A Care Setting Experience with Shared Decision Making
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A Care Setting Experience with Shared Decision Making



Presentation given at the Foundation's Jan. 26, 2011 Research and Policy Forum by David Swieskowski, MD, MBA and Kelly Taylor, RN, MSN, CCM from Mercy Clinics in Des Moines, IA.

Presentation given at the Foundation's Jan. 26, 2011 Research and Policy Forum by David Swieskowski, MD, MBA and Kelly Taylor, RN, MSN, CCM from Mercy Clinics in Des Moines, IA.



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A Care Setting Experience with Shared Decision Making Presentation Transcript

  • 1. Foundation for Informed Medical Decision Making Research & Policy ForumJanuary 26, 2011Washington, D.C. A Care Setting Experience with Shared Decision Making
    David Swieskowski, MD, MBA
    - Chief Executive Officer, Mercy Clinics, Inc.
    Kelly Taylor, RN, MSN
    - Director of Quality, Mercy Clinics, Inc.
  • 2. Mercy Clinics, Inc.
    • 27 Clinics, 150 Physicians
    • 3. 70% Primary Care
    • 4. 877,956 patient visits in FY10
    • 5. Owned by Mercy Medical Center in Des Moines
    • 6. MMC employs 325 physicians
    • 7. MMC owned by Catholic Health Initiatives
    • 8. Virtual Private Practice Comp Plan
    • 9. Revenue - expenses
  • Why & How We Started
    • Why:
    • 10. Professionalism
    • 11. Competitive advantage
    • 12. How:
    • 13. Joined IHI impact program in 2002
    • 14. Joined Pilot Collaborative on Self-Management-Support in 2003
    • 15. Started small in pilot clinics and spread successes throughout the system
    • 16. Used the PDSA approach
    • 17. Shift from Ad Hoc projects to a comprehensive plan to redesign care based on:
    • 18. Wagner’s Care Model
    • 19. Six IOM Aims Dimensions of Quality
  • MCI Practice Redesign Goals - 2004
    A whole person orientation
    Systems to ensure patients receive proper care
    Registries to track patients
    Team based care
    Self-Management Support
    Safety ensured by processes
    Improved access
  • 20.
  • 21. Disease Registry“The single most important step to improve chronic care”
    Disease Registries Do Five Things
    Accept Data
    • Electronically and manually at point of care
    Create patient summary reports
    Create actionable lists
    • With a defined condition
    • 22. Overdue for care
    • 23. Not meeting outcome goals
    Create performance reports
    • % of the population meeting a measure
    Export data – PQRI, P4P programs
  • 24. Monthly Clinic Level Quality Report
  • 25. Delivery System RedesignThe Office Based Health Coach
    MCI has 27 full time Health Coaches
    At least one in every primary care clinic
    New job description
    Started as RN, CMA, LPN, Receptionist and was more data oriented
    New Health Coaches must be RNs and are more clinically oriented
    Group meeting for 2 hours twice a month
    Training & sharing of learning
    Formal 28 hour “Certification” Program
  • 26. Five Essential Functions Of The Office Based Health Coach
    Oversees the disease registry database
    Conducts pre-visit chart review
    Works with patients & families on self-management support
    Coordination of care across the care continuum
    Involvement in QI activities
  • 27. Pre-visit Review Audit
    Mercy West Medical Clinic
  • 28. One Day of Charges from Pre-visit Chart Review
    Urbandale FP Clinic
  • 29. Self-Management Support
    • Health Behavior Change
    • 30. Goal setting and action plans
    • 31. Medication Adherence
    • 32. Only 40% of Mercy Clinic patients are highly adherent
    • 33. Patient Education
    • 34. Provided or arranged by Health Coaches
    • 35. Shared Medical Appointments
    • 36. Shared Decision Making
  • Primary Care Practices can profitably make delivery system changes now
    Increased volume of medically necessary services leads to increased revenue
    Registry callbacks
    Pre-visit chart review
    Redistribution of doctor work increases efficiency
    Chart review, SMS
    Standardization leads to improved quality and reduce costs of producing a product or service
    Wellmark P4P opportunities
  • 37. Systems Ensure Quality:
    Hypertension Process Map
  • 38. Mercy Clinics BP run chart
  • 39. Diffusion of Hybrid Seed Corn in Two Iowa Communitiesby Bryce Ryan and Neal Gross; Rural Sociology; March 1943
    • Hybrid Corn was introduced in 1928
    • 40. Yields were 20% higher
    • 41. Knowledge of a change is different than acceptance
    • 42. Time lag of about 7 years between first knowledge and adoption
    • 43. Acceptance is influenced by
    • 44. Shared experiences of Early Adopters
    • 45. Ability to personally perform small tests change (PDSA)
  • Diffusion of Hybrid Seed Corn in Two Iowa Communities
    The Part of the diffusion curve from about 10% to 20% is the heart of the diffusion process
  • 46. Lessons on Diffusion
    • Measurement to prove the advantages is key
    • 47. Diffusion is fundamentally a social process
    • 48. Exchange of personal experiences is at the heart of diffusion
    • 49. Encourage the use of small tests of change (PDSA)
    • 50. Resistors are irrelevant to the change process
