PROJECT SUMMARY Up to eighty percent of clinic visit information is forgotten by patients immediately post visit. This is a significant barrier to self-management, especially in older adults with multimorbidity leading to poor health outcomes. After visit summaries (AVS) can improve recall, yet concerns exist about their layout, accuracy and low patient uptake. A new strategy to augment the AVS is to share visit recordings with patients. When patients receive an audio recording of the visit, 71% listen and 68% share it with a caregiver, resulting in greater recall. Despite growing interest, there is limited research on the impact of recording and sharing clinic visits of patient self- management ability, health outcomes or healthcare utilization of older adults. The objective of this proposal is to conduct a multisite trial evaluating the impact of adding an audio recording of clinic visits (AUDIO) to usual care in older adults with multimorbidity, including diabetes, compared to AVS alone (Usual Care; UC). The specific aims are: Aim 1 Conduct a three-site trial in primary care where older patients with multimorbidity including diabetes (n=336) will be randomized to receive an audio recording as well as AVS (AUDIO) versus AVS alone (UC) for all scheduled clinic visits over 12 months; patients will be assessed at baseline, 1 week, 6 months and 12 months; Aim 2 Identify factors that impact the implementation and sustainable use of visit audio recordings. Applicants Hypothesize (Main Effect) that: compared to those receiving UC, patients randomized to also receive audio recordings (AUDIO) of clinic visits will report a greater self-management ability (Primary Outcome), with improved quality of life, medication adherence, and satisfaction (Secondary Outcomes) at 12 months. Applicants will explore the impact of AUDIO on general medical regimen adherence, diabetes quality of care indicators, healthcare utilization and clinician practice behavior. They will also explore potential moderators of AUDIO, asking whether its impact on self-management is greater for individuals at highest risk of poor self-management including those with less caregiver support, moderate to severe depression, lower health literacy, and high disease burden. In Aim 2, applicants will interview patients, caregivers, clinicians, and clinic staff to identify barriers and facilitators to the implementation and sustainable use of recordings using the Consolidated Framework for Implementation Research (CFIR). The research is innovative: i) it seeks to shift current clinical practice where visit information is provided via AVS, by adding recordings; ii) the routine provision of visit recordings over time moves beyond prior studies focused on one-off recordings of specialty care visits; and iii) a trial in real-world settings of patients with multimorbidity, who are often excluded from trials, is novel and has greater external validity. Results are expected to have a major positive impact as they will increase clinical understanding of the impact and implementation of audio recording on the significant challenge of improving patient self-management in the face of the public health burden of multimorbidity.

PROJECT NARRATIVE Up to 80% of clinic visit information is forgotten immediately by patients, a significant impediment to self- management for older adults with multimorbidity, that leads to poor health outcomes. The proposed research will determine the impact of the emerging strategy of audio recording and sharing of clinic visits on the ability of older adult patients to manage their healthcare. It is expected that findings from this project will inform future policy related to the use of audio-recording as part of routine care and guide implementation strategies.