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Person & Family Engagement in Office Prac5ce:
Advancing TCPI, Building on Pa5ent Centered Medical Home
Prepared for HCDI SAN
Knitasha V. Washington, DHA MHA FACHE
Execu5ve Director Consumers Advancing Pa5ent Safety
Welcome
Dr. Knitasha Washington, FACHE Execu9ve Director Consumers Advancing Pa9ent Safety
Objec5ves/Topics • Describe the theore9cal, social and healthcare policy vectors driving new thinking regarding the partnership between providers of care, pa9ents, their families and other community stakeholder,
• Understand and apply the PFE change concepts and tac9cs in the TCPI change package as well as new office-‐based PFE interven9ons in development by AHRQ, the QIN-‐QIO network and healthcare providers
• Recognize and explore opportuni9es for PFE in improvement work in office prac9ce and community sePngs that par9cipants can be in ac9on on now.
3
Re-‐Examining the Pa5ent-‐Clinician Rela5onship: An Emergent Partnership
Model
Kim Blanton Story
hTps://www.youtube.com/watch?v=sikdSUnBmos
Re-‐Examining the Pa5ent-‐Clinician Rela5onship:
An Emergent Partnership Model
Key Terms
• Pa9ent Ac9va9on • Pa9ent Ac9va9on
Measures (PAM) • Pa9ent-‐Centered Care • Pa9ent (or Person) &
Family Engagement (PFE)
• Pa9ent Sa9sfac9on • Chronic Care Model
• Shared Decision-‐Making • Self-‐Management • Systems Approach • High Reliability Organiza9ons • Safety Across the Board
(SAB)
Rx For The ‘Blockbuster Drug’ Of Pa5ent Engagement, Health Affairs 32(2), 202 (2013)
Even in an age of hype, calling something “the blockbuster drug of the
century” grabs our a;en<on. In this case, the “drug” is
actually a concept—pa<ent ac<va<on and engagement—that should have formed the heart of health care all
along.
Susan Dentzer, Editor Health Affairs
7
BeTer Care
Healthier People
Smarter Spending
Goals • Make care safer
• Strengthen person and family centered care
• Promote effec9ve communica9ons and care coordina9on
• Promote effec9ve preven9on and treatment
• Promote best prac9ces for healthy living
• Make care affordable
Founda9onal Principles • Enable Innova9on • Foster learning
organiza9ons • Eliminate dispari9es • Strengthen infrastructure
and data systems
PFE Now Embedded in CMS Quality Strategy as
“Person” & Family Engagement
Re-‐Examining the Pa5ent-‐Clinician Rela5onship: An Emergent
Partnership Model
Partnership includes re-‐evalua9ng the roles that pa9ents and their families play... • with their providers in their own care and the care of family
members or others for whom one is responsible, • in designing or improving care processes in hospitals, physician
prac9ces and other healthcare delivery organiza9ons, and • in se_ng social and regulatory policies and priori5es, including
healthcare payment policies
Re-‐Examining the Pa5ent-‐Clinician Rela5onship: Major Drivers
1. Growing social consensus about the importance of Pa5ent-‐Centered Care or more holis9cally: Person and Family Centered Care
2. Accumula9ng Research in the Chronic Disease and Pa5ent Centered Medical Home Domains
3. The paradigm shi` from reliance on professional responsibility for healthcare outcomes to a Systems Approach for ensuring healthcare safety and quality
Pa5ent Ac5va5on = Pa5ent Engagement at the Point of Care
Health Affairs 2013, 32(2) 216-‐222
Pa<ent Ac<va<on is the combina<on of skills and confidence that equip
pa<ents to become ac<vely engaged in their
healthcare.
Judith H. Hibbard, PhD, MPH Research Professor, Health Policy Research Group University of
Oregon
Many physicians have come to see Pa5ent Ac5va5on and Shared Decision-‐Making as prac5cal ways to be pa5ent-‐centered.
But physicians are now being challenged by CMS and other policymakers and healthcare thought
leaders to establish partnership strategies beyond the point of pa5ent care.
