Foundation for Informed Medical Decision Making Research & Policy

ForumJanuary 26, 2011Washington, D.C.

A Care Setting Experience with Shared Decision Making

David Swieskowski, MD, MBA- Chief Executive Officer, Mercy Clinics, Inc.

Kelly Taylor, RN, MSN- Director of Quality, Mercy Clinics, Inc.

Mercy Clinics, Inc.• 27 Clinics, 150 Physicians

– 70% Primary Care• 877,956 patient visits in FY10• Owned by Mercy Medical Center in

Des Moines• MMC employs 325 physicians• MMC owned by Catholic Health Initiatives

• Virtual Private Practice Comp Plan• Revenue - expenses

Why & How We Started• Why:

• Professionalism• Competitive advantage

• How:• Joined IHI impact program in 2002• Joined Pilot Collaborative on Self-Management-Support in 2003• Started small in pilot clinics and spread successes throughout the

system– Used the PDSA approach

• Shift from Ad Hoc projects to a comprehensive plan to redesign care based on:

– Wagner’s Care Model– Six IOM Aims Dimensions of Quality

MCI Practice Redesign Goals - 2004

1. A whole person orientation2. Systems to ensure patients receive proper

care3. Registries to track patients4. Team based care5. Self-Management Support 6. Safety ensured by processes7. Improved access

Disease Registry“The single most important step

to improve chronic care”

