an aco case study: quality improvement in healthcare

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Quality Improvement in Healthcare:An ACO Palliative Care Case Study



Learning Objectives

Using technology-enabled solutions to drive

community engagement

Driving patient, physician and community

engagement

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1Learn how OSF – a Pioneer ACO – is improving healthcare quality and delivering on the Triple Aim

2Explore innovative ways to improve care coordination



Presenters

Dr. Robert SawickiSenior Vice President, Supportive Care

Linda Fehr, RNDivision Director, Supportive Care

Roopa Foulger Executive Director, Data Delivery

2014 IHA Tim Phillip

Award for Excellence

in Palliative Care

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Poll Questions

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a. Integrated delivery system – 19%

b. Hospital – 15%

c. Physician Group – 3%

d. Other – 62%

1 How are you involved in healthcare? 146 respondents

2 What is your role? 166 respondents

a. Management – 37%

b. Quality Improvement – 15%

c. IT – 19%

d. Consultant – 29%





OSF and the Triple Aim

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OSF Healthcare

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93Locations

667Providers

1.5M Patients annually

185K Home Health annually

267 Hospice daily census (avr)

Vis

its


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OSF Mission


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OSF ACO “Triple Aim”



OSF Triple Aim & IOM Six Aims for Improvement

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OS

F T

riple

Aim

Institute of Medicine

(IOM) Six Aims for

Improvement

Safety

Effectiveness

Efficiency

Patient-Centered Care

Timeliness

Equitable



Poll Question

On a scale of 1 to 5, with 5 being the highest, how

would you rate your healthcare organization’s

progress on achieving the Triple Aim and the IOM Six

Aims for Improvement? 133 respondents

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1 2 3 4 5

9% 21% 44% 23% 3%



Palliative (Supportive) Care

Palliative care is specialized medical care for people with serious illness. It is provided by a team of doctors, nurses and other specialists who work with a patient’s other doctors to provide an extra layer of support and is appropriate at any age, any stage in an illness and can be provided together with curative treatment.

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Palliative Care



The Why of Supportive Care“It’s always too early, until it’s too late” *

What does Advance Care Planning mean to patients?

To understand, discuss and record plans for a future scenario

when they cannot make their own medical decisions

To feel confident that their end-of-life care preferences will be

honored

Who is Advance Care Planning appropriate for?

All of us, ideally, but especially chronically ill patients

Why is Advance Care Planning important?

To provide higher quality end-of-life care that honors patients'

values, goals, and preferences

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*Source: Dr. Lachalan Forrow



Advance Care Planning

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Durable Power of Attorney-

Healthcare (DPOA-HC)



Poll Question

Does your healthcare organization have a palliative

(supportive) care program? 160 respondents

a) Yes – 36%

b) No – 14%

c) Unsure or not applicable – 50%

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Improving the Quality of Care2014 IOM Dying in America Report

Key Objectives

Evaluate end-of-life care strategies to integrate patient- and family-centered framework

Recommend options for aligning care with values, preferences and beliefs to promote high quality cost effective care

Offer a communication strategy to promote public engagement

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IOM Findings

Financial incentives are

misaligned with patient desires

Major reform is needed to ensure

higher quality, affordable, and

sustainable end-of-life care

Chronic conditions and functional

limitations are key drivers of high

health care costs

Increased health care spending

is not associated with higher-

quality care

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An estimated 13 % of

$1.6 T in healthcare costs

is for the care of

individuals in their

last year of life*

*Source: Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life © 2014

13%



IOM Recommendations

An early palliative care approach affords the

highest quality of life

Improve quality and availability of medical and social

services

Early and continuous conversations with patients

on advance care planning

Advance care planning should be paid for by

government and private health insurers

Improve alignment of financial incentives with patient

desires

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NEJM Study: Benefits of Palliative Care

Source; Temel, J.S., et al. (2010). Early palliative care for patients with metastatic non-small cell lung cancer. NEJM. 363, 733-742.