PfP Safety Across the Board Initiative Patients expect more than being protected
from 2 or 3 causes of harm (Dennis Wagner, PfP Co-Lead)
Four Principles: 1. Commitment to safety/reliability as a strategic
imperative 2. Composite scoring and reporting so
improvement work is not just projects & projects
3. Provide big picture that engages all staff, leadership, governance and patients & families we serve
4. Inclusion of PFE and elimination of disparities in safety outcomes
CMS Systems Approach: Safety Across the Board
How does the SAB Approach regard Pa5ent Engagement?
Although Systems Approach models emphasize the roles and exper5se of physicians & other healthcare professionals, as pa5ents & family caregivers become more engaged, new vistas open up for understanding their contribu5ons
to safer, higher quality care.
• Partnership from Pa9ents (PfP) Campaigns 1.0, 2.0 – Frameworks/Roadmaps – Metrics – Alignment of PFE with outcomes improvement work
• CMS overall PFE strategy, announced at 2015 Quality Conference – Signaled the shid from “pa9ent” to “person”
• AHRQ Toolkits – Seven Pillars Program – CANDOR = Communica9on and Op9mal Resolu9on – Guide to Pa9ent and Family Engagement in Primary Care
• New Quality Improvement Organiza9on (QIN-‐QIO) Campaign on Medica9on Self-‐Management
• Transforming Clinical Prac9ce Ini9a9ve (TCPI)
PFE Environmental Scan of Federal Transformation Efforts
15
Partnership for Patients (PfP)
Launched in April 2011 • Coordinated by CMS Innovations Center • Projected Outcomes:
• 60,000 lives saved, 1.8 million fewer injuries • 1.6 million people recover without readmission • $35 billion saved ($10 billion to Medicare)
Partnership for Pa5ents: Beher Outcomes, Lower Costs
PfP Par5cipa5ng Hospitals PFE Metrics, Jul 2013 -‐-‐ Nov 2014
Minnesota HEN “Pahern PFE and Campaign Outcomes
0.987
0.798 0.817
0.631
0.6
0.7
0.8
0.9
1.0
1.1
2009 2010 2011 2012-‐1 2012-‐2 2012-‐3 2012-‐4 2013-‐1 2013-‐2 2013-‐3 2013-‐4
PPR ra5o
Comparing Minnesota PPR of Low Performers (0-‐3 PFE) to High Performers (4-‐5 PFE)
# PFE met 0-‐3 # PFE met 4-‐5
PFE Contributions to the PfP Campaign
• PFE as a provider/user partnership strategy – Pa9ent stories as mo9vators – Pa9ent and family contribu9ons to learning/improvement
• PFE as a pull strategy to drive demand for improvement – Pa9ent advocate buzz about the PfP Campaign created
excitement or change of opinion – Outreach to pa9ent advocacy groups reframed PFE as an
improvement strategy – Engagement of PFAC members in safety work is crea9ng
expecta9on of a new normal in U.S. healthcare system? • PFE as a culture change strategy
– The conversa9on changes when the pa9ent is in the room
AHRQ Guide to PFE in Primary Care Research Ques5on
What are effec5ve and poten5ally generalizable approaches for engaging pa5ents
and families to improve pa5ent safety in primary care se_ngs?
21
AHRQ Environmental Scan 1. Synthesize research in the field 2. Inventory and describe
interven9ons 3. Qualita9vely evaluate
effec9veness and usability of interven9ons iden9fied
4. Iden9fy gaps in the field and areas ready for interven9on development
Pa9ent Safety
Primary Care
SePngs
Pa9ent & Family
Engagement (PFE)
Four Key Threats to Pa5ent Safety
• Breakdowns in communica5on – Among pa9ent, provider, prac9ce staff
• Medica5on management – Prescribing, filling, adherence, overuse
• Diagnosis and treatment – Decision making, informa9on transfer, missed diagnosis, delayed diagnosis
• Fragmenta5on and environment of care – Care coordina9on, safety culture, repor9ng, error iden9fica9on and management
August 16, 2016 23
AHRQ Environmental Scan Implica5ons for the Guide
• PFE interven9ons focused primarily on the pa9ent as the agent of change haven’t been measurably successful
• Educa9on alone is unsustainable yet it is the focus of most interven9ons
• Limited evidence of usability and adop9on • Health equity and literacy are cited as a concern, but not oden a focus of interven9ons
August 16, 2016 24
AHRQ Guide Model for Advancing PFE in Primary Care
August 16, 2016 25
AHRQ Guide: Recommended Interven5ons
(= TCPI Tac5cs?)
