Panel Discussion: Patient Centered Care Toolkit Patrick Conway, MD, MSc Virna Elly Thomas Carr Brian Murray, MD, FACP, FRCPI Donald Molony, MD Becky Lee, RN A renal community collaboration September 17-18, 2013
Patient Centered Care Patrick Conway, M.D., MSc CMS Chief Medical Officer Director, Center for Clinical Standards and Quality Acting Director, Center for Medicare and Medicaid Innovation September 18, 2013
PATIENT-CENTERED CARE Patient-Centered care meets the goals, preferences, and strives to achieve the outcomes most meaningful to patients - Measures - Experience of Care - Quality Improvement that directly involves patients and their caregivers - Care delivery system orients to needs of patients, not based on provider preferences - Shared decision-making 3
Maximizing Impact For success, the ESRD Networks will lead transformation by Convening, organizing, and motivating Leveraging technology Serving as a partner Securing commitments Achieving and measuring changes Disseminating and spreading best practices Participating in CMS national framework 4
Strategic Aims - What will be done AIM 1: Better Care for the Individual through Beneficiary and Family-Centered Care Beneficiary and family engagement Patient Experience of Care Promote Appropriate Access to Outpatient Dialysis Care Vascular Access Management Patient Safety: Reduction of Healthcare Acquired Infections (HAIs) 5
Strategic Aims - What will be done AIM 2: Better Health for the ESRD Population Community Focused Learning and Action Networks/Innovation Pilot Projects Increasing Immunization Rates Transplant Coordination with a Focus on Reduction of Disparities Cardiac Health Care Coordination Exploring Treatment Modalities Quality of Life Hospitalization 6
Strategic Aims - What will be done AIM 3: Lower Costs of ESRD Care through Improvement of Care Support of the ESRD QIP for Performance Improvement Support facility data submission Other Rapid Cycle Projects 7
National Medicare 30 Day Readmissions An Example of Aligning Incentives and QI Support
Ongoing Policy Considerations How will policy decisions impact the patient, family and caregivers? How will practice patterns change as a result of the patient-centered model? Are we disproportionately impacting facilities based on it characteristics? How do we allow for the greatest level of participation and what are the trade offs? Are the measurements of performance accurate, fair, feasible and reflective of systematic difference? 9
The Future of Quality Measurement for Improvement and Accountability Meaningful quality measures increasingly need to transition away from setting-specific, narrow snapshots Reorient and align measures around patient-centered outcomes that span across settings Measures based on patient-centered episodes of care Capture measurement at 3 main levels (i.e., individual clinician, group/facility, population/community) Why do we measure? Improvement Source: Conway PH, Mostashari F, Clancy C. The Future of Quality Measurement for Improvement and Accountability. JAMA 2013 June 5; Vol 309, No. 21 2215-2216
Opportunities and Challenges of a Lifelong Health System Goal of system to optimize health outcomes and lower costs over much longer time horizons Payers, including Medicare and Medicaid, increasingly responsible for care for longer periods of time Health trajectories modifiable and compounded over time Importance of early years of life Source: Halfon N, Conway PH. The Opportunities and Challenges of a Lifelong Health System. NEJM 2013 Apr 25; 368, 17: 1569-1571
Financial Instruments and models that might incentivize lifelong health management Horizontally integrated health, education, and social services that promote health in all policies, places, and daily activities Consumer incentives (value-based insurance design) Warranties on specific services Bundled payment for suite of services over longer period Measuring health outcomes and rewarding plans for improvement in health over time Community health investments ACOs could evolve toward community accountable health systems that have a greater stake in long-term population health outcomes
Why do we do this work? As a practicing hospitalist physician I see the need for system changes Left a hospital medicine and quality improvement position I loved to help foster a broader system enabling others to drive improvement Almost all of us have family members in the populations we serve The nation needs our service Focus on better health, better care, and lower costs Patients, Caregivers, and Families First - Always 13
Virna Elly Forum s Beneficiary Advisory Council (BAC) Mid-Atlantic Renal Coalition (Network 5) A renal community collaboration September 17-18, 2013
Thomas Carr Forum s Beneficiary Advisory Council (BAC) A renal community collaboration September 17-18, 2013
