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
SOURCE: National Accountable Care Organization Patient Activation and
Engagement Survey
ResultsLeader Beliefs About Patient Activation and
Engagement Efforts
SOURCE: National Accountable Care Organization Patient Activation and
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
Commonly Reported Findingsfrom Open Ended Questions
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.”
SOURCE: National Accountable Care Organization Patient
Activation and Engagement Survey
Commonly Reported Findingsfrom Open Ended Questions
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.”
“”
SOURCE: National Accountable Care Organization Patient
Activation and Engagement Survey
Interviewees and Site Visit Respondents Speak Their Voice
“”
SOURCE: National Accountable Care Organization Patient
Activation and Engagement Survey
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.”
Interviewees and Site Visit Respondents Speak Their Voice
(cont’d)
“”
SOURCE: National Accountable Care Organization Patient
Activation and Engagement Survey
“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.”
Interviewees and Site Visit Respondents Speak Their Voice
(cont’d)
“”
SOURCE: National Accountable Care Organization Patient
Activation and Engagement Survey
“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.”
Interviewees and Site Visit Respondents Speak Their Voice
(cont’d)
“”
SOURCE: National Accountable Care Organization Patient
Activation and Engagement Survey
“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.”
Interviewees and Site Visit Respondents Speak Their Voice
(cont’d)
“”
SOURCE: National Accountable Care Organization Patient
Activation and Engagement Survey
“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/
Thank You!
QUESTIONS AND DISCUSSION