling and care that is centered around the patient’s needs and goals, designed to reduce bias and avoid coercion. We regularly update our curriculum to reflect best practices in patient-centered care, including content related to the historical context that impacts our work and how bias impacts the patient experience.
  • It means starting with pregnancy intention. Like an increasing number of healthcare providers, we believe that asking patients of reproductive age whether they want to get pregnant in the next year is a way to assess in most cases whether they may want contraception. It also centers the conversation around the patient’s needs and desires – whether that be to plan or to prevent a pregnancy.
  • It means training staff and providers to ask patients what they are looking for in a birth control method. Upstream utilizes shared decision-making, a collaborative process that allows patients and their providers to discuss healthcare decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences. This process provides patients with the support they need to make the best individualized care decisions. Some patients are seeking contraception for benefits in addition to, or other than, pregnancy prevention. They may be looking for a method that will give them more regular periods or no periods, a specific non-contraceptive benefit, or a method that can be hidden from a partner. Therefore asking the patient what they want from a method helps to tailor the counseling appropriately.
  • It means using effective patient education materials before and during the appointment, which can present a range of methods at a glance, providing information such as duration of protection and relative and absolute effectiveness. This also enables patients to dig deeper on methods or topics that interest them.
  • It means following up after training to reinforce the counseling approach. Our Quality Improvement Advisors provide on-site support for continuous improvement to healthcare providers and staff throughout the course of our typical engagement, and our Implementation Coaches work elbow-to-elbow with staff as they implement quality contraceptive care practices.
  • It means measurable accountability. Upstream conducts patient surveys at Upstream-trained health centers to measure adherence to a patient-centered approach. Patient survey results to date indicate that over 99% of patients either made their own decisions about contraceptive methods or shared decision-making with their provider. Over 98% of patients responded that they felt listened to by their provider and did not feel pressured to choose any specific method of birth control.

Finally, we train providers and staff to understand that some patients don’t want or need contraception. The choice is always the patient’s, and it must be respected. There is an ugly, and recent history of forced sterilization and reproductive coercion in this country, targeted towards people of color and low income individuals; a chapter we abhor. Upstream’s work gives all patients access to quality education and choice around contraception when they visit their healthcare provider.

Siobhan Shand serves as Partner and Vice President of Programs for Upstream. She is committed to ensuring that all patients have access to best-in-class contraceptive care.

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