Disease Registries Do Five Things1. Accept Data

• Electronically and manually at point of care

2. Create patient summary reports3. Create actionable lists

• With a defined condition• Overdue for care• Not meeting outcome goals

4. Create performance reports• % of the population meeting a measure

5. Export data – PQRI, P4P programs

MCI Quality Measures Clinical Detail

Clinic

A1C Within

Last Year A1C > 9% LDL < 100DM BP

< 140/80HTN BP < 140/90

Coumadin % in Goal

3rd Next Available

Appointment

Lab Audits Patient

Documentation Notification

Lab Audits

Average Time

CLINIC AVERAGE 86% 22% 68% 62% 76% 74% 2.93 Days 97% 1.42 Days

Beaverdale 95% 9% 71% 70% 82% 89% 1.80 100% 1.50

Campus 80% 31% 61% 51% 70% 56% 5.33 90% 0.78

East 89% 18% 62% 46% 57% 70% 4.78 100% 0.60

FMU 75% 32% 64% 67% 87% 65% 1.88 90% 3.00

Indianola 73% 32% 72% 81% 90% 88% 1.00 100% 2.40

Johnston 80% 26% 64% 64% 89% 71% 1.40 100% 0.60

North 98% 10% 69% 53% 63% 81% 3.27 100% 0.70

Panora 94% 24% 66% 68% 71% 75% - 90% 1.33

Perry 82% 28% 67% 57% 78% 69% 6.20 90% 3.78

South 93% 16% 68% 52% 72% - 3.55 100% 1.20

Urbandale 89% 16% 86% 70% 80% 78% 1.50 100% 0.10

West 88% 20% 63% 64% 78% 71% 1.57 100% 1.00

September 2010

Monthly Clinic Level Quality Report

Delivery System RedesignThe Office Based Health Coach

• MCI has 27 full time Health Coaches– At least one in every primary care clinic

• New job description– Started as RN, CMA, LPN, Receptionist and was more data

oriented– New Health Coaches must be RNs and are more clinically

oriented• Group meeting for 2 hours twice a month

– Training & sharing of learning• Formal 28 hour “Certification” Program

Five Essential Functions Of The Office Based Health Coach

1. Oversees the disease registry database2. Conducts pre-visit chart review3. Works with patients & families on self-

management support 4. Coordination of care across the care

continuum5. Involvement in QI activities

Pre-visit Review Audit

Mercy West Medical Clinic

$1,173$1,597TOTAL

30.0030.001Microalbumin

102.0051.002PSA

95.0095.001Ped Hep A & Admin fee

FRBL7Colonoscopy282.0094.003Pneumonia & Admin fee

Shared revenue3DEXA639.00213.003

HPV & Admin fee

$225.00$45.005Occult blood190.0095.002DTAP & Admin fee

$948.00$158.006CPX259.00259.001Zostavax& Admin fee

Charges added in future

# of patients needing

Scheduled for future date

Charge added today

Number of patients receiving

Done the same day

$1,173$1,597TOTAL

30.0030.001Microalbumin

102.0051.002PSA

95.0095.001Ped Hep A & Admin fee

FRBL7Colonoscopy282.0094.003Pneumonia & Admin fee

Shared revenue3DEXA639.00213.003

HPV & Admin fee

$225.00$45.005Occult blood190.0095.002DTAP & Admin fee

$948.00$158.006CPX259.00259.001Zostavax& Admin fee

Charges added in future

# of patients needing

Scheduled for future date

Charge added today

Number of patients receiving

Done the same day

One Day of Charges from Pre-visit Chart Review

Urbandale FP Clinic

Self-Management Support

• Health Behavior Change– Goal setting and action plans

• Medication Adherence– Only 40% of Mercy Clinic patients are highly

adherent • Patient Education

– Provided or arranged by Health Coaches• Shared Medical Appointments• Shared Decision Making

Primary Care Practices can profitably make delivery system changes now

• Increased volume of medically necessary services leads to increased revenue– Registry callbacks– Pre-visit chart review

• Redistribution of doctor work increases efficiency– Chart review, SMS

• Standardization leads to improved quality and reduce costs of producing a product or service

• Wellmark P4P opportunities

BP <=140/90

Pt. adherentChange in

PlanRecheck BP in

1 monthBP up for3 months

Counseling andcall back

F/U in1 month

Routine F/U3-6 months

ChangePlan

Yes

NO

NO

NO NOYes

Yes

Yes

Systems Ensure Quality: Hypertension Process Map

Mercy Clinics BP run chart

74%

40%

60%

80%

100%

Sep.09

Oct.09

Nov.09

Dec.09

Jan.10

Feb.10

Mar.10

Apr.10

May.10

Jun.10

Jul.10

Aug.10

Sep.10

n=14960

Diffusion of Hybrid Seed Corn in Two Iowa Communitiesby Bryce Ryan and Neal Gross; Rural Sociology; March 1943

• Hybrid Corn was introduced in 1928– Yields were 20% higher

• Knowledge of a change is different than acceptance– Time lag of about 7 years between first knowledge and

adoption• Acceptance is influenced by

– Shared experiences of Early Adopters– Ability to personally perform small tests change (PDSA)

The Part of the diffusion curve from about 10% to 20% is the heart of the diffusion process

Diffusion of Hybrid Seed Corn in Two Iowa Communities

Lessons on Diffusion• Measurement to prove the advantages is key• Diffusion is fundamentally a social process

– Exchange of personal experiences is at the heart of diffusion

• Encourage the use of small tests of change (PDSA)• Resistors are irrelevant to the change process

– Developing the critical mass with enough positive experiences is what counts

– Work with the willing– Don’t waste time on the laggards

Health Reform Expectations• Downward pressure on FFS payments

– CMS payment Per RVU• 1998 = $36.60 2010 = $36.06 2011 = $33.98

• Increased number of insured– Increased demand for primary care services

• New payment incentives– Utilization– Coordination of care– Quality– Patient satisfaction– Decision quality– Taking risk

• Commercial insurers will follow the CMS lead

Mercy Medical Center ACO Plans

• Create the legal structure– Primarily physician employment

• Create IT systems to measure value– Quality and Utilization

• Integrated Care system– Guidelines across specialties and sites

• Advanced Primary Care (Medical Home)• Wellness care – Healthy living center• Transition Coach project• Shared Decision Making

Mercy Clinics as a Primary Care Research Lab

• Transition Coach Program (starts March 1, 2011)

– Patients randomized to a transition coach program or usual care

– Outcomes: Readmit rate, ED visits, Quality Measures and Patient satisfaction

• Planning – Wellness programs– Improved access to care for NH patients

• Shared Decision Making

Share Decision Making - Project Aims

• Fully inform patients about preference sensitive conditions using decision aids– Preference sensitive conditions are those that have

multiple treatment options without clear evidence that one option is superior. Therefore the decision about which option to choose is based upon the preference of the physician and / or patient

• Evaluate the Impact of decision aids on decision quality– Using before and after questionnaires

• Evaluate patient satisfaction with the process

Hypothesis we are testing

• We can’t measure quality of outcomes or costs of care so as surrogates we are testing the following two hypothesis:1. Patients participating in SDM will have higher

decision quality2. Patients participating in SDM will have high

satisfaction with SDM process.

