Records 

Stanford Coordinated Care“Support the patients, manage

their care”

Alan Glaseroff MDCo-Director, Stanford Coordinated Care

IOM Committee on Recommended Social and Behavioral Domains and Measures for

Electronic Health 11/25/13

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Causes of Premature Mortality

Schroeder, NEJM 357; 12

15%

5%

10%

40%

30% SocialEnvironmentalMedicalBehavioralGenetic

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Patient–Driven Care

• “Others have struggled to find a proper definition of patient-centeredness. Three useful maxims that I have encountered are these:” – “The needs of the patient come first.”– “Nothing about me without me.”– “Every patient is the only patient.”

Donald M. Berwick, What 'Patient-Centered' Should Mean: Confessions Of An Extremist Health Affairs, 28, no.4 (2009):w555-w565.

New Definition: Patients largely determine their own outcomes within the context of their lives

4Clarifying Multimorbidity Patterns to Improve Targeting and Delivery of Clinical Services for Medicaid Populations Cynthia Boyd, Bruce Leff, Carlos Weiss, Jennifer Wolff, Allison Hamblin, and Lorie Martin CHCS DECEMBER 2010

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Depression is Often Notthe Only Health Problem

DepressionNeurologicDisorders10-20%Geriatric

Syndromes20-40%

Diabetes10-20%

Heart Disease20-40%

Chronic Pain40-60%

Cancer10-20%

2010 University of Washington – AIMS Center

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Individual Self-Reported Patient Assessments

• SF-12• PAM• Domains• PHQ-9• (Activity level)• (Nutrition Assessment)• (Stanford Presenteeism Scale)

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Activation is Developmental with Four Progressively Higher Levels

10-15% of the population*

20-25% of the population*

35-40% of the population*

25-30% of the population*

* Medicaid and Medicare populations skew lower in activation

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Patient Activation and Utilization

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Patient Variation – what the patient faces

Domains

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Domains: “What to do?Patient Activation Measure: “How to do it?”

PAM

Domains

1 2 3 4

Social

Access

Behavioral

MedicalTrajectory

Workflows based on patient variation

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The Often Hidden Driver:Adverse Childhood Events & Trauma

ACE Score = 1 point each for positive responses to 10 questions inquiring about exposure to:

• Physical abuse• Emotional abuse• Sexual abuse• Physical neglect• Emotional neglect• Divorce/separation• Domestic violence in the home• Parent that used drugs or alcohol• Parent that was incarcerated• Parent that was mentally ill

From: www.acestudy.org

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How do ACE play out in later life?

• Depression:– A person with an ACE score of 4 was 4.6 x more likely to be

suffering from depression than a person with an ACE score of 0

• Suicide:– There was a 12.2 x increase in attempted suicide between these

two groups; at higher ACE scores, the prevalence of attempted suicide increases 30-51 fold!

– Between 66-80% of all attempted suicides could be attributed to ACE.

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Relationship of ACEs to Alcohol & IV Drug Abuse%

Alc

ohol

ic

4+

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00 1 2 3 4 or more

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0.5

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1.5

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2.5

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3.5

ACE Score

% H

ave

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cted

Dru

gs%

Hav

e In

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Relationship of ACEs to Smoking & COPD

Click icon to add picture

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PTSD

“Adverse Childhood Experiences (ACE) are common, destructive, and have an effect that often lasts for a lifetime. They are the most important determinant of the health and well-being of our nation.”--Vincent Felitti, MD, co-chair of study

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SCC Approach

• From:“What bothers you the most?

• To:“Where do you want to be in a year?”

First step

Next step

Getting there…

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Population Health – Risk MeasuresSummary of overall risk for patient population

Panel View by care team, clinician, patient demographics

View by chronic condition

Patient Panel list by Risk Markers

Navigate to patient health portrait

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Population Health – Health Portrait

Patient / Provider selectable measures to trend and track at point of care

Care gap measures

Health Portrait – Personalized view of a patient displaying care gaps alongside risk measures

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Obesity

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Patient Advisors to SCC

• Clinic designed after input from 34 patient interviews

• 8 people meet monthly (led by Patient Chair, with LCSW as “recorder” of minutes; MDs only come by invite)

• ACE: Cannot be “part of the chart” – data must be kept separately, with patients “consenting” to complete the survey

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Thank You!

Alan Glaseroff MD– aglasero@stanford.edu