Are Accountable Care Organizations Engaging Patients and Their Families? Results from a National Survey and Site Visits

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1 Are Accountable Care Organizations Engaging Patients and Their Families? Results from a National Survey and Site Visits Stephen M. Shortell, PhD, MBA, MPH Blue Cross of California Distinguished Professor of Health Policy and Management Director, Center for Healthcare Organizational and Innovation Research (CHOIR), School of Public Health Professor, Organizational Behavior, Haas School of Business, UC Berkeley Fifth National Accountable Care Congress Hyatt Regency Century Plaza Los Angeles, CA November 11, 2014

2 Research Team UC Berkeley Salma Bibi, MPH Linda Neuhauser, PhD Patricia Ramsay, MPH Neil Sehgal, MPH

3 External Advisory Committee Dominick Frosch, PhD The Betty and Gordon Moore Foundation Judith Hibbard, DrPH Oregon Health Sciences Cemter Lynn Paget, Managing Partner, Health Policy Partners Glen Elwyn, MD The Dartmouth Institute and Geisel School of Medicine Elliott Fisher, MD, MPH Director, The Dartmouth Institute and Geisel School of Medicine Stephen Samis, Canadian Health Services Research Foundation

4 Acknowledgements The Betty and Gordon Moore Foundation The Commonwealth Fund

5 Essential Requirement: New Ways to Deliver Care

6 Major Implication: Cannot be done without more active engagement with patients and their families There is growing evidence that patient/family engagement is associated with higher quality and better outcomes at the same or lower cost (Cosgrove, et al. 2103; Green and Hibbard 2012; Hibbard, et al. 2013)

7 Major Challenges Historical doctor/patient relationships Asymmetry of information and knowledge Physician autonomy Time demands Complex change process: Many people involved; a lot moving parts; a lot of training needed Variance in patients desires, wishes, etc.

8 Definitions and Dimensions PATIENT ACTIVATION involves understanding one s own role in the care process and having the knowledge, skills, and confidence to take on that role. PATIENT ENGAGEMENT is a broader concept that includes patient activation, the interventions designed to increase it, and the patient behavior that results from it. Preventing disease and promoting health Involvement in care planning and treatment shared decision making Involvement in advanced serious illness and end of life care Involvement in the overall design and operation of the health care delivery organization itself

9 Data Sources National Web based survey of ACOs (N = 101 respondents) Phone interviews with 11 ACOs key informants, both Medicare and commercial contracts. Site Visits: Group Health Cooperative of Puget Sound UCLA Medical Center and Health System

10 Results Patient and Family Direct Engagement in their Care SOURCE: National Accountable Care Organization Patient Activation and Engagement Survey

11 Results Patient and Family Engagement in Practice Improvement SOURCE: National Accountable Care Organization Patient Activation and Engagement Survey

12 Results Leader Beliefs About Patient Activation and Engagement Efforts SOURCE: National Accountable Care Organization Patient Activation and Engagement Survey

13 Results The greater the impact of patient activation and engagement in the ACO s quality, cost and overall success, the more likely they are to directly involve patients in their care

14 Commonly Reported Findings from Open Ended Questions Setting Treatment Goals: Common Themes Interdisciplinary care teams: PCP s, care managers, nurses, social workers, health coaches, etc. Staffers trained in motivational interviewing techniques, shared decision making, evidence based communication, etc. Additional measures taken for high risk and chronic disease patients: individually assigned care managers, etc. Setting Treatment Goals: Key Quotes We have Health Coaches who have been trained in motivational interviewing and self management support who work with our patients after they have seen their PCP to establish self management goals. This has been a difficult process to implement and the lack of education of the physicians has been a barrier. SOURCE: National Accountable Care Organization Patient Activation and Engagement Survey

15 Commonly Reported Findings from Open Ended Questions Training of Clinicians: Common Themes ACO provides online training services or webinars on shared decision making Training in shared decision making incorporated into new hire training with classes or training sessions held periodically thereafter Focus in trainings on use of evidence based care protocols and patient aids/resources to support SDM efforts PAE training focused on community health workers/health coaches/care coordinators but it is challenging Training of Clinicians: Key Quotes Video coaching for improved patient communication techniques, utilization of evidence based treatment programs, proactive office strategies to help close care gaps of patients, and patient education. Health coaches are formally trained in motivational interviewing, etc. Providers not yet, though we are considering the development of a curriculum for them. SOURCE: National Accountable Care Organization Patient Activation and Engagement Survey

