Shared Decision Making & Patients with Multiple Chronic Conditions

Disclosures Our Shared Decision Making project is funded by the Informed Medical Decisions Foundation http://informedmedicaldecisions.org/ Physician Office-Based Health Coach Training is provided by Mercy Clinics, Inc., in collaboration with The Advisory Board Company http://www.advisory.com/talent-development

Background: Primary Care Medical Home

Mercy Clinics, Inc. 59 Clinics, 150 Physicians 70% Primary Care 926,000 patient visits in FY11 Owned by Mercy Medical Center - Des Moines which employs 325 physicians is owned by Catholic Health Initiatives Virtual Private Practice Compensation Plan: Revenue - expenses

Mercy ACO Approach to Patients with Multiple Chronic Diseases Same day access to care Easy access to health coaches Direct phone and e-mail Entered into the registry for each chronic disease Proactive follow-up between visits

Mercy ACO Approach to Patients with Multiple Chronic Diseases Team Based Care Coaches, Providers, Mid-levels, pharmacy, dieticians, therapists, CDE Communication and coordination of care Close all the loops: referrals, labs, testing Service contracts with specialists Target patients with multiple chronic diseases as the greatest opportunity for shared savings

What of our future steps did we accomplish? Beginning of MPMCC collaborative goals: Accountable Care Organization (ACO) preparation Transition Coach program Data warehouse for clinical and claim information Service contracts between specialties Re-organization of employed physician groups to merge into one governance structure

What of our future steps did we accomplish? Beginning of MPMCC collaborative goals: Consultants hired to help develop ACO Negotiation with state s largest insurer about a shared savings program New physician incentive compensation system Integrate Shared Decision making into routine office care Implementation of AEHR Implementation of How s Your Health as risk assessment tool

If you sat at a restaurant table and the server ungraciously plunked down a dish without the benefit of giving you a menu, you d walk out. I would. Yet in medical care today, this is routine. Dr. Steven Kussin Doctor, Your Patient Will See You Now: Gaining the Upper Hand in Your Medical Care. Springen, Karen // Booklist; 7/1/2011, Vol. 107 Issue 21, p12

What is Shared Decision Making (SDM)? Collaborative process between patient and provider Takes into account patient values and preferences framed within scientific evidence http://informedmedicaldecisions.org/shared-decision-making-in-practice/decision-aids/

Shared Decision Making (SDM)? SDM honors both the provider s expert knowledge and the patient s right to be fully informed of all care options and the potential harms and benefits. This process provides patients with the support they need to make the best individualized care decisions, while allowing providers to feel confident in the care they prescribe. http://informedmedicaldecisions.org/shared-decision-making-in-practice/decision-aids/

Shared Decision Making - Project Goals Fully inform patients about preference-sensitive conditions using Decision Aids Conditions that have multiple treatment options No clear evidence that one option is superior. Decision for which option to choose is based on preference of physician & / or patient Evaluate impact of Decision Aids on decision quality Using before & after surveys Evaluate patient satisfaction with the process

Shared Medical Decision Making Fully informed patients Will choose the best plan for themselves, yielding better outcomes Will often choose less expensive options Have greater satisfaction in their treatment plans

Decision Aids We Are Distributing 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

Decision Aids (DAs)

Decision Aids (DAs) DAs are designed to Complement, not replace, counseling from health care professional Use real patient interviews IMDFoundation does not accept funding from any source with financial interest in any particular approach to medical testing or treatment.

Preliminary Process Tracking and Illume Data as of 1-July-2012 Mercy Clinics: Distribution and Returns for Viewing Worksheets Response Rate 51% HIP 42 83 51% KOA 156 303 42% ALBP 76 182 40% 43% CLBP DIA 97 106 244 247 Distributed Returned 38% MENO 103 269 24% Other 11 46 0 50 100 150 200 250 300 350 N Distributed = 1374 N Returned = 591 17 2012 Mercy Medical Center, Mercy 9/21/12 Clinics, Inc. All rights reserved.

Unweighted data submitted to Illume data warehouse as of 1-Aug-2012 Most patients who were not sure before the DA chose a leaning afterward Of these, more leaned toward nonsurgical treatments than surgery after the DA

Informed consent Definition of informed consent: informare, to give form, consentire, to sense permission obtained from a patient to perform a specific test or procedure. Signed consent should be obtained by the person performing the procedure. By law, informed consent must be obtained more than a given number of days or hours before certain procedures. An individual must be of a certain legal age to give consent; laws vary from state to state. Mosby's Medical Dictionary, 8th edition. 2009, Elsevier.