Implementation of Decision Aids and Current Status

Decision Aids We Are Distributing

• At all 5 clinics Hip OsteoarthritisKnee Osteoarthritis Acute Low Back PainChronic Low Back

PainSpinal Stenosis Herniated Disc

At FMU clinic Abnormal Uterine Bleeding Managing Menopause Uterine Fibroids

In the Future Spread DAs FMU clinic piloted

to other 4 pilots Diabetes CHF Advance Directives

Key elements to project buy-in and communication

• Governance Structures– Executive Governance Council and Council of Medical

Directors endorse this important work– Quality committee is updated on pilot routinely

• Clinics volunteer to be part of the pilot – Grant funding helps offset costs, but does not cover the

costs 100%.• Each clinic provides a provider champion and health

coach as key team members – Work on clinic strategies individually– Work together with other pilot clinics on best practices

and shared learnings

How we built this into existing models

• Basic philosophy: It takes a proactive, prepared practice team to effectively provide high quality chronic care (and SDM as well!) to our patients

• Health Coaches and provider champions are initially the key members of that practice team in each of the pilot sites

How we built this into existing models

• This is a new scope of work for coaches and providers– closely aligns with our advanced primary care and ACO vision

• But the strategies used to test and implement are the same used to redesign the delivery of chronic care– Senior level support and guidance from Clinic Administration– PDSA cycles-Part of the job of the coach is to try new things– Physician champions – Monthly Team meetings– Outcomes Data Review

Identifying the Denominatorfor Knee and Hip OsteoArthritis

• Original definition:– Age > 50– Chronic knee or hip pain

• Over 6 months or 3 (or more) visits for this problem– Any mention in the record or referral notes about possible

joint replacement

• New definition (Sept. 2010):– Identify the denominator by identifying all patients

referred to Ortho who are over age 50 with chronic knee or hip pain

• We still distribute to both definitions

Ortho Referral for Knee or Hip OA made or considered by provider

who notifies the Coach

Patient is in office

Coach in the office:- Distributes DA packet- Pre survey done in the office- Begins Data Collection form

Coach calls patient: - Mails DA Packet- Pre survey done by phone- Begins Data Collection form

Call patient post DA viewing to assist with decision making and collect survey (repeat calls if needed to get the survey)

Patient decides to keep Ortho

appointment

Mail post visit survey after Ortho Visit

Contact patient if post visit survey not back in 2 weeks

(repeat calls if needed)

Check Ortho note to see if patient decided

on surgery or not

Yes No

Yes No

End(complete data collection form)

DA Packet contains:- Decision Aid booklet & DVD- Return envelope (stamped & addressed)- Informed consent handout- MCI explanatory handout

Senior Level Support Example:

Decision Aid

Distribution and Follow-up Process Map 8/09

PDSA Cycles

• Clinic Admin provides the high level process to be achieved

• Health Coaches utilize the Model for Improvement/PDSA cycles to achieve rapid process improvements – Coaches are change agents in their individual

clinics– Have received training on the use of PDSA cycles

Physician Champions

• Absolute key to the spread of any quality initiative throughout the clinic and the clinic system

• Key Duties:– Guinea pig-try PDSA tests with coaches– Cheerleader-to their peers and their nurses– Communicator-to all internal staff, clinic system

and beyond!

Barriers to Physician Buy-in

• Perception that a significant portion of patients do not want share decision making

• Not current standard of care• May undermine their recommendations

– Synvisc injections– Bio-identical hormones

• Time to learn about the DA• Time it takes to arrange a handoff

Monthly Team Meetings

• Key concepts– Once a month every month– 1 hour in length– Clinic Administration sets agenda but always

leaves time in the agenda for individual team planning

– Provider champs and coaches expected to attend– Clinic managers encouraged to (and often do)

attend

Outcomes Data Review

• Standing agenda item at each team meeting• Data helps us see where we are doing well and

where opportunities for improvement exist.– Both are equally important!

