Patient-Centered Primary Care Collaborative of Central Ohio Q1 2013 Learning Session TOPIC: Provider-based Patient Engagement Learning Session Sponsored by Nationwide
Please save the following dates for 2013 learning sessions (7:30-10:30AM): • Friday, May 31 • Friday, September 27 • Friday, December 6
www.accesshealthcolumbus.org Lead Support
Major Support
Additional Support 100% Access HealthColumbus Board & Staff Individual & Corporate Donations
PatientCentered Medical Homes (PCMH)
Value-based Purchasing
2013-2014 Primary Care Improvement Projects
Provider-based PatientEngagement
Primary Care Quality Reporting
PatientCentered Medical Homes (PCMH)
Value-based Purchasing
2013-2014 Primary Care Improvement Projects
Provider-based PatientEngagement
Primary Care Quality Reporting
SPREAD: Patient-Centered Medical Homes (PCMH)
In coordination with Access HealthColumbus: Coordinated by others: Recognized PCMHs
Recognized PCMHs
Emerging PCMHs
SPREAD: Patient-Centered Medical Homes (PCMH) 1200
500,000 450,000
1000
400,000
800
350,000
600 400 200
Emerging PCMHs
1,205
Total PCPs
200
Emerging PCMHs
250
Recognized PCMHs
0 Recognized Total Primary PCMH Care Practitioners* Practitioners (PCPs)** Sources * National Committee for Quality Assurance (NCQA) ** Practicing PCPs in Franklin County provided by Columbus Medical Association
300,000 250,000 200,000
Recognized PCMHs
150,000 100,000 50,000 0 Estimated Patients Served by PCMHs
Feb 21, 2013 Ohio Receives Federal Grant to Advance Health Care Payment Innovation One of 16 states to receive design grant
Ohio’s State Innovation Model Proposal 1. Expand the capacity and availability of qualified medical homes to most Ohioans across Medicaid, Medicare, and commercially insured patients in a 3-5 year timeframe 2. Define and administer episode-based payments for a majority of acute medical events across Medicaid, Medicare, and commercially insured patients in a 3-5 year timeframe SOURCE: State Innovation Model Design Grant Application, Ohio Office of Health Transformation, September 21, 2012.
PatientCentered Medical Homes (PCMH)
Value-based Purchasing
2013-2014 Primary Care Improvement Projects
Provider-based PatientEngagement
Primary Care Quality Reporting
Primary Care Quality Reporting Measures & Values – Diabetes management outcomes For Diabetes management outcomes (test results), blood sugar levels and cholesterol have a mix of positive and negative change values. Blood pressure levels, however, show improvement in six of the seven practices reporting in the December 2012 reports. Graphed below are the aggregated results for the three practices that participated in all three Improvement Dashboard submissions.
Primary Care Quality Reporting Measures & Values – Utilization from health plan data Emergency Department utilization rates show favorable change patterns in six of eight practices, and are favorable in aggregate. Hospitalization rates show favorable change patterns in four of eight practices and are less consistent than emergency rates. They are favorable in aggregate.
PatientCentered Medical Homes (PCMH)
Value-based Purchasing
2013-2014 Primary Care Improvement Projects
Provider-based PatientEngagement
Primary Care Quality Reporting
Value-based Purchaser Collaborative of Central Ohio 2013-2014 Value-based Benefit Design Project Model actionable benefit strategies and designs that reallocate scarce resources from lower-value to higher-value health services based on evidence compiled by others Collaborative Approach WHAT: Higher-value health services DELIVERABLES: 1. HOW: (participating purchasers utilize learning 2. in alignment with their organizational Incentive-based 3. cultures and priorities) best practices 4. A. Inventory of actionable 5. value-based designs for: HOW: • Benefit Programs Health plan/TPA • Payment and Contracting administration WHAT: Lower-value B. Inventory of actionable best practice strategies and tools to health services support the engagement of 1. business leaders, health care HOW: 2. providers, health plans and Disincentive3. beneficiaries/patients based best 4. practices 5.
PatientCentered Medical Homes (PCMH)
Value-based Purchasing
2013-2014 Primary Care Improvement Projects
Provider-based Patient Engagement
Primary Care Quality Reporting
Today’s Objectives
As a patient/parent/caregiver…. AWARENESS on value of improving Provider-based Patient-Engagement EXPLORE promising best practices from around the country -- a good place to start! IDENTIFY commitments to advance patient engagement as a standard of care in Central Ohio
Today’s Objectives As a patient/parent/caregiver…. AWARENESS on value of improving Provider-based Patient-Engagement EXPLORE promising best practices from around the country -- a good place to start! IDENTIFY commitments to advance patient engagement as a standard of care in Central Ohio
SPREAD PROVIDER-BASED PATIENT ENGAGEMENT: New project starting 2013
Is Patient Engagement the next “Blockbuster Drug�? What could happen that would make patient engagement a standard of care in Central Ohio? What could be different? Patient and caregiver voices and perspectives embedded in quality improvement initiatives
Purchasers provide incentives to primary care teams to accelerate patient engagement as a standard of care
Clinicians fully utilizing their potential as the three most trusted* professions: Nurses, Pharmacists, Doctors (*Gallup poll)
More patients have improved health status and economic productivity
patient activation Understanding one’s role in the care process and having the knowledge, skill, and confidence to manage one’s health and health care patient engagement A broader concept that includes activation; the interventions designed to increase activation; and patient’s resulting behavior standard of care A formal diagnostic and treatment process a doctor will follow for a patient with a certain set of symptoms or a specific illness. That standard will follow guidelines and protocols that experts would agree with as most appropriate, also called "best practice. local provider-based patient engagement objective Based on best practices, partner with primary care teams to implement improvements that advance patient engagement as a standard of care in Central Ohio
Feb 2013
why?
