M1: Flipping Healthcare: Operationalizing What Matters Most

Transcription

1 Orlando, Florida No Disclosures M1: Flipping Healthcare: Operationalizing What Matters Most IHI Summit March 20 22, 2016 Presenters Ana Tuya Fulton Director of Geriatric Medicine & Butler Chief of Medicine Care New England Health System Anthony DiGioia Medical Director University of Pittsburgh Medical Center (UPMC) Dayna Jornsay-Hester Organizational Development Consultant University of Pittsburgh Medical Center (UPMC) Kate DeBartolo National Field Manager Institute for Healthcare Improvement Kate Lally Director of Palliative care Care New England Health System Michelle Giarrusso Director of Patient and Family Centered Care University Of Pittsburgh Sarah Clayton Accountable Care Outcomes Specialist PFCC Innovation Center 1

2 Session Objectives Describe how different practices operationalize "what matters" and use the results to redesign care delivery Identify a replicable approach to integrating what matters as well as what s the matter into their clinical encounters Develop skills to engage with patients in what matters most and in advance care planning Today s Plan 4 12:00 PM 12:15 PM Introduction and Overview 12:15 PM 1:45 PM Care New England 1:45 PM 2:00 PM Break 2:00 PM 2:40 PM Care New England 2:40 PM 4:00 PM UPMC 4:00 PM 4:15 PM Break 4:15 PM 5:10 PM UPMC 5:10 PM 5:30 PM Combined Panel 2

3 Framing 5 Five considerations for operationalizing What Matters? Use your own words What works for your setting? How to Ask What Matters Geraldine Marsh, NHS GG&C and Healthcare Improvement Scotland Design Council, England Jennifer Rodgers, Yorkhill, NHS Scotland Cincinnati Children s Home Care Services What should I know about you that may not be on your medical chart? What does a good day look like to you? (end-of-life) What do you want to be doing six months from today that you re not able to do now? (procedure) Is there anything you re worried or concerned about? (discharge) What will success look like to you? (surgery) 3

4 Framing 7 Five considerations for operationalizing What Matters? Use your own words What works for your setting? Engage clinicians Power of small tests of change Framing 8 Five considerations for operationalizing What Matters? Use your own words What works for your setting? Engage clinicians Power of small tests of change Consider reliability (Always Events) 4

5 Framing 9 Five considerations for operationalizing What Matters? Use your own words What works for your setting? Engage clinicians Power of small tests of change Consider reliability (Always Events) Learn for the organization Framing 10 Five considerations for operationalizing What Matters? Use your own words What works for your setting? Engage clinicians Power of small tests of change Consider reliability (Always Events) Learn for the organization Be thoughtful about scale 5

6 11 Change Areas Asking What Matters Documenting What Matters Physician asks at primary care visit Pen and paper PA asks during vital signs Standardized form Pre-visit planning?????? Whiteboard EHR??? Sharing What Physician Form in Care team?????? Matters head record meeting Updating What N/A N/A Pre-visit?????? Matters planning Learning System N/A Team Meeting Champion Database??? Flipping Healthcare: Operationalizing What Matters Most Kate M. Lally MD, FACP Ana Tuya Fulton, MD, FACP 6

7 Goals for today 12:15-12:45- CNE model overview 12:45-1:45 Group exercise & Case 1:45-2:00 BREAK 2:00-2:40 Didactics Conversations Documentation Billing Disclosures Ana Tuya Fulton & Kate Lally are faculty on and receive funding from Rhode Island Geriatrics Workforce Enhancement Program (#U1QHP28737 from the US Health Resources and Services Administration) Kate Lally serves as a Faculty member for IHI for Conversation Ready 7

8 Acknowledgements Thanks to Dr. LaugeSokol-Hessner, Kelly McCutcheon Adams, and Kate DeBartolo Much of this material developed for the IHI Stat Call Series End of life Conversations: Preparing your Team for Success and CMS reimbursement Thanks to Dr. Joan Teno Welcome and Prework 16 8

9 Setting the stage Advance Care Planning: A Definition a structured dialogue with the ultimate goal that clinical care is shaped by a patient s preferences when the patient is unable to participate in decision making Teno& Lynn

10 Advance Care Planning Tool box Advance Directives are just one of the many tools in the box Limitations of Advance Directives Legal language Hypothetical & limited Don t evolve with the patient and their condition over time We will never have one perfect one size fits all form 10