Donald Molony, MD University of Texas Medical School Chair, Forum s Medical Advisory Council (MAC) Chair, Medical Review Board, ESRD Network 14 A renal community collaboration September 17-18, 2013
1. How does a culture of, an approach of providing care that is patient-centered, help me in my role of assisting the patient in achieving their best health status? 2. How do I need to change what I do on a daily basis? 3. What are the barriers to patient centered care that are the result of my actions and behaviors? A renal community collaboration 9/18/2013
Patient / family centered care is about the patient and not the physician Ideally, patients who are engaged in their care have defined and thus are better able to understand the goals of therapy Patients so engaged in their care manage their disease in collaboration and with the guidance of the physician, care-providers Shared goals safe and effective care that minimizes suffering, discomfort, stress A renal community collaboration 9/18/2013
1. Creating a safe environment that invites patient initiated dialogue. Zero tolerance for retaliation. 2. Retaliation can come in many forms from more subtle to the overt. Toolkit on how to recognize actions that might be perceived as retaliation. Toolkit on enabling patient grievances. A renal community collaboration 9/19/2013
Retaliation can come in many forms from more subtle to the overt. Movement to a less desirable chair Change in shift time Labeling patient as trouble maker Ignoring the patient Involuntary Discharge Toolkit on how to recognize actions that might be perceived as retaliation. Toolkit on enabling patient grievances. A renal community collaboration 9/19/2013
Consideration Appreciation Invitation Tangible evidence of credible response Process that can be modeled in a Toolkit A renal community collaboration 9/19/2013
Physicians often question how patients can make decisions about their care when there is only one correct decision. Acknowledge that medical decisions should be made in the context of the patient s values and goals of care. Acknowledge / understand the uncertainty in the evidence and always invite the patient to decide on such matters. Know the evidence. Determine the shared goals of treatment and work towards achieving these shared goals. Toolkit on evidence and shared decision making. A renal community collaboration 9/19/2013
1. This takes time. 2. Health literacy / understanding is insufficient for the patient to understand the issues. 3. I do not know how to or do not want to ask. A renal community collaboration 9/19/2013
What can the networks and the forum do? Best practice. Dr. Brian Murray will include some thoughts, examples in his remarks. A renal community collaboration 9/19/2013
Brian M. Murray, MD, FACP, FRCPI Associate Professor of Medicine University of Buffalo Chairman, Medical Advisory Board, ESRD Network 2 A renal community collaboration September 17-18, 2013
Conditions Of Coverage Patients have the right to know about and participate in their care and treatment to the extent they desire. The facility must encourage patient participation in care planning. Examples of ways to promote this participation include, but are not limited to, offering the patient the option to participate in interdisciplinary team care planning or to attend a planning meeting in-person or by teleconference from home. Chair-side review of the plan of care is also acceptable, if sufficient privacy can be provided. Patients also have the right to accept or decline to participate in their care.
Patient Education Informal Physician Practice Nurse Educator Family and Friends Formal Classes LDO Da Vita Kidney Smart Fresenius RightStart Local National Kidney Foundation Online Resources NKDEP National Kidney Foundation Website American Association of Kidney Patients Care Planning in ESRD
The Communication Gap Researchers conducted in-person interviews with 62 chronic hemodialysis patients whose predicted 1-year mortality, based on validated prognostic tools, was at least 20%. Not a single patient reported receiving an estimate of life expectancy from a nephrologist. Nephrologists reported having given prognosis to only 2 patients of these 62 patients The patients were more optimistic about their 1 and 5 yearyear survival than their nephrologists. While patient estimates were more accurate about their 1-year survival, patients longer-term survival expectations significantly overestimated their actual 2-year and 5-year survival rates: Only 6% of dialysis patients thought they had less than a 50% chance of being alive in 5 years. Unfortunately, nearly half of the interviewees were dead at less than 2 years of follow-up. Lastly, more than 1/3 of patients whose nephrologists said they were not transplant candidates believed they were Wachterman et al. JAMA Intern Med. 2013;173(13):1206-1214..
