Innovative Implementation of Shared Medical Decision Making in a Clinic-based ACO


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Charlie Keller, a primary care physician at Mercy Clinics, Inc. describes Mercy's experience with shared decision making implementation.

This presentation was part of a Shared Decision Making Month webinar -- Shared Decision Making in the Real World: Stories from the Frontline.

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  • Thank you for allowing me the opportunity to present at this webinar. It is an honor to help kick off Shared Decision Making Month with the Foundation.
  • I am a new addition to a long-standing team here at Mercy Des Moines. In the interest of full disclosure I will say that our Shared Decision Making project is funded by the Informed Medical Decisions Foundation. I truly appreciate their support and collaboration.
  • A little bit about Mercy Clinics in the Des Moines area.
  • The reality we all face is that health care financing is uncertain and changing as we speak. I think Shared Decision Making in particular enhances our response to the areas in red. INTERESTINGLY: just 2 days ago there was new report from the National Commission on Physician Payment Reform that listed as the first recommendation as the elimination of nearly all fee-for-service payment schemes in healthcare, as well as focusing on quality and value.
  • Why did we start on this path to utilizing Shared Decision Aids?
  • First step was developing a Medical Home Model: Mercy started down this path some time ago, and as you will see this early work has paid off in implementing the SDM project. We started small using pilot projects, which then spread throughout the system based on those successes
  • What helped Mercy was to have a mission and a vision – this provided the roadmap and helped to focus the projects. Much of the success Mercy has had is thanks to the hard work over many years of the people on the second slide as well as many others in the individual clinics.
  • Health Coaches are the people who really make all this work for us. They are the linchpin of our operation. These are special people in a special role.
  • Briefly – this is the charge of each Health Coach, and as you shall see, Shared Decision Making fits nicely into these functions.
  • What do our Health Coaches hear from patients? Some quotes: Thank you for making me accountable for my health. You have no idea how much you have changed my life.  Thank you for taking time to make me understand my  diabetes and how it affects my body.  You saved my life.   You have been my coach, my mentor, my friend, and will always remain so. So, From this day forward, success with integrity,  abundance with wisdom,  honor with character,  health and  healing,  fullness of joy,  never ending peace,  long life with satisfaction,  and laughter be upon you and your household all the days of your life. 
  • Briefly, what were the aims of our project?
  • Based on those aims, we focused on Osteoarthritis of the Hip and Knee, Acute and Chronic Low Back Pain, Colon Cancer Screening, and 2 different Advanced Directives Programs.
  • Well, what do our patients think of the Shared Decision Aids? I think you can see that they think they are very valuable to helping them make the best decision for their condition.
  • Briefly, let me give you 3 examples of how this has worked in my practice. These are but 3 examples of patients who have very different goals, values, and problems who have been helped by the unbiased and patient oriented materials provided.
  • If you haven’t seen it, there was a wonderful article in Health Affairs last month on the implementation of Shared Decision Aids in Primary Care Clinics. A few key findings…
  • So, what was it that has allowed Mercy to be successful thus far? As you’ll see, the previous groundwork with our Health Coaches and the Medical Home approach helped tremendously. It provided both a top down and a bottom up approach. This gave it the support of key movers within the organization, as well as people on the front lines.
  • It is really pretty organic, and while we have a basic structure in place, the teams are allowed to explore what will be successful in their clinic and share it with others.
  • Health Coaches are acting in concert with the Physician Champions, who volunteered to work on this project.
  • What have we specifically experienced, some of which is noted in HA article.My experience has been that the handoff is key, and despite physician concerns about the time it may take, it usually only takes a few minutes to introduce the concept, discuss the Shared Decision Aid, and get the Health Coach involved to ensure appropriate documentation and follow-up.
  • We have found several keys to utilizing the Shared Decision Aids. As stated before, the warm handoff seems to be a key ingredient for success. Sometimes this involves the Health Coaches handing off tasks to the physician by identifying appropriate patients via pre-visit chart reviews. Sometimes it is the opposite with the physician handing off to the Health Coach when they identify an appropriate patient. Ideally everyone who has patient contact would be aware of the project and help identify appropriate patients.
  • Bottom line – we at Mercy have seen that we can make changes in an uncertain environment that profit our physicians and system right now.