1. Family engagement in care 2. Teach back 3. Warm hand-‐offs 4. Medica5on safety interven5ons
• Pa9ent and family advisory councils • Shared decision-‐making
August 16, 2016 26
27
Phase 2. (18 months) Health coalitions in 50% of counties in US have adopted the evidence-based medication self-management system by 12/18.
Phase 1. (12 months) Develop and test successful patient medication self-management programs by 1/1/17 using rapid cycle prototyping
Outcome: Health coalitions in 50% of counties adopt evidence-based medication self-management system
Impact: CMS estimates increase in patient at goal, reduce care utilization, reduced
total cost of care.
National Medication Safety Network formed to
Continue Spread and Improvement of Medication Self-
Management System
QIN-QIO Campaign for Meds Management
A Two Phase Campaign
Pa9ent and Family
Physician & Office Staff
Situa9on Assessment & Community Support
Payer
• Community Pharmacist • Home Health • Social Services • …
Medication Self-Management For Patients & Family: A Stable and Resilient 3-Dimensional
Structure
Four Guides in the CMM Change Package
A. Guide for Physicians B. Guide for Payers C. Guide for Assessment and Support D. Guide for Pa9ents and Families
The TCPI Change Package Structure: Expanded Driver Diagram
30
Prac%ce''Bold'Aim'
Secondary'Drivers'
Change'Concepts'
Ac%on'Items'
Change'Package'Structure'
Primary'Drivers'
Opera&onal*Defini&ons*of*a*Driver*
Ac&onable*
Intended*Results*
Strategy*&*Program*
Broad concepts that prompt specific change ideas derived from site visits/ high performers
Prac5ce aims aligned with TCPI goals
Change Tac5cs
TCPI AIMs/Goals
Con5nuous, Data-‐Driven Quality
Improvement
Pa5ent and Family-‐Centered Care Design
Sustainable Business
Opera5ons
Primary Drivers
1.1 Pa5ent & family engagement 1.2 Team-‐based rela5onships 1.3 Popula5on management 1.4 Prac5ce as a community partner 1.5 Coordinated care delivery
1.6 Organized, evidence based care 1.7 Enhanced Access
Secondary Drivers
3.1 Strategic use of prac5ce revenue
3.2 Staff vitality and joy in work
3.3 Capability to analyze and document value
3.4 Efficiency of opera5on
Drivers: Essential to Achieving TCPI Aims
31
2.1 Engaged and commihed leadership 2.2 Quality improvement strategy suppor5ng a culture of quality and safety 2.3 Transparent measurement and monitoring 2.4 Op5mal use of HIT
6) Reduced costs: Prac5ce controls its internal costs as well as other elements of total cost of care.
7) Documented Value: Prac5ce can ar5culate its value proposi5on and increases par5cipa5on in available value-‐based payment agreements.
1) PracBce TransformaBon. Evidence of a culture of quality where the vision is clear and data is used to drive con5nuous improvement in quality, outcomes, cost of care and pa5ent, family and staf experience.
2) EffecBve soluBons moving to scale. Evidence of prac5ce spreading effec5ve improvement strategies to full scale for the en5re popula5on under its care 3) High Clinical EffecBveness: Prac5ce is effec5ve in bringing all pa5ent segments to their health status goals.
4) Reduced Avoidable Hospital Use: Rates of readmission and unnecessary admissions for prac5ce’s pa5ents have been reduced.
5) Reduced Unnecessary TesBng & Procedures: Prac5ce demonstrates a reduc5on in unnecessary tes5ng and in the use of the ED by its pa5ent popula5on.
Change Tactics… What practice can really do to make the drivers come alive!
• Actionable • Specific • Customizable to type of practice or practice
environment • Have worked in several practices, but do not
necessarily apply to all---why we encourage small scale testing
32
TCPI PFE Na5onal Strategy
Strategic Managem
ent P
lan
Support and Alignment of Change Package
Evolu9on of PFE Tac9cs
Align PFE Across Transforma9on Plamorms
Buy-‐In and Spread Across Consumer Advocacy
Networks
33
Transforma5on Improvement Assistance
Prac5ce Assessment
Tool
TCPI change package
TIA – Process to provide technical assistance to prac9ces. Ongoing, with quarterly roll-‐up report
PAT – Query prac9ces on level of transforma9on. Repeated every 6 months
Change Package – “Roadmap” to Transforma9on
PFE Comes Together in Overall TCPI Improvement Process
Crea5ng Pa5ent Partnerships
• Establish clear measures that track the TCPI Campaign Person and Family Engagement (PFE) progress.
