accountable care organizations engaging patients and their

Are Accountable Care Organizations Engaging Patients and Their Families?

Results from a National Survey and Site Visits

Stephen M. Shortell, PhD, MBA, MPHBlue Cross of California Distinguished Professor of

Health Policy and ManagementDirector, Center for Healthcare Organizational and

Innovation Research (CHOIR),School of Public Health

Professor, Organizational Behavior, Haas School of Business, UC Berkeley

Fifth National Accountable Care CongressHyatt Regency Century PlazaLos Angeles, CANovember 11, 2014

•Salma Bibi, MPH

•Linda Neuhauser, PhD•Patricia Ramsay, MPH

•Neil Sehgal, MPH

Research Team – UC Berkeley

•Dominick Frosch, PhD – The Betty and Gordon Moore

Foundation•Judith Hibbard, DrPH – Oregon Health Sciences Cemter•Lynn Paget, Managing Partner, Health Policy Partners•Glen Elwyn, MD – The Dartmouth Institute and Geisel School of

Medicine•Elliott Fisher, MD, MPH – Director, The Dartmouth Institute and

Geisel School of Medicine•Stephen Samis, Canadian Health Services Research Foundation

External Advisory Committee

The Betty and Gordon Moore Foundation

The Commonwealth Fund

Acknowledgements

Essential Requirement:

New Ways to Deliver Care

Major Implication:

Cannot be done without more active engagement

with patients and their families

There is growing evidence that patient/family engagement is associated with higher quality and better

outcomes at the same or lower cost(Cosgrove, et al. 2103; Green and Hibbard 2012;

Hibbard, et al. 2013)

Major Challenges

•Historical doctor/patient relationships•Asymmetry of information and knowledge•Physician autonomy•Time demands•Complex change process: Many people

involved; a lot moving parts; a lot of training needed

•Variance in patients’

desires, wishes, etc.

PATIENT ACTIVATION involves understanding one’s own role in

the care process and having the knowledge, skills, and confidence

to take on that role.

PATIENT ENGAGEMENT is a broader concept that includes

patient activation, the interventions designed to increase it, and

the patient behavior that results from it.

•

Preventing disease and promoting health

•

Involvement in care planning and treatment–

shared decision

making

•

Involvement in advanced serious illness and end‐of‐life care

•

Involvement in the overall design and operation of the health

care delivery organization itself

Definitions and Dimensions

•

National Web‐based survey of ACOs (N = 101 respondents)

•

Phone interviews with 11 ACOs – key informants, both Medicare and commercial contracts.

•

Site Visits: •

Group Health Cooperative of Puget Sound

•

UCLA Medical Center and Health System

Data Sources

ResultsPatient and Family Direct Engagement

in their Care

SOURCE: National Accountable Care Organization Patient Activation and

Engagement Survey

ResultsPatient and Family Engagement in Practice

Improvement


Engagement Survey

ResultsLeader Beliefs About Patient Activation and

Engagement Efforts


Engagement Survey

Results

The greater the impact of patient activation and engagement in the ACO’s quality, cost and

overall success, the more likely they are to directly involve patients in their care

Commonly Reported Findingsfrom Open Ended Questions

Setting Treatment Goals: Common Themes

• Interdisciplinary care teams: PCP’s, care managers, nurses, social

workers, health coaches, etc.• Staffers trained in motivational interviewing techniques, shared

decision‐making, evidence‐based communication, etc.• Additional measures taken for high‐risk and chronic disease patients:

individually‐assigned care managers, etc.

• “We have Health Coaches who have been trained in motivational interviewing

and self‐management support who work with our patients after they have seen

their PCP to establish self‐management goals.”

• “This has been a difficult process to implement and the lack of education of the

physicians has been a barrier.”

Setting Treatment Goals: Key Quotes

SOURCE: National Accountable Care Organization Patient

Activation and Engagement Survey


Training of Clinicians: Common Themes

Training of Clinicians: Key Quotes

• ACO provides online training services or webinars on shared decision making• Training in shared decision making incorporated into new hire training with classes

or training sessions held periodically thereafter

• Focus in trainings on use of evidence‐based care protocols and patient

aids/resources to support SDM efforts

• PAE training focused on community health workers/health coaches/care

coordinators but it is challenging

• “Video coaching for improved patient communication techniques, utilization of

evidence‐based treatment programs, proactive office strategies to help close

care gaps of patients, and patient education.”