  • We feel strongly that Shared Decision Making is the next emerging trend in patient centered care.WE WANT TO BE THERE FIRST.
  • Innovative Implementation of Shared Medical Decision Making in a Clinic-based ACO

    1. 1. INNOVATIVE IMPLEMENTATION OFSHARED MEDICAL DECISIONMAKING IN A CLINIC-BASED ACO Shared Decision Making in the Real World: Stories from the Frontline March 6, 2013 Webinar
    2. 2. Authors• Dave Swieskowski, MD, MBA – CEO, Mercy ACO, Mercy Medical Center - Des Moines, IA• Charles Keller, MD – Physician Lead, Shared Decision Making Project – Physician, Mercy West Family Practice & Urgent Care Clinic, Clive, IA• Kelly Taylor, RN, MSN, CCM – Director Care Management/Quality Improvement, Mercy ACO• Del Konopka, RN, MS – ACO Education Coordinator, Mercy ACODisclosures• Our Shared Decision Making project is funded by the Informed Medical Decisions Foundation• Physician Office-Based Health Coach Training is provided by Mercy ACO3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights 2 reserved.
    3. 3. Mercy Clinics, Inc.• 59 Clinics, 150 Physicians – 70% Primary Care• 926,000 patient visits in FY11• Owned by Mercy Medical Center - Des Moines – Employs 325 physicians – Owned by Catholic Health Initiatives• Currently operate under Virtual Private Practice – Compensation Plan: Revenue – Expenses 3 3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights reserved.
    4. 4. Health Reform Expectationsand Pressures New Payment Incentives Based On: – Utilization – Coordination of care – Quality – Patient satisfaction – Decision quality – Taking risk3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights 4 reserved.
    5. 5. Importance of SDM to Mercy’s ACO• Fully informed patients – Choose the best plan for themselves, often less $$, yielding safer, better outcomes – Experience improved satisfaction with care• Shared Decision Making is – Patient-centered, consistent with our values – Frees up physician time• Will have a positive return on investment 3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights 5 reserved.
    6. 6. Starting Our Medical Home• Why we did it – Professionalism – Competitive advantage – Right thing to do• How we started – Institute for Healthcare Improvement IMPACT program 2002 – Pilot Collaborative on Self-Management-Support 2003 – Started small in pilot clinics, spread successes throughout system • PDSA approach – Shift from ad hoc projects to comprehensive plan to redesign care • Wagner’s Care Model • IOM’s 6 Aims for Improvement 6 3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights reserved.
    7. 7. Mercy Clinic’s Practice Redesign Goals• 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 7 3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights reserved.
    8. 8. Physician Office-Based Health Coaches• Mercy has 26 Health Coaches – At least one in every primary care clinic, including pediatrics – Three at our hospital for Transitions of Care – Must be RNs, more experienced and clinically oriented, work at highest capacity of licensure – 28 hours of competency training in coaching & HC role 8 3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights reserved.
    9. 9. Five Essential Functions ofOffice-Based Health Coach1. Oversees disease registry2. Conducts pre-visit chart reviews3. Works with patients and families on self-management support4. Coordination of care across continuum5. Quality Improvement activities 9 3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights reserved.
    10. 10. Health Coaches Provide Self-Management Support• Supporting Health Behavior Change – Goal setting & action plans• Improving Medication Adherence• Providing Patient Education• Shared Medical Appointments• Shared Decision Making 10 3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights reserved.
    11. 11. Shared Decision Making –Project Aims• Fully inform patients about preference-sensitive conditions using Decision Aids – Conditions with multiple treatment options – No clear evidence one option is superior – Decision to choose option is based on preference of patient and/or physician• Evaluate impact of Decision Aids on decision quality – Surveys before and after viewing Decision Aids• Evaluate patient satisfaction with the process 3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights 11 reserved.
    12. 12. Decision Aids We Are Distributing• Focus at all 8 pilot clinics – Hip OA – Knee OA – Acute Low Back Pain – Chronic Low Back Pain – Colon Cancer Screening – 2 Advance Directives programs• 35 topics now available from Health Dialogue 3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights 12 reserved.