11 Goals to strive for Series of conversations that evolve over time in an ongoing relationship with a provider Tailored, adapted communication styles to reach many patients with different needs Timing of discussions based on changes in condition or prognosis A treatment plan is the outcome clear wishes, goals of care, and contingency plans known ACP as a routine part of care with health care provider It applies to everyone John is a 26 year old man with no medical history coming in for his annual routine physical. His provider addresses advance care planning by asking In the event that you become incapacitated or unable to speak for yourself do you have someone who you d designate as your decision maker? Alda is an 89 year old widow with multiple medical issues included advanced heart and lung disease. Her doctor asks her about her wishes. She expresses a desire to not feel short of breath, and to avoid extraordinary measures of support. A care plan is completed to provide ongoing palliative care, and to prevent hospitalization. 11

12 Who are we at Care New England? Care New England by the numbers (fiscal year 2014): 8,063 employees 963 licensed beds Four hospitals Our own VNA homecare agency Dedicated hospice program and palliative programs >30% of 13,000 inpatient admissions/year are >65 Integra ACO Where we started July 2008 Butler hospital geriatric unit geriatrics co-management August 2012 Started an inpatient palliative care program Had a very small hospice One MD four days a week Hospice liaison RN June 2014 Added inpatient geriatric medicine consult service 1 community hospital, 1 MD two days per week 12

13 What our needs were Sick, complex, older patients Palliative care consults experienced explosive growth About 70% were for goals of care Have more conversations with limited resources Conversation Nurse Model: Conversation Nurse Palliative care = Team based Conversation nurse role developed & nurtured Direct ordering physician to conversation nurse communication/collaboration Education about role and team based care Now broad acceptance Growth three positions for conversation nurses (or SW) 13

14 How did we expand Expanded to inpatient palliative care consults at all four hospitals ( MDs, NPs, Conversation RN and MSW) Developed home based palliative care program Developed Palliative care outpatient clinics Boots on the ground approach to primary care offices Education Physician education Resident Simulation Palliative care and geriatrics rotation Nursing education and in-services Lunch and Learns at each operating unit Public awareness campaign Move The Conversation into the home 14

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16 Mr. L 85 yowith Prostate CA, CHF referred to VNA by PCP for urinary catheter management Seen monthly by VNA and 4-6x a year by PCP for 6 years At Age 91 admitted to ICU on ventilator with pneumonia Family discussion in ICU, He wouldn t have wanted this Put on hospice, died 2 days later What Mattered to Mr. L? 6years of monthly visits by RN. Multiple visits with PCP and various specialists Pt well known to our institutions No one ever asked what mattered? 16

17 What We Heard from Staff Feel it isn t their job to ask Not comfortable having conversations about what matters Did not know where to document Did not know what to document How to Change the Culture Document what you hear when you ask What Matters to You Examples I want to die at home I want to see my sister before I die I want my children to make amends with each other I want to continue all treatment until it is clear that I cannot communicate with my family 17

18 VNA of CNE Conversation training with nurses on Palliative care teams Case Conferencing to identify patients with serious illness Conversation nurses who can go into the home and have ongoing conversations Moving into the office Hartford grant Pts seen by inpatient PC are often transitioned to home based services No great way of communicating those wishes Sending Conversation RNs into the community for ongoing goals of care Ongoing communication with PCP Goals of improving transitions/reducing readmissions in Palliative care population 18

19 Integra ACO Multidisciplinary team providing care to high risk patients Weekly meeting with PC and Geriatrics Focus on advance care planning Focus on conversation skills training Conversation Nurse as NCM She is assigned patients most in need of a conversation Moving into the office HRSA grant Meet with primary care team in their office Patient identification process trigger the conversations Who are the high risk patients Education on advance directives/molst Education about community resources NP available to do home visits for patients with highest need (Seen as extension of PCP office) Symptom management Goals of care Goal of providing more of a team to the practices Process development to track the conversations from site to site 19

20 What have we done? Added an extra layer of support to practices Conversations can be with non-physician team members Some patients respond better to non-physician providers Continuum of conversations hospital to home primary care office Group exercise The Conversation 20