Challenges to Patient Participation Care Planning Nephrologist, Nurse, Dietitian, Social Worker meet to review 8 areas of care Within 30 days, 3 months, annually If patient becomes unstable Patient? Extra visit? Transportation? Family member availability? Skype/Facetime Variable time requirement
Potential Areas of Contention Dialysis prescription May require longer time, patients often resistant Anemia Low Hgb cause symptoms, need for transfusion High levels may increase mortality What is optimal? Blood pressure, fluid management Excess fluid gains increase mortality Dialysis Access Fistula>Graft>Catheter What if patient opts for catheter Impact of the QIP
IPRO ESRD Network of New York 2013 Marketing, Engagement and Community Outreach AIM 1: Better Care for the Individual through Beneficiary and Family Centered Care Presentation to the MRB April 11, 2013 End-Stage Renal Disease Network of New York 31
Network Deliverables Foster Patient and Family Engagement at the Facility Level Involve Patients/Families in CMS Meetings Convene Patient Engagement Learning and Action Network (LAN) Patient Developed QIA and Marketing Campaign An engaged patient will be your best customer. Network Communication and End-Stage Renal Disease Network of New York 32
Patient Subject Matter Experts Bring a wealth of real world experience: Executives Health Care Providers Community Leaders Law Enforcement Entrepreneurs Teachers All with a common interest: Living a better life while being treated for ESRD. End-Stage Renal Disease Network of New York 33
PFeLAn Project Update Based upon July reporting: Quality Improvement Activity: Transplant Talks Toolkit 57 Facilities targeted; 13 volunteer facilities in targeted area Webinar on 8/30/2013 Campaign I: Kidney Chronicles: July 2013: 35 of 72 facilities reported data. Based upon feedback: Added QR Code for online subscription; Enlisting PAC Reps to assist in handing out Kidney Chronicles; Network offering to print and mail to facilities in targeted area. Campaign II: Annual Care Plan Patient and Family Involvement : July 2013: 29 of 64 facilities reported data. Best Practice Identified: At this facility our approach has been to have RD, RN and Social worker member meet with the patient/care givers INDIVIDUALLY, and develop the care plan and goals ahead of time. End-Stage Renal Disease Network of New York 34
Hospital Transition Solutions New ESRD Patient Becky Lee, RN Director Clinical Operations Davita VillageHealth A renal community collaboration September 17-18, 2013
Challenges Identified Patient/Family Knowledge Deficit No single point of contact Lack of detail communication Comprehensive Post Discharge POC High Risk of Readmission Dialysis Center Selection Placement and Transportation Multiple post hospital appointments, procedures Physician Interactions Primary Access CVC Lack of Modality education/selection VAP not Initiated A renal community collaboration September 17-18, 2013
Solutions to the Challenges Patient Pathways, subsidiary of Davita HealthCare Partners, supplements partnering hospitals' staff with onsite renal nurses and patient liaisons who are experts in kidney patient care management and discharge planning. Patient Pathways provides hospitals with unbiased, onsite renal nurses and patient liaisons who specialize in the admission, complex case management, insurance expertise, discharge and 30-day post-discharge care of patients by means of the telephonic care managers. Renal nurses and patient liaisons provide bedside and telephonic support and education about the disease process and next steps regarding transitioning to ESRD, helping to alleviate fears and concerns about what the new diagnosis may mean to them personally and for the family. Also in preparing the social worker and other caregivers/providers in the facility, insight to those psycho-social and physical needs that may be identified in the hospital setting and additional actions/interventions post discharge. A renal community collaboration September 17-18, 2013
Widespread Implications of the Challenges Patients and Families overwhelmed: Adjustment to Dialysis Impact on medical coverage and employment Fear of unknown, death, denial, feelings of hopelessness Hospital team communication gaps lack renal expertise to provide reassurance/education to alleviate concerns A renal community collaboration September 17-18, 2013
Minimizing the Implications VillageHealth acute teams are prepared to educate patients, caregivers and hospital staff about end stage renal disease (ESRD), treatment modalities, diet and emotional considerations and increase coordination with hospital partners, nephrologists and discharge planners. To improve communication and transition of care among physicians and imbedded caregivers, acute and chronic nurses, utilization of HIPAA secure communication handheld technology is being piloted. Confirmations, updates and status of the newly transitioned patient is communicated and tracked to improve outcomes for the patient on the initial outpatient setting and subsequently. Additional Pilot programs utilizing imbedded integrated nurse care managers/np s in dialysis centers, to include oversight and facilitation of in hospital support of the patient including transition of care from the hospital setting and post discharge support face to face/telephonically. A renal community collaboration September 17-18, 2013
VillageHealth Integrated Care Management Approach Key to Integrated Care Management is to improve patient quality of life. A partner who focuses on their care and needs including education, preparation and transition of care from CKD to ESRD and beyond can help to achieve this. Physicians appreciate that their orders are being closely followed and patients take a more active role in their care as a result. The care manager coordinates care with the patient, caregivers, physician(s) and Dialysis Centers as needed when the patient moves to the ESRD state. Provides a patient-centric approach to care Utilizes motivational interviewing as needed to assist the patient in decision making and empowerment. A renal community collaboration September 17-18, 2013
The Best Solution- CKD Education, Preparation, Outpatient Initiation of Dialysis A renal community collaboration September 17-18, 2013
Panel Discussion: Patient Centered Care Toolkit Questions Comments Discussion A renal community collaboration September 17-18, 2013