Victor Montoi - Minimally Disruptive Medicine: A Respectful Approach to Chronic Care Delivery

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Utah's Annual Health Services Research Conference

Victor Montori's Slides from the 11th Annual Health Services Research Conference - Bringing Utah's Patient Voices to Research

Minimally Disruptive Medicine
a respectful approach to chronic care delivery
Victor M. Montori, MD, MSc
Professor of Medicine
KER UNIT
Center for Clinical and Translational Sciences
Mayo Clinic
montori.victor@mayo.edu @vmontori

Multiple chronic conditions
On dialysis
Lives with son and his family
Does not speak English
Bland diet
Contact by phone

What is best for me?
What is best for my family?
Is our care the answer?

Disclosure Statement
I do not have financial
relationships to disclose.

Violence
Pollution
Chronic
stress
Multi
morbidity
Loneliness
Obesity
Poverty
Alienation
Age, sex, genes

Comorbidities are common
Dumbreck et al. BMJ 2015;350:h949

Richardson and Doster J Clin Epidemiol 2014
Do the other conditions and their management impact…
Baseline risk
Vulnerability
Responsiveness
Antidepressant
+
antihyperglycemic
Diabetes
+
HTN
+
Hyperlipidemia
Neuropathy
+
Antihypertensive
+
Anticonvulsant

Drug-disease
interactions rare, but for
chronic kidney disease.
Drug-drug interactions
are common, and ~20%
serious
Dumbreck et al. BMJ 2015;350:h949
Expected interactions
between guidelines

Observational
RCT RC
RCTRCT
RCT
RCT
Observational

Increasingly complex regimens
Limited to no prioritization
Poor care coordination
Evidence-based guidelines
Care pathways
Quality measures
Specialist care
are
disease focused and context blind
Overwhelmed patients and families

The work of being a patient
Sense-making work Organizing work and enrolling others
Doing the work Reflection, monitoring, appraisal
Gallacher et al. Annals Fam Med 2012

New work
Prepare for the consultation
Watch educational video
Bring questions; be ready for new ones
Record and review the visit
Review the medical record
Communicate via portal and transmit data
Self-measure, self-monitor, self-manage
Manage appointments, prescriptions, bills
Keep family and important others informed
Take care of significant other
Advocate for self and others

Prevalence of Treament Burden
Clinicians ask for too much,
the work is too hard, and it
gets delayed or not get done.
More common in low SES and
sicker patients who were more
likely to delegate.
Wolff JL, Byd CM. JGIM 2015 30: 1497-504
Nationally representative survey of 2040 >65 Americans

Capacity
WorkloadPurpose
Resilience
Literacy
Bandwidth
Health
Financial
Social
Environmental

Workload-capacity imbalance?
Workload Capacity
Life
Treatment burden
Sick
Personal
Socio-economical
Functional

Mullan et al Arch Intern Med 2009
KER UNIT | Mayo Clinic Video / Web
What aspect of your next diabetes
medicine would you like to discuss first?

Summary of Mayo experience
Age: 40-92 (avg 65)
Primary care, ED, hospital, specialty care
74-90% clinicians want to use tools again
Adds ~3 minutes to consultation
58% fidelity without training
Effects on SDM are similar in vulnerable populations
Variable effect on clinical outcomes, cost
Wyatt et al. Implement Sci 2014; 9: 26
Coylewright et al CCQO 2014, 7: 360-7

Workload-capacity imbalance?
Capacity
Treatment burden
Prioritize (SDM)
De-prescribe
Coaching
Self management training
Palliative care
Mental health
Physical and occupational therapy
Financial and resource security services
Community and governmental resources

25 yrs and 42 RCTs
30-day readmission
Interventions supporting capacity
30% more effective
Leppin A et al. JAMA Intern Med 2014
Shippee N et al JCE 2012

Accountability
Imbalance of
workload : capacity
Burden of illness
Burden of treatment
Adapted from NQF: MCC Measurement Framework 2012
Satisfaction with and
ease of access,
continuity, transitions
Physical and mental health
Role function
Disease control

minimallydisruptivemedicine.org
montori.victor@mayo.edu
@vmontori
Minimally Disruptive Medicine
Symposium
Sept. 27-29, 2016
Mayo Clinic
Rochester, Minnesota

Although mental health and substance abuse (behavioral health) services have historically been segregated from traditional medical care, its impact on patients’ well-being, physical health and cost-of-care has become increasingly critical to improving clinical quality outcomes while significantly decreasing financial costs by tens of billions of dollars. Drs. Daviss and Coleman will discuss the advances in policy and practice regarding the integration of behavioral health with physical health, as well as some of the gaps in identifying, aggregating, and analyzing data critical to a more holistic and comprehensive view of the individual. In addition, the speakers will: * Identify the clinical, legal, social, and financial impacts of behavioral health disorders on chronic medical conditions. * Describe the challenges involved in improving clinical and financial outcomes in patients with chronic medical conditions who also have behavioral health symptoms and/or conditions. * Demonstrate the rewards for implementing new information technology applications and analysis for better clinical and financial outcomes for these specific populations. Moderator * Mark E. Lutes, Member of the Firm and Chair of Epstein Becker Green's Board of Directors Speakers * Charles A. Coleman, PhD, Senior Sponsor of IBM's Population Health Insights and Programs Management of IBM's Healthcare Solutions Board * Steven R. Daviss, MD, DFAPA, Chief Medical Officer at M3 Information, LLC, a DC-based mobile mental health information technology company that developed the peer-reviewed multi-dimensional, patient-centered mental health screening tool, M3Clinician Epstein Becker Green Webinar - Moderated by Mark E. Lutes - http://www.ebglaw.com/events/the-challenges-and-rewards-of-integrating-behavioral-health-into-primary-care-%E2%80%93-thought-leaders-in-population-health-webinar-series/ These materials have been provided for informational purposes only and are not intended and should not be construed to constitute legal advice. The content of these materials is copyrighted to Epstein Becker & Green, P.C. ATTORNEY ADVERTISING.

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