    • 51. Developing the critical mass with enough positive experiences is what counts
    • 52. Work with the willing
    • 53. Don’t waste time on the laggards
  • Health Reform Expectations
    Downward pressure on FFS payments
    CMS payment Per RVU
    1998 = $36.60 2010 = $36.06 2011 = $33.98
    Increased number of insured
    Increased demand for primary care services
    New payment incentives
    Coordination of care
    Patient satisfaction
    Decision quality
    Taking risk
    Commercial insurers will follow the CMS lead
  • 54. Mercy Medical Center ACO Plans
    • Create the legal structure
    • 55. Primarily physician employment
    • 56. Create IT systems to measure value
    • 57. Quality and Utilization
    • 58. Integrated Care system
    • 59. Guidelines across specialties and sites
    • 60. Advanced Primary Care (Medical Home)
    • 61. Wellness care – Healthy living center
    • 62. Transition Coach project
    • 63. Shared Decision Making
  • Mercy Clinics as a Primary Care Research Lab
    Transition Coach Program (starts March 1, 2011)
    Patients randomized to a transition coach program or usual care
    Outcomes: Readmit rate, ED visits, Quality Measures and Patient satisfaction
    Wellness programs
    Improved access to care for NH patients
    Shared Decision Making
  • 64. Share Decision Making - Project Aims
    • Fully inform patients about preference sensitive conditions using decision aids
    • 65. Preference sensitive conditions are those that have multiple treatment options without clear evidence that one option is superior. Therefore the decision about which option to choose is based upon the preference of the physician and / or patient
    • 66. Evaluate the Impact of decision aids on decision quality
    • 67. Using before and after questionnaires
    • 68. Evaluate patient satisfaction with the process
  • Hypothesis we are testing
    We can’t measure quality of outcomes or costs of care so as surrogates we are testing the following two hypothesis:
    Patients participating in SDM will have higher decision quality
    Patients participating in SDM will have high satisfaction with SDM process.
  • 69. Implementation of Decision Aids and Current Status
  • 70. Decision Aids We Are Distributing
    • At all 5 clinics
    • 71. Hip Osteoarthritis
    • 72. Knee Osteoarthritis
    • 73. Acute Low Back Pain
    • 74. Chronic Low Back Pain
    • 75. Spinal Stenosis
    • 76. Herniated Disc
    • 77. At FMU clinic
    • 78. Abnormal Uterine Bleeding
    • 79. Managing Menopause
    • 80. Uterine Fibroids
    • 81. In the Future
    • 82. Spread DAs FMU clinic piloted to other 4 pilots
    • 83. Diabetes
    • 84. CHF
    • 85. Advance Directives
  • Key elements to project buy-in and communication
    Governance Structures
    Executive Governance Council and Council of Medical Directors endorse this important work
    Quality committee is updated on pilot routinely
    Clinics volunteer to be part of the pilot
    Grant funding helps offset costs, but does not cover the costs 100%.
    Each clinic provides a provider champion and health coach as key team members
    Work on clinic strategies individually
    Work together with other pilot clinics on best practices and shared learnings
  • 86. How we built this into existing models
    Basic philosophy: It takes a proactive, prepared practice team to effectively provide high quality chronic care (and SDM as well!) to our patients
    Health Coaches and provider champions are initially the key members of that practice team in each of the pilot sites
  • 87. How we built this into existing models
    This is a new scope of work for coaches and providers
    closely aligns with our advanced primary care and ACO vision
    But the strategies used to test and implement are the same used to redesign the delivery of chronic care
    Senior level support and guidance from Clinic Administration
    PDSA cycles-Part of the job of the coach is to try new things
    Physician champions
    Monthly Team meetings
    Outcomes Data Review
  • 88. Identifying the Denominatorfor Knee and Hip OsteoArthritis
    Original definition:
    Age > 50
    Chronic knee or hip pain
    Over 6 months or 3 (or more) visits for this problem
    Any mention in the record or referral notes about possible joint replacement
    New definition (Sept. 2010):
    Identify the denominator by identifying all patients referred to Ortho who are over age 50 with chronic knee or hip pain
    We still distribute to both definitions
  • 89. Senior Level Support Example:
    Decision Aid
    Distribution and Follow-up Process Map 8/09
  • 90. PDSA Cycles
    Clinic Admin provides the high level process to be achieved
    Health Coaches utilize the Model for Improvement/PDSA cycles to achieve rapid process improvements
    Coaches are change agents in their individual clinics
    Have received training on the use of PDSA cycles
  • 91. Physician Champions
    Absolute key to the spread of any quality initiative throughout the clinic and the clinic system
    Key Duties:
    Guinea pig-try PDSA tests with coaches
    Cheerleader-to their peers and their nurses
    Communicator-to all internal staff, clinic system and beyond!
