Leveraging Shared Decision Making to Manage Population Health Partners HealthCare s Lessons Learned Gloria Stone Plottel, MS, MBA, Founder and CEO, GSPsquared LLC Adam Licurse, MD, MHS, Associate Medical Director, Partners Population HealthCare Management and the Brigham and Women's Physician Organization
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PX Continuing Education Credits In order to obtain patient experience continuing education credit, participants must attend the program in its entirety and return the completed evaluation. The planning committee members and presenters have disclosed no relevant financial interest or other relationships with commercial entities relative to the content of the educational activity. No off label use of products will be addressed during this educational activity. This activity has received no sponsorship or commercial support. No products are available during this educational activity, which would indicate endorsement.
Today s Presentation Leveraging Shared-Decision Making to Manage Population Health Partners HealthCare s Lessons Learned In this session, we'll take an in-depth look at Shared- Decision Making and learn why it is key to managing population health, improving patient outcomes, increasing patient engagement, and reducing healthcare costs. Partners HealthCare Population Health Management will share lessons learned from its work to expand and implement Shared-Decision Making in Partners HealthCare s 10 hospitals and hundreds of physician practices. Participants will learn how to use Shared-Decision Making to increase patient engagement, best practices for running a Shared-Decision Making program and key considerations for expanding a Shared-Decision Making program throughout an integrated health system. Gloria Stone Plottel, MS, MBA Founder and CEO GSPsquared LLC Adam Licurse, MD, MHS Associate Medical Director Partners Population HealthCare Management Brigham and Women's Physician Organization
Leveraging Shared Decision Making to Manage Population Health Partners HealthCare s Lessons Learned Gloria Stone Plottel, MS, MBA GSPsquared LLC Adam Licurse, MD, MHS Partners HealthCare Population Health Management Brigham and Women s Physician Organization December 3, 2015
Introductions Gloria Stone Plottel, MS, MBA Founder and CEO GSPsquared LLC Adam Licurse, MD, MHS Associate Medical Director Partners HealthCare Population Health Management and Brigham and Women s Physician Organization
Today s Objectives Tell the story of scaling Shared Decision Making across the Partners HealthCare System Shared Decision Making best practices How Shared Decision Making contributes to: o Managing population health o Improving patient outcomes o Increasing patient engagement o Reducing healthcare costs Key considerations when scaling Shared Decision Making throughout a health system
Setting the stage
Partners HealthCare System Founded in 1994 in Boston, Massachusetts by Massachusetts General Hospital and Brigham and Women s Hospital Includes: 2 Academic Medical Centers Community hospitals Specialty hospitals Managed care organization Community health centers Physician network Home care services Long-term care services Several hospitals are teaching affiliates of Harvard Medical School
Emerging regulatory landscape Pre 2006 Pre 2006 state HC law Many without health insurance Fee for service Focused on volume Rapidly increasing healthcare costs 2006-2012 Passed: 2 MA healthcare laws & national ACA Expanded access; 98% of Mass residents with health insurance Need to reign in healthcare expenditures Very focused on quality & measuring quality Emerging landscape Global payments Managing health of populations Improve outcomes Improve quality Reduce costs Reimbursement contracts changing at federal and state levels putting more risk on providers
Partners HealthCare covers ~500,000 lives in accountable care contracts 1 2 3 Medicare Commercial Self Insured Example: Pioneer ACO Example: Alternative Quality Contract Example: Partners Plus Covered lives: ~52k Covered lives: ~350K Covered lives: ~90k
Patient engagement strategic goals for population health management To increase patients participating in their own health care treatment so as to contribute to: Improving quality of care Improving patients experience of care Improving outcomes Reducing costs Meeting contractual risk obligations
Shared Decision Making (SDM) Interactive process between patient (and family) and clinician(s) Engages patient in decision making Gives accurate information about options and outcomes Tailors treatments to patient s goals and concerns Source: Massachusetts General Hospital and Health Decision Sciences Center
What s the purpose? Match the right treatment to the right patient at the right time, every time Source: Massachusetts General Hospital and Health Decision Sciences Center
SDM and Guidelines Chemoprevention for breast cancer: Clinicians should inform patients of the potential benefits and harms of chemoprevention. Screening for osteoporosis: clinicians also should consider each patient's values and preferences and use clinical judgment when discussing screening with women... Coronary revascularization: Shared patient/physician decision making for many scenarios would be expected and may result in the patient deferring coronary revascularization while maintaining medical therapy. Shared Decision Making and patient engagement are key facets of Patient-Centered Medical Homes Source: Massachusetts General Hospital and Health Decision Sciences Center
Evidence Base: Decision Aids 2014 Cochrane Systematic Review contains 115 RCTs: Decision aids increase decision quality: increase in knowledge increase in realistic expectations increase in value-choice concordance Decision aids engage patients less passive (RR 0.66) Fewer who remain undecided (RR 0.59) Decision aids address over- and under- use reduction in major invasive elective surgery (RR 0.79) reduction in PSA testing (RR 0.87) and HRT use (0.73) Stacey et al. Cochrane Database of Systematic Reviews, 2014
