suzie burke-bebee dnp msis ms rn diana r. jolles cnm...
TRANSCRIPT
Suzie Burke-Bebee DNP MSIS MS RN
Senior Health Informatician
Department of Health & Human Services/OS/ASPE
Diana R. Jolles CNM MS
Texas Woman’s University, Houston
PhD Student, Nursing Research
Unwarranted Variations in care
1 • Identify and understand the Shared Decision
Making Model as applied to clinical practice
2
• Recognize the benefits and challenges when implementing SDM throughout the patient’s life cycle (birth to end-of-life)
3
• Describe the impact of shared decision making in the context of providers and two elderly patients seeking care at the end of life
Landscape
Supreme Court
Patient Protection and Affordable Care Act (ACA)
Affordable, effective commerce
Impact Better care
Healthy people and
communities
Affordable care
1. Improve patient, family and caregiver experience
Quality Safety Access across settings
2. In partnership with patients, families and caregivers- and using a shared decision-making process- develop culturally sensitive and understandable care plans.
3. Enable patients and their families and caregivers to navigate, coordinate and manage their care appropriately and effectively.
Wide variation Safe
Effective
Affordable
Unwarranted Variations in Care
Supply Sensitive
Preference Sensitive
CHF
HIV
Dementia
Knee or hip osteoarthritis
Preventive screenings: breast, prostate, cervical
Family / Person Centered Care
Family/ Person centered
Satisfaction
Experience of care
Client engagement
Shared decision making
Values
Goals
Balance both clinical guidelines and family preferences.
Kim
• 1983
• Collaborative Decision Making
Hamilton
• 1995
• Therapeutic Partnership
Elwyn
• 2012
• Shared Decision Making
Deliberation
Initial Informed Preferences Preferences
Decision Support
Brief as well as Extensive
Decision
Talk
Option
Talk
Choice
Talk Decisions
Elwyn, G., Frosch, D., Thomson, R., Joseph-Williams, N., Lloyd, A., Kinnersley, P., Cording, E., Tomson, D., Dodd, C., Rolilnick, S.,
Edwards, A., and Barry, M. (2012). Shared decision making: a model for clinical practice. Journal of General Internal Medicine, 27 (10),
1361-1367. doi: 10.1007/s11606-012-2077-6.
Evidence
Research
Mortality risk
Optimal
NICE guidelines
Guidelines.gov
Practice
Lack of guidance to implement SDM25
“gray zone” (Kon)
Facultative rather than directive
Lack of communication
Accountability
NQF endorsed measures
Joint Commission
Hospital compare
DUALISM DISEASE VS PERSON FOCUS
Person centered
Access
Appropriate
Effective
Cultural humility
Values Based
Seamless
Understandable
Information sharing
Corr
ect qu
estio
n
• Perception
• Awareness R
ealit
ies
Patt
ern
s
• Directives
• Emergence
• Validation
Birth Payer
“choice” Death
Birth plan
Values
Needs
Culture
Death plan
Values
Needs
Culture
“Hospitals can also treat people inappropriately because staff do not recognize that the person is dying”
(Committee on Public Accounts, 2009)
70% prefer to die at home, 70% die in a facility
80% say that if seriously ill, they would want to talk to their doctor about end-of-life care, though 7% reported having a conversation. 60% report acknowledgement of their goals
40 % part of decision making team
Wide variation in informed consent (20%- 80%)16,24
COMMUNICATION AND ACCOUNTABILITY
INFRASTRUCTURE
TOOLS TO COMMUNICATE CLINICAL HISTORY, PREFERENCES, PROGNOSIS, VALUES
INFRASTRCTURE
ENVIRONMENT OF CARE, APPROPRIATE USE,
THE CULTURE OF MEDICINE
“developing an awareness of one’s own existence, sensations, thoughts and environment without letting it have an undue influence on those from other backgrounds;…..accepting and respecting cultural differences; adapting care to be congruent with the client’s culture”
(Flowers, 2004)
NURSING
TOOLS
ACCOUNTABILITY
LEADERSHIP
COLLABORATION
PRACTICE IMPROVEMENT
Interprofessional Teamwork
EHRs
Decision Aids
Mobile Apps
Tools Cultural Awareness Assessment Tool
Interproffesional Teamwork
Technocratic holistic spectrum
Patient Centered Care Improvement Guide (2008) Planetree.org
Liverpool Care Pathway
Decision Aids Cochrane (treatment or screening decisions)