16 Commonly Reported Findings from Open Ended Questions Challenges Involved: Common Themes Difficult to build momentum for increased PAE efforts within ACO Many ACO s just beginning to ramp up patient activation and engagement initiatives The work is challenging Challenges Involved: Key Quotes This has been a difficult process to implement, and the lack of education of the physicians has been a barrier. Patient engagement will determine whether or not an ACO will be successful. It is a struggle but worth it in the end. SOURCE: National Accountable Care Organization Patient Activation and Engagement Survey

17 Interviewees and Site Visit Respondents Speak Their Voice We had a patient who went 132 times in 12 months to the emergency department. She is in a wheelchair lives in a house with no ramp. She doesn t have much social support, doesn t have any food. A diabetic, out of control. She doesn t have a refrigerator for insulin. From one visit, we engaged our team of care management (who) built her a ramp, donated a refrigerator, and hooked her up to an equivalent of Meals on Wheels so she has food, and arranged for transportation to get her to regular visits to her primary care physician. And in the past ten months she s not been back (into the ER) one time. SOURCE: National Accountable Care Organization Patient Activation and Engagement Survey

18 Interviewees and Site Visit Respondents Speak Their Voice (cont d) We re evaluating how to engage patients, whether it s with third party software, whether it is texting. I don t think we ve cracked the code here. I think this is where we are going to spend a lot of our time. A provider could.say, I d like to have you watch a video, and we can talk about it later and decide what treatment option is right for you, or they could point them to My Group Health, our secure patient portal, and they could watch the video streaming online. Since January of 2009 we ve delivered over forty thousand decision aids. SOURCE: National Accountable Care Organization Patient Activation and Engagement Survey

19 Interviewees and Site Visit Respondents Speak Their Voice (cont d) We have the same struggles that I am sure everybody else does. And that is, are we really building patient centric care or is it just a continuation of provider centric? Our clinicians have..so much on their plates that it s really hard for them to think about the full package that s available for their patients..there s competing priorities. We have a lot of really good data; mining that data;.. and then acting on it is our biggest challenge. SOURCE: National Accountable Care Organization Patient Activation and Engagement Survey

20 Interviewees and Site Visit Respondents Speak Their Voice (cont d) We gave them [patients] an initial care pathway as we saw it, and had them fill in what we missed. Every single interview raised using catheters as a point of anxiety for the patient; and the urologist didn't realize that that was a point of anxiety. It is hard to do his kind of work because it s got to be professionally led but it s through the engagement of people in the trenches that you get the acceptance and the spread, but it takes time. It takes a lot of effort to do that. SOURCE: National Accountable Care Organization Patient Activation and Engagement Survey

21 Interviewees and Site Visit Respondents Speak Their Voice (cont d) So when we first started putting care coordinators in the offices, we got pushback from the doctors that you re taking away some of the things I used to do. But after they got familiar with it and realized that these aren t things that you really need a medical degree for and it actually means that the minutes I m in the room with the patient I can talk to the patient about their health (they were OK with it). SOURCE: National Accountable Care Organization Patient Activation and Engagement Survey

22 Limitations Likely over estimate the amount of PAE occurring to respondents more likely to be doing more than nonrespondents Cannot generalize Interviewed knowledgeable leaders. Frontline clinicians and staff may have different views. Findings reflect associations: no causal inferences

23 Emerging Developments Movement away from fee for serve to global budgets Increased patient cost sharing Accountability/transparency and advances in measurement Movement towards Accountable Communities for Health expanded opportunities for citizen participation and engagement

24 What Can Happen The Thedacare Collaborative Example Five hospital system; 26 clinics; Appleton, Wisconsin LEAN Production Developed a bedside care team composed of a physician (medical expert), nurse (care progression manager), pharmacist (medication expert), discharge planner (transitional needs coordinator), patient, and family. Developed a single care plan continuously updated in daily team huddles Set a discharge date from the beginning and work backwards to achieve it Source: Thedacare

25 Traditional vs. Collaborative Care

26 Benefits of the Collaborative Care Model Source: Thedacare

27 In Conclusion Moving from what is the matter with you? to what matters to you?

28 Thank You! QUESTIONS AND DISCUSSION