• “Health coaches are formally trained in motivational interviewing, etc. Providers

not yet, though we are considering the development of a curriculum for them.”




Challenges Involved: Common Themes

Challenges Involved: Key Quotes

• Difficult to build momentum for increased PAE efforts within ACO• Many ACO’s just beginning to ramp up patient activation and engagement

initiatives• The work is challenging

• “This has been a difficult process to implement, and the lack of education

of the physicians has been a barrier.”• “Patient engagement will determine whether or not an ACO will be

successful.”• It is a struggle but worth it in the end.”

“”



Interviewees and Site Visit Respondents Speak Their Voice

“”



We had a patient…

“who went 132 times in 12 months to the emergency

department. She is … in a wheelchair…

lives in a house with no ramp. She

doesn’t have much social support, doesn’t have any food. A diabetic, out of

control. She doesn’t have a refrigerator for insulin. From one visit, we

engaged our team of care management (who)…

built her a ramp, donated a

refrigerator, and hooked her up to an equivalent of Meals on Wheels so she

has food, and arranged for transportation to get her to regular visits to her

primary care physician. And in the past ten months…

she’s not been back

(into the ER) one time.”


(cont’d)

“”



“We’re evaluating how to engage patients, whether it’s with third

party software, whether it is texting. I don’t think we’ve cracked

the code here. I think this is where we are going to spend a lot

of

our time.”

“A provider could ….say, ‘ I’d like to have you watch a video, and

we can talk about it later and decide what treatment option is

right for you,’

or they could point them to My Group Health, our

secure patient portal, and they could watch the video streaming

online. …Since January of 2009 we’ve delivered over forty

thousand decision aids.”


(cont’d)

“”



“We have the same struggles that I am sure everybody else does. And

that is, are we really building patient‐centric care or is it just a

continuation of provider centric?”

“Our clinicians have…..so much on their plates that it’s really hard for

them to think about the full package that’s available for their patients.

….there’s competing priorities.”

“We have a lot of really good data; mining that data;.. and then acting

on it…

is our biggest challenge.”


(cont’d)

“”



“We gave them [patients] an initial care pathway as we saw it, and

had them fill in what we missed. Every single interview raised using

catheters as a point of anxiety for the patient; and the urologist didn't

realize that that was a point of anxiety.”

It is hard to do his kind of work because it’s got to be professionally led …but

it’s through the engagement of people in the trenches that you get the

acceptance and the spread, but it takes time. It takes a lot of effort to do

that.”


(cont’d)

“”



“So when we first started putting care coordinators in the offices, we got

pushback from the doctors that you’re taking away some of the things I

used to do. But after they got familiar with it and realized that these

aren’t things that you really need a medical degree for and it actually

means that the minutes I’m in the room with the patient I can talk to the

patient about their health (they were OK with it).”

•

Likely over‐estimate the amount of PAE occurring to respondents more likely to be doing more than non‐ respondents

•

Cannot generalize•

Interviewed knowledgeable leaders. Frontline

clinicians and staff may have different views.•

Findings reflect associations: no causal inferences

Limitations

•

Movement away from fee‐for‐serve to global budgets

•

Increased patient cost sharing•

Accountability/transparency and advances in

measurement•

Movement towards Accountable Communities for

Health –

expanded opportunities for citizen participation and engagement

Emerging Developments

•

Five hospital system; 26 clinics; Appleton, Wisconsin•

LEAN Production

•

Developed a bedside care team composed of a physician (medical expert), nurse (care progression

manager), pharmacist (medication expert), discharge planner (transitional needs coordinator), patient, and family.

•

Developed a single care plan continuously updated in daily team huddles

•

Set a discharge date from the beginning and work backwards to achieve it

What Can Happen ‐The Thedacare Collaborative Example

Source: Thedacare

Traditional vs. Collaborative Care

Benefits of the Collaborative Care Model

Source: Thedacare

Moving from “what is the matter with you?”

to

“what matters to you?”

In Conclusion

http://choir.berkeley.edu/

[email protected]

Thank You!

QUESTIONS AND DISCUSSION

http://choir.berkeley.edu/

accountable care organizations engaging patients and their

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