A Care Setting Experience with Shared Decision Making


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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

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