• Organize a diverse set of measures that are clinically relevant and important to both pa9ents and providers.
• Create Campaign-‐wide buy-‐in, adop9on and full implementa9on of newly established PFE measures.
35
1. Prac9ce’s quality improvement infrastructure has pa<ents and family in a proac9ve policy making and improvement role.
2. Prac9ce provides pa<ents and family with data transparency through the use of technology.
3. Prac9ce leadership stands for Pa<ent and Family Engagement
Crea5ng Pa5ent Partnerships
36
4. Prac9ce proac9vely forms community partnerships to create a comprehensive support network for pa<ents and family
5. Prac9ce demonstrates pa<ent and family engagement through advances in health equity and diversity
6. Prac9ce enables self-‐management of medica9ons by pa<ent and family
Crea5ng Pa5ent Partnerships
37
1. Quality role. Prac9ce’s quality improvement infrastructure has pa<ents and family in a proac9ve policy making and improvement role.
2. Access to data. Prac9ce provides pa<ents and family with data transparency through the use of technology.
3. A defining value. Prac9ce leadership stands for Pa<ent and Family Engagement
Crea5ng Pa5ent Partnerships
38
4. Community links. Prac9ce proac9vely forms community partnerships to create a comprehensive support network for pa<ents and family
5. Inclusive. Prac9ce demonstrates pa<ent and family engagement through advances in health equity and diversity
6. Self-‐management. Prac9ce enables self-‐management of medica9ons by pa<ent and family
Crea5ng Pa5ent Partnerships
39
Collabora5ve Self-‐Management Support – Prac5ce Core Competencies
hhp://www.ihi.org/resources/Pages/Tools/SelfManagementToolkisorClinicians.aspx
• Emphasize patient’s central role
• Involve family members
• Build a relationship • Explore patient’s
values, preferences, cultural & personal beliefs
• Share information
• Collaboratively set goals • Use skill building &
problem solving to help patient’s identify & overcome challenges
• Follow-up on action plans
• Connect patients with community resources
Challenges to Pa5ent Self-‐Management Helping pa5ents with chronic condi5ons overcome barriers to self-‐care
2012 -‐ The Nurse PracBBoner, 13 Mar 2012, v37 No. 3, pp 38–39
Challenges (Examples)
• Physical (disability) • Psychological (depression,
distress) • Cogni9ve (health literacy,
literacy) • Economic (health insurance
adequacy) • Social and Cultural (isola9on)
Strategies for Overcoming Challenges (Examples)
• Structured Communica9on (teachback, mo9va9onal interviewing)
• Assessment (PAM) • Enhancing self-‐efficacy (shared
goal sePng & ac9on plans) • Ongoing support (prac9ce
follow up, peer support)
Tom Evans, Iowa Healthcare Collabora9ve
Stage 1. Working without paBent input “For them but not with them” Stage 2. Dropping the wall of silence Invi9ng pa9ents into the
improvement work “room” Stage 3. Listening to paBent stories Using their stories to mo9vate
and guide Stage 4. Engaging paBents in our work Showing pa9ents our improvement work,
asking for feedback Stage 5. Partnering with paBents Pa9ents bring ideas up and providers
listen; providers and users of care jointly make decisions, set priori9es.
COMPASS PTN Leader Tom Evans, MD: Our “Long Journey” to Partnering with
Pa5ents
Transforming your Prac5ce: Leaving in Ac5on
1. Family engagement in care 2. Teach back 3. Warm hand-‐offs 4. Medica5on safety interven5ons
• Pa9ent and family advisory councils • Shared decision-‐making • The evolving Care Team
August 16, 2016 43
Knitasha V. Washington, DHA, FACHE [email protected]
Consumers Advancing Pa9ent Safety 405 N. Wabash Ave., Ste. P2W
Chicago, IL, 60611 Telephone: 312-‐464-‐0602 www.pa9entsafety.org facebook/drknitashawashington
@drknitasha or @CAPS_SafetyORG – TwiTer