21 Am I taking away hope? Does this patient trust me? Relationship and Emotions Do I trust this person? Does she recognize how this will affect my life? Let s talk about your illness Content What are my options? Provid er Patient Mrs. Smith Well Ms. Smith is 68 year-old woman with hypertension, hyperlipidemia, and history of smoking. She was recently diagnosed with emphysema/copd. She s coming in for a routine follow-up for her hypertension with her daughter. You wonder Does she need a conversation? At this stage, what s the purpose? How do I begin? How do I document and bill for this? 21

22 Background and goals 90% of people want to talk about their end-of-life care preferences <30% have actually done so with loved ones <10% have done so with their doctor Conversation goals when there is no serious illness Build trusting and respectful relationships Learn about the patient as a person Establish a surrogate decision maker Promote patient-surrogate-family conversations National Survey by The Conversation Project 2013 Survey of Californians by the California HealthCare Foundation 2012 Triggers for the conversation: the 5 D s Death in the family Moment of reflection Divorce Previously selected surrogate may no longer be valid Decade People and preferences change with time Decline would you be surprised if this patient became seriously ill or died? Diagnosis of serious illness Difficult decisions may be ahead 22

23 Starting the conversation Key is to normalize the conversation Try starting it after family history Can you tell me about the supports in your life? Who should speak for you if you cannot speak for yourself? Have you ever thought about your end-of-life wishes? or about the kind of care you d want if you got really sick someday? The conversation (continued) If they already have an advance directive (AD) May I see it? What does it say? If they do not have an AD Can I offer you some tools to start thinking about it? Conversation Project Starter Kit State durable power of attorney form Regardless of AD It is important that your surrogate know what your wishes are A lot can happen beyond what is written in your AD The Conversation can be more powerful than the paper Would it be ok if we talk about this at your next visit? Consider delegating follow up to another member of your team 23

24 Mrs. Smith Advanced Illness Since that visit, Ms. Smith did well for a few years, and then at age 71 developed a COPD exacerbation, which turned into a pneumonia with significant shortness of breath. She was admitted to the hospital and required an ICU stay for BiPAP. There was a disagreement between her children about what her wishes were. You wonder At this stage, what s the purpose of the conversation? How can I begin the conversation, document, and bill for it? Prognosis: recognizing serious illness Who has a serious illness or condition? eprognosis.ucsf.edu Clinical criteria Surprise question It s not just risk of death Incapacity, difficult treatment decisions, anticipated emergencies Identifying risk ahead of time gives us an opportunity to mitigate it Early conversations are an important form of practice for the future Who are your seriously ill patients? Have they engaged in the advance care planning process? Population health management systems triggering the conversation 24

25 Prognosis: recognizing serious illness Has the patient had more than two unplanned hospital admissions in the last twelve months? Yes No Does this patient have Advanced long term condition Yes No New diagnosis of a serious illness Yes No Both Yes No Does the PCP believe that by controlling the symptoms and adding support, we will keep this patient out of the hospital? Yes No Does the patient have multiple chronic conditions resulting in: Functional impairment Yes No Decrease ability to self feed Yes No Inability to walk independently. Yes No Need for more personal care at home Yes No Ambulance trip in the last six months? Yes No Difficult to Control Symptoms Yes No Non-Healing Wound Yes No Recurrent Infections Yes No Three or More Falls Yes No Nine of More Unique Medications Yes No Progressive weight loss Yes No Would you be surprised if this patient were alive in one year? Yes No If the 2 out of three answers are positive for questions 1-3 and there is at least 1 positive in question 4 the patient should be referred and evaluated to the advanced illness management team. Why have another Conversation? Conversation goals when there is a serious illness Continue to build trusting, respectful relationships Continue to learn more about the patient as a person Ensure a good understanding of diagnosis, prognosis, and treatment options Anticipate emergencies and make a plan when appropriate Promote patient-surrogate-family conversations 25

26 Starting the Conversation Talk about what matters most Can you tell me your understanding of what happened in the hospital? What was that like for you? How are you doing now? If surrogate decision making was needed, how was that? Identify the values that guided decision making, i.e. what mattered most Goals, hopes Fears, worries Tradeoffs Try using an RN or MSW to get at what matters most Ensure >50 % of time dedicated to patient, family talking* * Back et al, Compassionate silence in the patient-clinician encounter: a contemplative approach, J PalliatMed 2009 Suggested Language Align around hope, ask for permission We re all hoping things go well, but as you ve experienced, that doesn t always happen. Would it be ok to talk about a plan in case things don t go the way we d like? Ask if anyone else needs to be present Are the right family members/friends here? Explain potential emergencies, reflect on experiences I am worried that you might get sick again and that they might consider putting you on the breathing machine again Align around respect If you get sick again, it s important to me that we re certain we re respecting your wishes. Your family wasn t sure what your wishes were. Give them the gift of knowing what you want. 26

