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Engaging Patients: Shared Decision Making

March, 2013 Susan Brown, RN MBA

Assistant Group Operations Director

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Intermountain Healthcare

• 22 hospitals

• 185 clinics

• SelectHealth

• 33,000 employees

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Intermountain Medical Group

• 4,965 Total Employees (3856 FTEs)

• 984 physicians (865 FTEs)

325 primary care (Peds, FM, IM)

462 secondary care

83 hospitalists

114 urgent care

• 237 advanced practice clinicians (177 FTEs)

3 Source: Intermountain Medical Group Strategic Planning, January 2013

Susan Dentzer,, Editor-in-Chief, Health Affairs, 32(2): 202.

The ‘blockbuster drug of the century’ revealed in this issue!

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Many ways to define the concept…

• Patient engagement: actions that people take for their health and to benefit from care (Institute for Healthcare Improvement)

• Patient activation: understanding one’s own role in the care process and having the knowledge, skills, and confidence to take on that role

Source: Hibbard et al

• Share decision making is intended to improve patient knowledge and involvement in decision-making to promote an informed, value-based choice among two or more medically reasonable alternatives…

Many ways to define the concept…

Source: O’Connor et al

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Many ways to define the concept…

• Supports patient and clinician communication when faced with the task of making unique and complex medical decisions

• Facilitated by using specially designed education and decision tools

• Patients are supported to arrive at informed preferences based on their own values

7 Source: Lucy Savitz, Ph.D., MBA, Institute for Health Care Delivery Research

Optimism bias

• A Tour of the Irrationally Positive Brain by Tali Sharot

• NPR: Your Child’s Fat, Mine’s Fine: Rose Colored Glasses and the Obesity Epidemic

http://www.npr.org/templates/archives/archive.php?thingId=173277975

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Engaging and activating patients…

• Affordable Care Act – no patient role in ACOs

• Shared Accountability – payers, health care delivery, and patients all working together

• Implementation of shared decision making a key strategy

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Engaging and activating patients…

• Shared decision making: 2014 Intermountain Board goal

• Patient activation: CMMI contract ‘Disruptive Innovation @ Intermountain Healthcare’ awarded to Intermountain in June 2012

• Shared decision making: CMMI contract titled ‘Engaging patients to meet the Triple Aim’ awarded to Dartmouth College in June 2012

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Intermountain Healthcare Board Goal

We will use Shared Decision Making for 50% of Intermountain employees seeking care from an Intermountain Medical Group physician in five key medical interventions in 2014: – Bariatric surgery for morbid obesity

– Breast cancer treatment options

– Urologic cancer treatment decisions

– Low back pain

– Total joint replacement, hip and knee

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Intermountain Healthcare Board Goal

• Emmi Solutions selected

• Contract signed and executed January 2013

• Will implement in North Salt Lake and Central Salt Lake in 2013

• Expand implementation 2013-2014

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Emmi

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Emmi

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Emmi

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High Value Healthcare Collaborative

• Dartmouth awarded CMS Innovation contract on behalf of HVHC

• HVHC chose to use Health Dialog content

16 Source: Health Affairs, September 2012

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High Value Healthcare Collaborative

• The goal is to demonstrate triple aim outcomes for high cost conditions (diabetes, heart failure) and treatments (hip and knee arthroplasty, spine surgery)

• Strategies:

– Enhance infrastructure with Health Dialog content

– Develop and train new workforce

– Pilot in Southwest Region

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Health Dialog

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Health Dialog

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Health Dialog

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Health Dialog

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CMMI: Disruptive Innovation

• Intermountain Healthcare proposes to invest in technology and workforce development to test a new care delivery model that achieves the triple aim in a rapid, measurable, patient outcome enhancing, cost saving, and sustainable manner.

Source: Lucy Savitz, Ph.D., MBA, Institute for Health Care Delivery Research

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Individualized Guidelines and Outcomes (IndiGO)

• Simulation model of human physiology, clinical events, and health behaviors

• Accurately calculates changes in outcomes for several interventions

• Will interface with our EDW and surface within HELP2

• Validated in over 50 clinical trials

IndiGO

• Focuses on patient activation in self management of hypertension, cardiovascular disease, and diabetes

• In year 2 will develop and test an extension of the model that incorporates depression as a risk factor

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IndiGO

• Design to fit system data, implement production code, construct interfaces, and test data acceptance (July 2012 – August 2013)

• Phased clinical rollout Feb 2013 – March 2015

• Implementation resource is available through the CMMI contract

Copyright 2010 Archimedes

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Copyright 2010 Archimedes

Copyright 2010 Archimedes

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Health Affairs

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Despite evidence that they can inform

patients, decision aids alone are not

sufficient to ensure that shared decision

making will take place. Even after a patient

uses a decision aid, shared decision making

still requires that the provider learn the

patient’s values and preferences, that the

patient and provider reach a decision

together, and that the patient receive care

concordant with this decision.

Source: Health Affairs, March 2013

Implementation structure

Support and leadership from

• Senior leaders and trustees

• Executive teams (Medical Group, SelectHealth, Clinical Programs, hospitals)

• Central operations and quality improvement leadership, project management, and coordination

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Implementation structure

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Region based

– Region Nurse Consultant

– Medical Director

– Operations Director

– Advisory Committee

Clinical Quality Medical Director

Cost of Care Operations Director

Patient Experience Region Nurse Consultant

Implementation structure

Clinic level teams

– Lead physician

– Lead clinician (RN, MA, PSR)

– Clinic manager, department manager, department lead

– Personalized Primary Care

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Care Management teams

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RN Care Manager

Health Advocate (Medical Assistant)

Clinician – Medical Assistant team

Long term success…

• The people who take care of people

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Metrics

These are in development and may include

• Number of times ordered by team

• Number of times viewed by unique patient

• Engagement of care management for health coaching

• Utilization rates of preference sensitive therapies

• Improvements in optimal chronic disease management metrics

• Trends in overall patient experience

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Your questions and comments…

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