How is SDM different? We have always encouraged our patients to ask questions but about what? What if they don t know the right questions to ask? SDM allows the patient identify appropriate questions that can be asked in a conversational setting with their provider.

How is SDM different? Takes place prior to procedure during a more relaxed, comfortable time Allows time for the patient to process new information and identify questions or concerns Allows for family involvement in the decision process. Does not consent to a procedure, but is simply a supportive tool

To, For, & With Informed Consent Shared Decision Making Things we do TO the patient What we do WITH the patient! Things we do FOR the patient

How is SDM different? Shift from: Patient as a consenter to care / services Patient as partner

What about SDM and Patients with Multiple Chronic Conditions (PMCC)? COPD Diabetes CHF CAD Chronic Pain Anxiety Depression Osteoarthritis / Osteoporosis Spinal Stenosis

Chronic disease from the patient s perspective Word cloud of one word descriptors from a recent discussion of patients on the website http://www.patientslikeme.com/

What about SDM and Patients with Multiple Chronic Conditions (PMCC)? PMCC are at greater risk for complications during invasive screenings or surgical procedures Treatment decisions take on more weight with PMCC High risk patients need amplified attention that the providers don t always have the time to give

What about SDM and Patients with Multiple Chronic Conditions (PMCC)? End of life issues: Looking Ahead: Choices for Medical Care When you re Seriously Ill Peace of Mind: Personal Stories about Advanced Directives

Does this help patient & provider engagement? http://www.youtube.com/watch?v=z0bia68zksy&feature=relm fu (4 minutes)

We moved from # of DAs Delivered to Patient Satisfaction Our data tells us that we have an opportunity to improve patient satisfaction scores Importance of patient satisfaction measurement Providing value to patients Satisfaction scores help senior leadership evaluate value of Implementing Decision Aids Spreading Shared Decision Making Sustaining this program throughout all of Mercy Clinics system..

Patient Responses After Viewing DA: Overall how would you rate the program? Preference-Sensitive Poor or Fair Good Very Good or Excellent 38% 56% n=404 DA TOPICS Abnormal uterine bleeding Acute low back pain Benign uterine fibroids Herniated disc Hip osteoarthritis Knee osteoarthritis Spinal Stenosis Chronic 41% 55% n=208 Chronic low back pain Diabetes 0% 50% 100% Unweighted data submitted to Illume data warehouse as of 1-Aug-2012.

Patient Responses After Viewing DA: How important for providers to give DAs to patients? Preference-Sensitive Not at all Somewhat Very Extremely n=401 16% 60% 24% DA TOPICS Abnormal uterine bleeding Acute low back pain Benign uterine fibroids Herniated disc Hip osteoarthritis Knee osteoarthritis Spinal Stenosis Chronic 11% 59% 30% n=209 Chronic low back pain Diabetes 0% 50% 100% Unweighted data submitted to Illume data warehouse as of 1-Aug-2012.

Mercy ACO s Beliefs about SDM s Importance to Healthcare Reform Fully informed patients will Choose the best plan for themselves, yielding safer, better outcomes Often choose less expensive options Experience improved patient satisfaction.

More: Importance of SDM & ACO Shared Decision Making is Patient centered Consistent with our values Frees up physician time Helps provide self-management support more effectively at less cost Will have a positive return on investment.

What s next? Registry tracking: Immunizations, standards of care, cancer screening Preferred access (through the health coach) Individualized written care plans (in planning) Health Risk Assessment - How s Your Health (piloting at three sites) Includes screening for Depression, Adherence Functional status

What s next? Assessment of home and family support Access to community services Health behavior change interventions - Coaching Medication adherence Diet Exercise Smoking Shared decision making decision aids Palliative Care

What s next? Extensivist Clinic - Rapid response team for outpatients (in planning) Track patients through transitions in care with coaches Consistent advice especially after hours (needs to be developed) Disease specific interventions in partnership with specialists

Shared Decision Making is the next emerging trend in patient-centered care We want to be there, along with our patients..

Thank you! Sheri Ver Steeg, RN, MSN-HCSM ACO Health Coach Manager sversteeg@mercydesmoines.org Monica Vail, RN ACO Health Coach Manager mvail@mercydesmoines.org