27 Handling difficult situations Patient/family is reluctant to talk about the serious illness Family disagree with patient s choices 53 Handling difficult situations Patient/family is reluctant to talk about the serious illness Ask why? How much information do you like to know about your medical problems? If you only want to know the basics, who can I talk with about the details? Hope for the best, but plan for the worst Ask permission to talk with their surrogate, loved ones, or another support system (e.g. clergy) and include them in the next conversation Family disagree with patient s choices Ask why? Try to understand what they see when they look at the patient Always focus on the patient try to get the patient to express their choices in front of the family and normalize their experience Build and strengthen relationships you may need to draw on them later 27

28 Mrs. Smith Approaching EOL Ms. Smith did well for a few years after your last conversation. She had a couple admissions for less severe COPD exacerbations. She was eventually placed on home oxygen, and then about 2 months ago her illness seemed to progress. She was no longer able to walk around the block as she had been able to, and now can only go to and from the bathroom before getting so short of breath that she has to stop and rest. A hospital social worker during her most recent admission, introduced her to the How to talk with your doctor kit. She read this and decided to come in to see you again. She s now 75 years old and starts the visit by telling you how tired she is. You and she talk more, and it becomes clear that she doesn t want to have to go back to the hospital if it isn t necessary. She really prefers to stay at home. Her daughter is with her again today. Consider your goals You wonder At this stage, what s the purpose of the conversation? How can I begin the conversation? How can I introduce palliative care, and help the patient make a transition to hospice when the time is right for her? How do I document and bill for the conversation? Conversation goals when there is an advanced serious illness Rely on the trusting, respectful relationships that were built Keep the focus on the patient as a person Ensure a good understanding of diagnosis, prognosis, and treatment options before introducing hospice Continue to hope for the best, but prepare for when things don t go well 28

29 Suggested Language You have been in and out of the hospital quite a bit, how has that been? How do you feel about your quality of life? Given everything that has happened, what are you hoping for? Unfortunately, we don t have any more treatments to help your lungs get better. It seems to me what matters most to you is to stay out of the hospital, control your symptoms at home and make the most of each day, and I think hospice is the best way of doing that. Would it be ok if I had one of the hospice nurses come to your home and speak with you about what they can offer? Handling Difficult Situations I still want everything done when curative treatments would be harmful and offer no benefit I want hospice but my family doesn t agree 29

30 Handling difficult situations I still want everything done when curative treatments would be harmful and offer no benefit Return to understanding, ask 1 st, don t tell 1 st Can you help me understand what everything means to you? Work from the foundation of trust and respect that you built Return to what matters most and reflect on prior experiences Make a recommendation consider Temel et al.* I want hospice but my family doesn't agree Hold a family meeting, begin by asking everyone s understanding Then make what matters most to the patient the focus Ask a palliative care specialist or hospice agency for help *Temel et al., Early palliative care for patients with metastatic non-small cell lung cancer. N Engl J Med 2010 Documenting the conversation Who was in the room What was discussed Understanding of illness Spiritual factors Reflections on family/personal losses Why making the decision they are making. Was advance directive offered/filled out Time spent (including start and end time) Follow up 30

31 Logistics & real world implementation System factors Will the documentation be easily available in the future? Is the documentation such that the next provider will know where to begin the next conversation? Do you have a way of managing different versions of the same information? What if a patient changes their surrogate? Will it be clear to the next provider who the right surrogate is? Which of your patients don t yet have a surrogate? Do you have a way of identifying your highest risk patients, identifying gaps, and tracking progress? How reliable are your processes? 31

32 Billing New Codes New advance care planning billing codes Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; first 30 minutes, face-to-face with the patient, family member(s) and/or surrogate) each additional 30 minutes Note: we are sharing our best understanding of these codes at this time, please be sure to work with your local billing compliance expert 32