  • 92. Barriers to Physician Buy-in
    Perception that a significant portion of patients do not want share decision making
    Not current standard of care
    May undermine their recommendations
    Synvisc injections
    Bio-identical hormones
    Time to learn about the DA
    Time it takes to arrange a handoff
  • 93. Monthly Team Meetings
    Key concepts
    Once a month every month
    1 hour in length
    Clinic Administration sets agenda but always leaves time in the agenda for individual team planning
    Provider champs and coaches expected to attend
    Clinic managers encouraged to (and often do) attend
  • 94. Outcomes Data Review
    Standing agenda item at each team meeting
    Data helps us see where we are doing well and where opportunities for improvement exist.
    Both are equally important!
  • 95.
  • 96. Data Review Example
  • 97. Data Review Example
  • 98. How We Went From Numbers To Patient Satisfaction
    Our initial focus was on implementing a process to distribute the decision aids.
    Reviewed data distribution numbers at each team meeting.
    Once data distribution numbers were high enough, we also began to look at how satisfied our patients were with this program.
  • 99. How We Went From Numbers To Patient Satisfaction
    Our data tells us that we have an opportunity to improve our patient satisfaction scores
    Why is it important to work on this?
    It’s all about providing value
    The satisfaction scores will help senior leadership evaluate the value of implementing, spreading and sustaining this program throughout all of Mercy Clinics Inc.
  • 100. Current Strategies to Improve Satisfaction
    Collaborating within our own system as well as with the FIMDM research team, we have learned about many best practice ideas we are excited to try that are focused on:
    Physician and staff one-on-one engagement
    Patient engagement
    Warm handoffs
    Teaming with Physical Therapy
  • 101. Patient Engagement
    DAs in x-ray
    Educational displays with DAs
    DAs in the exam room
    DAs in the referral area
    Have notes on them: “Ask about this booklet if you have any questions”
  • 102. Physician and Staff Engagement
    Internal marketing to the pilot physicians and staff
    Coffee bars
    Clinic newsletter
    One-on-one Champion discussions
    Academic detailing
    CME/CEU events provided by project coordinator at each of the pilot clinics have been completed
    CME/CEU events are now planned by providers at each individual pilot clinic regarding a specific DA of their choice
    Increase in the number of DA topics
  • 103. Efforts to Increase Warm Handoffs
    Coach pre-visit chart review
    Engage receptionists and schedulers
    Dr. Engagement
    PT referral plan
    Patient Engagement
  • 104. SDM at Mercy Clinics Inc.
    Care Team Reactions
    Each of the 4 original pilot clinics were given the option to opt out of the pilot going in to the 2nd year-none of the clinics did.
    Patient Reactions
    “This hits it so on the head. I’m not the only one going through this.”
    “I wish I would have had this information when my symptoms first started. The DVD my doctor asked me to watch has been extremely helpful.”
  • 105. SDM at Mercy Clinics Inc.
    Health Coach Reactions
    I had a patient write me a note thanking me for encouraging her to watch the DVD. When people take time to write you a note like that, you know you have made a difference and it feels great.
    Patients are happy when you take the time to do this. It doesn’t take too long.
    I’ve never had anyone be anything but positive.
    Provider Reactions
    Patients come back with really good questions. They are more focused and the visits are more productive and satisfying.
    They actually save me time during my busy day of seeing patients.
  • 106. DA Issues to Resolve
    • Identification of appropriate patients
    • 107. Who benefits most from DAs
    • 108. Who should identify the patient
    • 109. What is the best time to present the DA
    • 110. Is Satisfaction higher if presented at time of referral
    • 111. What is the best way to engage the patient
    • 112. Is face-to-face better than mailing
    • 113. What follow up should be done and by who
    • 114. How do we use Health Coaches to optimize use of DAs
  • Mercy Clinic Beliefs about SDMWhy it is Important to Health Reform Planning
    • Fully informed patients
    • 115. Will choose the best plan for themselves, yielding better outcomes
    • 116. Will often choose less expensive options
    • 117. Will improve patient satisfaction
    • 118. SDM is patient centered and consistent with our values
    • 119. It can free up physician time
    • 120. Provide self-management support more effectively and at less cost
    • 121. It will have a positive ROI
  • SDM is the next emerging trend in patient-centered care.
    We want to be there first.