person & family engagement in office pracnce:

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


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


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


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


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

person & family engagement in office pracnce:

Documents