33 Billing If billing for medical management If based on medical decision making bill as you normally would Then also bill based on time for advance care planning conversation If based on time do not double count time If not billing for medical management Use if you exceed 15 minutes Use if you exceed 45 minutes Use if you exceed 75 minutes Incident to rules apply in the outpatient setting Billing provider performs an initial service, a non-billing team member (e.g. RN, SW) helps deliver part of the service, with ongoing direct supervision and involvement of the billing provider 65 Summary of billing guidance Recognize the many (non-billing) barriers to these conversations Time Skill (and comfort level) Competing priorities Consider the business case for the new codes Can you use them to carve out more time for encounters? How might non-billing providers fit in? Incident to rules in the outpatient setting Many unknowns CMS will be learning from how they are used Work with your local billing compliance expert(s) 66 33

34 Conclusions Make advance care planning a routinepart of annual visits to health care provider for everyone Educate all providers on the tools they need, and give them the comfort level to have these difficult conversations Anyone on the team can start this conversation Make a living treatment plan that evolves over time and reflects changes in patient s goals and condition Utilize the billing codes and system resources to communicate wishes across the silos Resources 34

35 Our Conversation Nurse Orientation Shadow multiple members of the team for one month See what we do the same and what we do differently Think about things like body language, non-verbal communication, appropriate use of touch Review The Conversation Project starter kit Practice conversations with a team member observing Until ready to undergo formal evaluation Attend weekly team meetings where we all give feedback on how to do better ( All Teach, All Learn ) Undergo formal evaluation Assessment tools CONVERSATION EVALUATION TOOL Task: 1. Re-affirm the patient s goals for future care 2. Discuss CPR/DNR orders Check all skills satisfactorily completed. Basic Interviewing Skills Introduction nurse introduced him/herself Comfort nurse put patient at comfort, ensured privacy Nurse assumed a comfortable interpersonal communication distance Nurse made appropriate eye contact Nurse s posture was open (was leaning forward, didn t cross arms over chest, etc.) Used language that was clear and understandable; no medical jargon Nurse was attentive to comments nodding head, used verbal cues ( yes, hmm, I see ) Nurse gave me opportunity to ask questions Nurse answered questions in a straightforward manner Nurse suggested a follow-up plan Appeared empathic (indicate by body posture, tone of voice, facial expressions and choice of words, that they care about the patient and have some sense of understanding of the impact of the bad news) Copyright 2003, The Medical College of Wisconsin, Inc. Palliative Care Programs 35

36 Assessment tools Assess the understanding of diagnosis and prognosis How are things going? What is your understanding of what has happened? What have the doctors told you about your condition? Tell me more Can you explain what you mean? Can you tell me what you are worried about? You said you were worried about going home. Tell me more Nurse clearly articulated the current status of the disease Explained why the illness is advanced Reviewed treatments that have been tried Explained the probable course of the advanced illness Clarified the treatment options as focus changed from cure to comfort and quality of remaining life Goal: Therapeutic communication Nurse asked patient to articulate personal goals: What matters most? Summary Goal Setting/DNR Skills Nurse asked patient to articulate personal goals Nurse discussed the use of CPR within the context of the disease, and prognosis Nurse made a clear recommendation regarding CPR/no-CPR Summary Copyright 2003, The Medical College of Wisconsin, Inc. Palliative Care Programs Tools for teaching and training about conversation skills Download the app on itunes for 2.99 ihi.org/conversationproject TheConversationProject.org 36

37 Member based organization with membership fee Fantastic resources for all aspects of palliative care CME/CEU courses Pain management Communication skills Palliative care across settings Getting leadership support Gives you sample patient statements and asks for your response $2.99 app for the iphone Can review before a difficult conversation or debrief after Can choose to focus on specific skills Detailed advice If unsure what patient is feeling ask- What is going through your mind? Notice and respond to emotion A moment of silence helps Allows you to watch an expert 37

38 IHI Open School The IHI Open School brings you essential training and tools in an online, educational community to help you and your team deliver excellent, safe care. When you engage with the Open School courses and Chapters, you join more than 250,000 learners from universities, organizations, and health systems around the world in building core skills in improvement, safety, and leadership. There is a free course available that is related to today s topic: ihi.org/conversationproject Great mix of video and text Free CME/CEU! You must be a registered IHI.org user. Focus on why this is so important Focus on engaging with your own family The Conversation Project starter kit TheConversationProject.org 38

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