A “first of its kind” program developed by Bar-Ilan University that sends medical students to monitor discharged patients at home shows a “significant improvement” in well-being and possibly a reduced risk of repeat hospitalization, according to a study that evaluated the impact of the program.
The new research on the ETGAR project, which was developed by Bar-Ilan’s Azrieli Faculty of Medicine and has been running since 2015, shows that the program benefits patients and trains future doctors on how to work successfully with the most disadvantaged sectors of society.
Too often, patients experience problems following a hospital stay, especially when they are poor, isolated, understand little Hebrew, or lack education.
“One of the big challenges facing the healthcare world is that of health inequalities — people from different backgrounds have different rates of disease and different severity of disease and it is largely due to social-cultural factors,” said Prof. Mary Rudolf, who developed the program, in a phone interview.
It is often “not the genetics” that is behind illness, she said. “It is the social and cultural backgrounds which determine whether they get sick and what the course of the disease is.”
In conditions like diabetes and heart disease, for example, poverty is “particularly” a factor, she said. So the healthcare world is trying to figure how how to work across different cultures to reduce the existing inequalities. Medical research — especially that of Sir Michael Marmot, a professor of Epidemiology and Public Health at the University College in London, who has been studying health inequalities for over 35 years in the UK and internationally — points to the fact that healthcare workers must have the skills to give people from different backgrounds appropriate care for their needs.
In healthcare, “not one size fits all,” said Rudolf. Instead, care needs to be personalized.
So, ETGAR aims to train medical students to “work across the different communities and give quality healthcare to people from all backgrounds, across different cultures and open their eyes to how important people’s social backgrounds are to how they cope with the disease,” she said.
“When you have only learned about medical patients in a hospital, lying between clean sheets and a bed, you have a very different understanding of who the person is and what their lives are like,” she added.
ETGAR is designed to help patients make a smooth transition following their discharge from the hospital. It trains medical students to do follow-up visits at home when hospital staff see there is a need, in order to make sure the patients are taking their medications and following medical instructions. They also see how the patients are coping in general, and determine whether they need to be put in touch with social services.
Rudolf, a soft-spoken immigrant from the United Kingdom, is the head of the Department of Public Health at the Azrieli Faculty of Medicine at Bar-Ilan University in Safed, in the north of Israel. The university invited her to be a founding member of the medical school, and she agreed, immigrating from Leeds in 2011. She is also behind the HENRY program that is seeking to buck the rising trend of child obesity globally.
A year after the introduction of the program, developed by Rudolf, Dr. Sivan Spitzer-Shohat and Doron Sagi, all of the Department of Population Health, it became a required component of the medical curriculum.
Five hospitals in the Galilee – one apiece in Safed, Nahariya and Poria, and two in Nazareth – are involved in the program. ETGAR, the Hebrew word for challenge, is also a Hebrew acronym for Health Literacy, Support and a Bridge between Medicine and Community. Students bring patients a simplified personalized discharge letter translated into Arabic, Russian or English, if necessary. They read the letter together with the patient and check medications.
The study, which involved over 1,000 patients and 300 medical students who participated in ETGAR, found that patients’ understanding of their medical condition and their medications improved, with patients reporting that the students make a big difference to their transition home.
“The patients themselves very much appreciate the service,” said Rudolf. “They talk about how the students are extremely attentive and listen very well to them. They feel that it should be a service that is offered very widely.”
The program has also impacted the students, the study showed. “The students’ skills in communication with patients increases; both the written communication and their oral communication and they are much more sensitive to the social factors that influence health. They are more confident, more aware of the different cultural backgrounds,” Rudolf said.
The husband of one of the patients who participated in the study said that the follow-up was helpful, with his wife feeling that someone was “caring and thinking about her, helping her with the pain, supporting her, helping to better understand her medical condition, explaining the discharge letter.”
Students also benefit, the study showed. An in-depth analysis of their discharge letters and home visit reports showed that their sensitivity to social influences on health and their ability to communicate in plain language improved.
As one student said in a follow-up interview: “The project opened me up to a new world of medical care beyond medical treatment alone.”
The student said that often patients “lost their will to invest in themselves,” but showed more interest following the visits. “Perhaps I succeeded in giving them another small nudge of motivation,” the student wrote.
The head of internal medicine in one hospital echoed these views, the study said. “Most patients do not understand the discharge letter; a home visit makes sure that the patient understands and there is also increased cooperation with the family doctor,” the head of internal medicine said in the study. “The interpersonal connection allows students to engage emotionally, and makes the patient feel that someone cares for them — reduces fear, explains medication, and even helps reduce re-admissions.”
The researchers are still looking into whether ETGAR helps patients avoid relapses and swift returns to the hospital. Preliminary work on the numbers look “hopeful,” Rudolph said, “but we don’t have the figures on that yet.”
All medical students at Bar-Ilan are today required to participate in ETGAR during their clinical years and can receive scholarships, funded by Israel’s Council for Higher Education, to visit additional patients.
The ETGAR program is different from other programs in medical schools around the world, Rudolf said. “Medical schools around the world realize that this issue of how social factors affect health is terribly important, so they try and teach it to students. But, on the whole, they do it theoretically in the classroom as a sort of one-off exercise.”
“Where ETGAR is special,” she said, is that the students actually visit patients’ homes, and go there specifically to make sure that after their hospital release the patients understand their conditions and are taking their medications as they should. “The students are given a real responsibility,” she said, increasing their experience and exposure.
It is still “early days” to know if ETGAR will expand to other medical centers, said Rudolf. The researchers have presented their findings at a few conferences and are hoping to present them at a major medical education conference in Israel in February.
“There is a lot of interest from other medical schools, but it is big deal to introduce a new course in the medical curriculum,” she said. The publication of the results of the ETGAR study — the researchers are about to submit two papers for publication – will hopefully show the public how beneficial the program is and get other medical centers on the bandwagon too, she said,