From Massachusetts General Hospital to Partners HealthCare system-wide SDM at MGH: 15 PC practices + clinics; 4,000 shared dec s/yr.; about 2% of patient volume Strategic options and scaling tactics SDM used at Partners 10 hospitals and 100s of physician practices
Legal
Clinician training
IT and the electronic medical record
Patient portal
Mail services
Patient decision points and clinical office protocols
Leadership
Advisory group
How are we doing? Implementation Process Outcome
Collaboration
MGH Stoeckle Center for Primary Care Innovation MGH Health Decision Sciences Center Susan Edgman-Levitan, PA; Executive Director, Massachusetts General Hospital The John D. Stoeckle Center for Primary Care Innovation Karen Sepucha, PhD; Director, Massachusetts General Hospital Health Decision Sciences Center Leigh Simmons, MD; Massachusetts General Hospital Health Decision Sciences Center and The John D. Stoeckle Center for Primary Care Innovation
Use of patient decision aids at MGH 25000 20000 15000 10000 5000 0 Cumulative distribution of decision aids 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 By the numbers: 22,000+ decision aids distributed since 2005 500+ orders/month >800 unique clinicians and staff have prescribed programs Top Programs Overall: 1. PSA testing 2. Advance Directives 3. Colon Cancer Screening 4. Knee Osteoarthritis 5. Insomnia Most Popular Patient-Triggered Program Orders a) Insomnia b) Anxiety c) Depression d) Low back pain e) Living with Chronic Pain Source: Massachusetts General Hospital and Health Decision Sciences Center
Some challenges we face Some clinicians very interested, others rarely use decision aids Ordering system very clinician-driven; but they are busy and forget, and might not always know what patients want How to identify patients at decision points outside of visits Balance between clinician time and conversation quality Source: Massachusetts General Hospital and Health Decision Sciences Center
Case 1: Clinician training Pilot project launched in 2005 at 1 practice and in 2006 spread to all 18 MGH adult primary care practices Clinician-driven ordering of video/booklet decision aids, during the visit, supported by EMR, with centralized distribution thru SDM Center. Steady use (~100 orders/month) BUT not nearly what it could be, most orders were from a few physicians, and significant variation among clinics Source: Massachusetts General Hospital and Health Decision Sciences Center
Designed Training Course 1-hour session held during regular practice meeting Overview of shared decision making (what, why, how) Feedback: usage data (practice and provider level), patient & provider comments View video decision aid Discussion 1 hour CME credit for physicians 15/18 practices hosted course Source: Massachusetts General Hospital and Health Decision Sciences Center
Impact and Lessons Learned More than doubling orders Comparative data is a strong motivator Providers enjoyed a little competition! Physician champion role important Quarterly newsletter and biannual training Source: Massachusetts General Hospital and Health Decision Sciences Center
Case 2: Automating Delivery of Decision Aids Goal to take advantage of EMR/IT applications to help with delivery Early project: sent decision aids to patients based on problems in problem list (e.g. osteoarthritis, fibroids) Easy and increased use of decision aids, but Overall a disaster not at a decision point (wasted time) and/or not relevant (e.g. sent fibroid program to a woman who had already had a hysterectomy) Need more nuanced approach to identify patients who actually need the decision aid Source: Massachusetts General Hospital and Health Decision Sciences Center
Mental Health Integration Interest: Providers open to using more decision aids in practice, but low-prescribing practice; nursing leader invested in improving patient education processes Workflow: MAs offered patients PHQ-2 at all annual visits; if PHQ-2 + for depression, patients were offered order form for mental health programs (depression, anxiety, and insomnia) Source: Massachusetts General Hospital and Health Decision Sciences Center
Enabling patient-directed ordering Pre-visit and during visit models 10-fold increase in orders when opened up to patients Patients and clinicians order different programs Source: Massachusetts General Hospital and Health Decision Sciences Center
Measurement and feedback Patient surveys to assess impact on knowledge, goals and decisions Source: Massachusetts General Hospital and Health Decision Sciences Center Quarterly newsletters with practice- and provider- level reports
What s next? Expand integration into primary care PCMH and pre-visit preparation In-visit tools Enhance referrals to specialty care Orthopedics (hip & knee osteoarthritis and back) Acute low back pain (urgent care, Occ Health and ED) Innovation and research Evaluate impact of new decision aids, in-visit tools, web based tools Decision quality measurement Source: Massachusetts General Hospital and Health Decision Sciences Center
Making it happen: Key factors for successful implementation: o Receptive culture for clinicians, staff, administration training and feedback, link to incentives and broader initiatives o Engaged, prepared patients high quality tools o Infrastructure and resources EMR, IT Source: Massachusetts General Hospital and Health Decision Sciences Center
Today we focused on How Shared Decision Making contributes to managing population health, increasing patient engagement, improving patient experience Shared Decision Making best practices Key considerations for scaling SDM in a health system Partners HealthCare s lessons learned
Q & A and Thank you Gloria Stone Plottel, MS, MBA Founder and CEO GSPsquared LLC gloria@gspsquared.com 617-584-4903 Adam Licurse, MD, MHS Associate Medical Director Partners HealthCare Population Health Management and Brigham and Women s Physician Organization alicurse@partners.org
PX Continuing Education Credits This program is pending approval for 1 PXEs In order to obtain PXEs, participants must attend the program in its entirety and complete evaluation.
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