0

10

20

30

40

50

60

70

80

Total Decision Aids Distributed per Month All Clinics

Data Review Example

Viewing Worksheets Returned / DA's Given

0%

10%

20%

30%

40%

50%

60%

70%

Waukee

Indianola

West

FMU

East

Data Review ExamplePatient Satisfaction Scores

KEY - • Total • Excellent / Extremely • Very Good / Very Important

0

10

20

30

40

50

Jul Aug Sep Oct Nov Dec

Total - Rating

0

10

20

30

40

50

Jul Aug Sep Oct Nov Dec

Total - Importance

How We Went From Numbers To Patient Satisfaction

• Our initial focus was on implementing a process to distribute the decision aids.

• Reviewed data distribution numbers at each team meeting.

• Once data distribution numbers were high enough, we also began to look at how satisfied our patients were with this program.

How We Went From Numbers To Patient Satisfaction

• Our data tells us that we have an opportunity to improve our patient satisfaction scores

• Why is it important to work on this?– It’s all about providing value– The satisfaction scores will help senior leadership

evaluate the value of implementing, spreading and sustaining this program throughout all of Mercy Clinics Inc.

Current Strategies to Improve Satisfaction

• Collaborating within our own system as well as with the FIMDM research team, we have learned about many best practice ideas we are excited to try that are focused on:– Physician and staff one-on-one engagement– Patient engagement– Warm handoffs– Teaming with Physical Therapy

Patient Engagement

• Posters• DAs in x-ray• Educational displays with DAs• DAs in the exam room• DAs in the referral area

– Have notes on them: “Ask about this booklet if you have any questions”

Physician and Staff Engagement• Internal marketing to the pilot physicians and

staff– Coffee bars– Posters– Clinic newsletter– One-on-one Champion discussions

• Academic detailing– CME/CEU events provided by project coordinator at each

of the pilot clinics have been completed– CME/CEU events are now planned by providers at each

individual pilot clinic regarding a specific DA of their choice

• Increase in the number of DA topics

Efforts to Increase Warm Handoffs

• Coach pre-visit chart review• Engage receptionists and schedulers• Dr. Engagement• PT referral plan• Patient Engagement

SDM at Mercy Clinics Inc.

• Care Team Reactions– Each of the 4 original pilot clinics were given the

option to opt out of the pilot going in to the 2nd year-none of the clinics did.

• Patient Reactions– “This hits it so on the head. I’m not the only one

going through this.”– “I wish I would have had this information when my

symptoms first started. The DVD my doctor asked me to watch has been extremely helpful.”

SDM at Mercy Clinics Inc.• Health Coach Reactions

– I had a patient write me a note thanking me for encouraging her to watch the DVD. When people take time to write you a note like that, you know you have made a difference and it feels great.

– Patients are happy when you take the time to do this. It doesn’t take too long.

– I’ve never had anyone be anything but positive.

• Provider Reactions– Patients come back with really good questions. They are

more focused and the visits are more productive and satisfying.

– They actually save me time during my busy day of seeing patients.

DA Issues to Resolve• Identification of appropriate patients

– Who benefits most from DAs– Who should identify the patient

• What is the best time to present the DA– Is Satisfaction higher if presented at time of referral

• What is the best way to engage the patient• Is face-to-face better than mailing

• What follow up should be done and by who• How do we use Health Coaches to optimize use of

DAs

Mercy Clinic Beliefs about SDMWhy it is Important to Health Reform Planning

• Fully informed patients– Will choose the best plan for themselves, yielding better

outcomes– Will often choose less expensive options – Will improve patient satisfaction

• SDM is patient centered and consistent with our values• It can free up physician time

– Provide self-management support more effectively and at less cost

– It will have a positive ROI

SDM is the next emerging trend in patient-centered care.

• We want to be there first.