    13. 13. Patient Responses After Viewing DA: Overall how would you rate the program? Poor or Fair Good Very Good or Excellent DA TOPICS • Abnormal uterine bleeding Preference- n=404 • Acute low back pain Sensitive 38% 56% • Benign uterine fibroids • Herniated disc • Hip osteoarthritis • Knee osteoarthritis • Spinal Stenosis n=208 • Chronic low back Chronic 41% 55% pain • Diabetes 0% 50% 100% Unweighted data submitted to Illume data warehouse as of 1-Aug-20123/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights 13 reserved.
    14. 14. Patient Stories• D.S. – 62 year old male with low literacy level, has had many years of chronic back pain, one prior back surgery, prior epidural injections. Wanting to return to work as a truck driver. Outcome – conservative/medication management, improved function.• R.J. – 81 year old male with Spinal Stenosis, no prior interventions, rare medication use, wondering about his options for treatment now that his pain is worsening. Outcome – pending.• M.W. – 37 year old female with DM who recently lost her insurance, poorly controlled with one oral agent, wondering what her next step should be to improve diabetes control. Outcome – reviewing diet, exercise, and medication options along with meeting with the Health Coach individually.3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights 14 reserved.
    15. 15. Health Affairs February 2013 – SDM Implementation • Barriers to Implementation – Overworked physicians – Insufficient provider training – Inadequate clinical information systems (EHR, registries, etc.) • Facilitators of Implementation – Automatic triggers – Engaging nonphysicians in the processMark W. Friedberg, Kristin Van Busum, Richard Wexler, Megan Bowen, and Eric C. Schneider. A Demonstration of Shared Decision Making in Primary Care Highlights Barriersto Adoption and Potential Remedies. Health Affairs. February 2013, vol 32, #2, 268-275. DOI: 10.1377/hlthaff.2012/1084 ©2013 Mercy Medical Center, Mercy ACO. All rights 3/7/2013 reserved. 15
    16. 16. Key Elements to ProjectBuy-in & Communication• Governance Structures’ Endorsements – Executive Governance Council – Council of Clinic Directors (elected physicians from clinics)• Quality Committee involvement – Routine updates on project• Clinics volunteer to be pilot sites – Grant funding helps offset costs, still not covered 100% 3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights 16 reserved.
    17. 17. Mercy’s Basic Philosophy It takes a proactive, prepared practice team to effectively provide high quality chronic care (& Shared Decision Making!) for our patients• Initial Key Members at each clinic include a Provider Champion, the Clinic Manager, & the Health Coaches – Work on clinic strategies individually – Utilize the PDSA approach – Work together with other pilots sites on best practices & shared learning 3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights 17 reserved.
    18. 18. Success Came from Building Onto Existing Structures• New scope of work for coaches, providers – Closely aligns with advanced primary care model & ACO vision• Same strategies were used here as in the redesign of our delivery of chronic care – Senior level support – Model for Improvement Plan-Do-Study-Act (PDSA) – Physician champions – Monthly team meetings – Outcomes data review 3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights 18 reserved.
    19. 19. Physician Champions• Absolutely key to the spread of any quality initiative throughout the individual clinic & the clinic system in general• Act as – Guinea pig • Try PDSA tests with Coaches – Cheerleader • To their peers & their staff – Communicator • To all internal staff • Clinic system • And beyond! 3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights 19 reserved.
    20. 20. Barriers to Physician Buy-in• Perception that significant portion of patients do not want shared decision making• Lack of familiarity with concept• Not a current standard of care• May undermine their own treatment preferences or income – Synvisc injections – Bio-identical hormones• Time to learn about the DA• Time it takes to arrange a handoff 3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights 20 reserved.
    21. 21. Efforts to Increase WarmHandoffs • Coach pre-visit chart review • Shared Medical Appointments • Engage all available staff – Receptionists & Schedulers – Physicians – Patients – Nurses – Health Coaches – Radiology Staff3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights 21 reserved.
    22. 22. 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 reviews to find evidence based appropriate health needs• Redistribution of doctor work increases efficiency – Pre-visit chart review – Self Management Support• Standardization – Improves quality – Reduces costs of product or service 3/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights 22 reserved.
    23. 23. Shared Decision Making is the next emerging trend in patient-centered care We want to be there first. Contact information: 515-222-7000, option 13/7/2013 ©2013 Mercy Medical Center, Mercy ACO. All rights 23 reserved.