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Median survival was

longer among patients

receiving early

palliative care

(11.6 months vs. 8.9

months, P=0.02)

Improve-

ments in

quality of

life

Fewer

depressive

symptoms



Additional Research FindingsInt J Crit Illness Inj Sci (2012): Advance Directives in the trauma ICU*

Advance directives, when approached in the conventional way, have limited utility

They are not helpful in improving care quality, improving patient/family satisfaction, or lowering costs

A DPOA-HC does not capture the patient’s values and preferences

Advance care planning does

Help better ensure patients’ desires are respected

Reduce caregiver stress and symptoms of post-traumatic anxiety and depression

Help family members feel more peaceful and satisfied that their loved one’s wishes were acted upon

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*Source: “Advance directives in the trauma intensive care unit: Do they really matter?” Int J Crit Illn Inj Sci. 2011 Jul-Dec; 1(2): 132–137



Poll Question

On a scale of 1 to 5, with 5 being the highest, how

well do you think your healthcare organization

understands the value of advance care planning?

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1 2 3 4 5

7% 25% 35% 24% 9%





Using Innovation to Improve Care Coordination

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High Risk Patients: Project Goals Understand and align patients’ value system with their healthcare

goals

Leverage the OSF supportive care program in a community-wide

initiative

Dramatically increase the number of patients completing advance

care planning

Drive the engagement of clinician, employees and facilitators to help

patients complete advance care planning

Provide optimized care coordination for patients

Quickly deploy a solution that could be used by all individuals who

were engaging with the patients to document their conversations,

advance care plan and DOPA-HC

Provide real-time customized reporting to track targets versus goals

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The Importance of Care Coordination

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Outpatient

Home

Clinic care Hospice

Skilled nursing facility

Inpatient

Home health care

Care

CoordinationCommunity outreach

and education



Improved Quality of Life and Care Coordination

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Pain

Shortness of breath

Fatigue

Constipation

Nausea

Loss of appetite

Difficulty sleeping

Depression

Improve quality of life

Emotional support

Spiritual support

Doctor

Nurse

Social Worker

Chaplain

Physical therapists

Music & art therapists

Home health aides

Treatment options

Improve quality of

life

Emotional support

Spiritual support

Help navigating the

system

Smoother care

transitions

Source: Center to Advance Palliative Care © 2012

Family/

caregiver support

Pain & symptom

controlSupport for patient

Team approach:

Communication &

Coordination



Technology-Enabled Solutions to Drive Community Engagement

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Custom reporting

(supportive care team,

clinicians, executives)

EDW

Platform

Identification of

high risk patients Community enters data into an

easy to use, accessible

database

Supports heterogeneous EHR

environments

Deployable in days

Advance care planning

information is integrated

into the OSF patient EHR



Driving Engagement

Physicians, care providers, facilitators, employees

were trained to…

Initiate the conversation

Identify the patients’ values

Translate the patients’ values into medical decision making

Document the patients’ stated preferences for care

Co-sponsored “Considering the Conversation”

screening with 2 large hospital systems

Developed a healthy competition with accessible,

customized reports

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Outcomes

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Outcomes

Outcome Targets Actuals

Number of high-risk patients

who had completed advance

care planning

1200 1243

Total number of patients who

completed advance care

planning

4,300 in 2014;

16,000 to date

Number of engaged

physicians, nurses, parish

nurse facilitators, employees…

980

One common database to

enable tracking and reporting

Easy-to-use

Accessible for OSF and

community-wide

patients and individuals

Rapid deployment

Easy-to-use interface

Supports heterogeneous

EHR environment

Deployed in days

Timely, customizable reporting

Facilitator reporting,

identifying high-risk patients

Customized reports

(supportive care, clinicians

and executives)

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Patient Perspective

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“I didn’t expect to need palliative care services

so soon. But this summer I underwent cancer

surgery. It was a huge relief to know my advance

care planning was already done — and that my

desires were understood by my family members.

I’ve told everyone about the palliative care

services OSF provides and how grateful I am for

their community wide service.”

- Oncology patient





What’s Next

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Future Goals

Expand advance care planning discussion targets to non-high risk patients

Continue to drive employee and employee family member engagement in their own advance care planning

Ensuring patients wishes are met

Compare desired versus actual treatments

Correlate how well the patients’ care goals were met and the timing of the advance care planning discussion

Analyze readmissions rates for patients with advance care plans, versus those without advance care plans

Evaluate the number of referrals to patients with advance care plans who are referred to hospice

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Concluding Reflections

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Palliative care

improves the quality of

life for the patient

It is a team-approach to

care that addresses the

patient and family’s

physical, emotional and

spiritual needs

Palliative care is

integral to

healthcare

organizations

meeting the Triple

Aim