Decrease hip and knee surgery and cost
Breast and prostate cancers
National Maternity Care
Caringinfo.org/stateaddownload/
AHRQ 10 Questions you should know
1. What is the test for?
2. How many times have you done this procedure?
3. When will I get the results?
4. Why do I need this treatment?
5. Are there any alternatives?
6. What are the possible complications?
7. Which hospital is best for my needs?
8. How do you spell the name of that drug?
9. Are there any side effects?
10. Will this medicine interact with medicines that I’m already taking?
SDM Resources
Ottawa Personal Decision Guide (OPDG)
International Patient Decision Aids Standards (IPDAS) Collaboration
Mayo Clinic SDM National Resource Center
MAGIC Program
Shared Decision Making Resource Centre
Informed Medical Decisions
Foundation
40 Court Street
Suite 300
Boston, MA 02108
National Quality Forum Endorsed Measures
NQF 0469: Elective Delivery (Joint Commission)
NQF 0480: Exclusive Breast Milk Feeding (Joint Commission)
NQF 1626: Patients admitted to the ICU who have care preferences documented (RAND) NQF palliative care endorsement summary
NQF 1641: Hospice and palliative care- treatment preferences: percentage of patients with chart documentation of preferences for life sustaining TX
NATIONAL QUALITY FORM
ENDORSED MEASURES
Family-Centered Shared Decision Making
Effective Access
Shared decision making
Accountability
values
prognosis
goals
transformation
Effective Communication
MJ CASE STUDY SYSTEMS ROOT CASE
LC CASE STUDY SYSTEMS ROOT CAUSE
Family-Centered life course approach
Systems level failure and systems level solutions DNP opportunity
DNP/PhD collaborations
INTERPROFESSIONAL education
1. Jost, T. The Supreme Court on the individual mandates constitutionality: an overview. Health Affairs Blog; June 12, 2012. http://healthaffairs.org/blog/2012/06/28/the-supreme-court-on-the-individual-mandates-constitutionality-an-overview/. Accessed March 13, 2013.
2. Triple Aim IHI http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx
3. Triple Aim IOM http://www.iom.edu/~/media/Files/Activity%20Files/Quality/VSRT/Core%20Metrics%20Workshop/Core%20Metrics_1pager_13Mar12.pdf
4. Intent of moving from FFS to VBP
5. Roades, C. What the Supreme Court’s ACA ruling will mean for providers. Health Affairs Blog; June 28, 2012. http://healthaffairs.org/blog/2012/06/28/what-the-supreme-courts-aca-ruling-will-mean-for-providers/. Accessed March 13, 2013.
6. Millenson, M. & Macri, J. Will the Affordable Care Act move patient-centeredness to center stage? Urban Institute. March 2012. http://www.urban.org/UploadedPDF/412524-will-the-affordable-care-act.pdf. Accessed March 13, 2013.
7. Frampton, S., Guastello, S., Brady, C., Hale., & Horowitz, S., et. al. Patient-Centered Care Improvement Guide. October 2008. http://planetree.org/wp-content/uploads/2012/01/Patient-Centered-Care-Improvement-Guide-10-28-09-Final.pdf. Accessed March 13, 2013.
8. Emanuel, E. & Emanuel, L. (1992). Four models of the physician-patient relationship. The Journal of the American Medical Association, 267 (16), 2221-2226.
9. Allen, A., Stevenson, l., Grady, K., Goldstein, N., Matlock, D., Arnold, R., Cook, N., Felker, G., Francis, G., Hauptman, P., Havranek, E., Krumholz, H., Mancini, D., Riegel, B.,& Spertus, J. Decision making in advanced heart failure: a scientific statement from the American Heart Association, 125, 1928-1952. doi: 10.1161/CIR.0b013e31824f2173
10. Frosch, D. & Kaplan, R. (1999). Shared decision making in clinical medicine: past research and future direction. American Journal of Preventive Medicine, 17 (4), 285-294.
11. Frosch, D., Moulton, B., Wexler, R., Holmes-Rovner, M., Volk, R., & Levin, C. (2011). Shared decision making in the United States: policy and implementation activity on multiple fronts,
12. Lee, E. & Ezekiel, E. (2013). Shared decision making to improve care and reduce cost. New England Journal of Medicine, 368 (1), 6-8.
13. Godlee, F. interview with J. Wennberg. (2011). Time to tackle unwarranted variations in practice. British Medical Journal, 342, 687-690.
14. Arterburn, D., Wellman, R., Westbrook, E., Rutter, C., Ross, T., McCulloch, D., Handley, M., & Jung, C. (2012). Introducing decision aids at Group Health was linked to sharply lower hip and knee surgery rates and costs. Health Affairs, 31 (9), 2094-2104. doi: 10.1377/hlthaff.2011.0686
15. Ricciardi, L., Mostashari, F., & Murphy, J. (2013). A national action plan to support consumer engagement via e-health. Health Affairs, 32 (2), 376-384.
16. Alston, C., Paget, L., Halvorson, G., Novelli, B., Guest, J., McCabe, P., Hoffman, K., Koepke, C., Simon, M.,
Sutton, S., Okun, S., Wicks, P., Undem, T., Rohrbach, V., & Von Kohorn, I. (2012).
Communicating with patients on health care evidence. Discussion Paper, Institute of Medicine, Washington, DC.
http://www.iom.edu/evidence. Accessed March 17, 2013.
17. Beach, M., Duggan, P., & Moore, R. (2007). Is patients’ preferred involvement in health decisions related to
outcomes for patients with HIV? Health Decisions, 22, 1119-1124.
18. Smebye, K., Kirkevold, M., & Engedal, K. (2012). How do persons with dementia participate in decision making
related to health and daily care? A multi-case study. BMC Health Services Research, 12 (241), 1-12.
19. Givens, J., Kiely, D., Carey, K., & Mitchell, S. (2009). Health care proxies of nursing home residents with
advanced dementia: decisions they confront and their satisfaction with decision-making. Journal of the American
Geriatric Society, 57 (7), 1149-1155. doi: 10.1111/j.1532-5415.2009.02304.x.
20. AHRQ Health Care Innovations Exchange: Shared decision making for breast cancer patients leads to high
levels of patient satisfaction, and comfort with decisions and treatment preferences. Dartmouth-Hitchcock Medical
Center. (2010). http://www.innovations.ahrq.gov/content.aspx?id=2811 Accessed March 20, 2013.
21. Sepucha, K., & Belkora, J. (2007). Putting shared decision making to work in breast and prostate cancers: tools
for community oncologists. Community Oncology, 4 (11), 685-691.
22. Volk, R., Cass, A., & Spann, S. (2009). A randomized controlled trial of shared decision making for prostate cancer screening. Archival Family Medicine, 8, 333-340.
23. Millenson, M. (2012). Building patient-centeredness in the real world: the engaged patient and the accountable care organization. http://www.nationalpartnership.org/site/DocServer/ACO-Report-HQA-NPWF.pdf?docID=10481
Accessed March 20, 2013.
24. Zikmund-Fisher, B., Couper, M., Singer, E., Ubel, P., Ziniel, S., & Fowler, F. (2010). Deficits and variations in patients’ experience with making 9 common medical decisions: the DECISIONS Survey, 30, 85S-95S. doi: 10.1177/0272989X10380466
25. Elwyn, G., Frosch, D., Thomson, R., Joseph-Williams, N., Lloyd, A., Kinnersley, P., Cording, E., Tomson, D., Dodd, C., Rolilnick, S., Edwards, A., and Barry, M. (2012). Shared decision making: a model for clinical practice. Journal of General Internal Medicine, 27 (10), 1361-1367. doi: 10.1007/s11606-012-2077-6.
26. Coylewright, M., Montori, V., & Ting, H. (2012). Patient-centered shared-decision making: a public imperative. The American Journal of Medicine, 125 (6), 545-547. doi: 10.1016/j.amjmed.2011.12.007
27. Kon, A. (2006). Answering the question: “Doctor, if this were your child, what would you do?” Pediatrics, 118, 393-397. doi: 10.1542/peds.2005-2655.