Better Care for Individuals Better Health for Populations Lower Per Capita Costs
why?
Barriers: What can hinder patient and family engagement? AHRQ: Guide to Patient and Family Engagement: Environmental Scan Report, May 2012
PATIENTS & FAMILIES • Fear and uncertainty • Health literacy • Provider reactions
PROVIDERS • Professional norms and experiences • Fear of litigation • Perceived level of effort
why?
Evidence is emerging on the value of patient engagement/activation
COLLABORATION BETWEEN PATIENTS , FAMILIES & PROVIDERS • Better health outcomes • Lower health costs • Improved satisfaction for providers, patients, and families Source: Health Affairs, February 2013
why?
Patients with lower activation associated with higher costs (per capita billed costs) All patients Hyperlipidemia (n=33,163) (n=10,515)
Hypertension (n=12,175)
Asthma (n=3,347)
Diabetes (n=4,253)
Lowest Activation
$4,679
$6,089
$7,687
$6,581
$8,474
Highest Activation
$4,320
$5,454
$6,750
$5,442
$7,901
$359 x 1,000,000 people in Central Ohio = real value As health care delivery systems move toward assuming greater accountability for costs and outcomes for defined populations, knowing patients’ ability and willingness to manage their health will be a relevant piece of information integral to health care providers’ ability to improve outcomes and lower costs.
Source: Health Affairs, February 2013
what?
Source: Engaging Patients and Families in the Medical Home, Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, June 2010
how?
Today’s Objectives As a patient/parent/caregiver…. AWARENESS on value of improving Provider-based Patient-Engagement EXPLORE promising best practices from around the country -- a good place to start! IDENTIFY commitments to advance patient engagement as a standard of care in Central Ohio
What might happen if patient engagement became a standard of care?
Patients and families engaged in their own care Communication and Information Sharing • Get help with organizing and coordinating care Self-care • Work with team to set self-care goals • Get help with managing chronic illness • Participate in activities to reduce health risks • Participate in peer support groups Decision-making • Use evidence-based decision aids • Discuss risks and benefits of different options • Decide jointly with the health care provider on a treatment Safety • Review medical information and treatment results with the clinician or practice team • Share information about medications and treatments received in other settings • Report on adverse events and potential safety problems Source: Engaging Patients and Families in the Medical Home, Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, June 2010
Insights from the OpenNotes
Please click on links below to view OPENNOTES videos: OPENNOTES Video #1 OPENNOTES Video #2
About the OpenNotes study • 12-month demonstration project, quasi-experimental design Summer 2010 – Summer 2011 (and still ongoing) • Patients invited to view their PCPs’ signed notes via secure portals (only notes signed during the project – not retroactive) • Each patient notified automatically via secure e-mail message when note was signed, and reminded to review it before next scheduled visit
3 Questions •
Does OpenNotes help patients become more engaged in their care?
•
Is OpenNotes the straw that breaks the doctor’s back?
•
After 1 year, will patients and doctors want to continue?
Participants 108 volunteer PCPs and almost 20,000 of their patients who use portals participated for 12 months •
Beth Israel Deaconess Medical Center, Boston • 39 PCPs • 10,300 patients
•
Geisinger Health System, Pennsylvania • 24 PCPs • 8,700 patients
•
Harborview Medical Center, Seattle • 45 PCPs • 270 patients
PCPs’ Experience
PCPs’ Main Concerns
OpenNotes impact on workflow Pre-intervention % BIDMC / GHS / HMC
Post-intervention % BIDMC / GHS / HMC 3/5/0
Visits significantly longer
23 / 32 / 21
More time addressing patient questions outside of visits
49 / 45 / 34
8/0/0
More time writing/editing/ dictating notes
46 / 36 / 34
21 / 14 / 0
‌and the volume of electronic messages from patients did not change
PCPs’ Main Concerns
OpenNotes impact on documentation
Pre-intervention % BIDMC / GHS / HMC
Post-intervention % BIDMC / GHS / HMC
Cancer/possibility of cancer
33 / 18 / 26
26 / 18 / 3
Mental health issues
44 / 27 / 53
36 / 27 / 11
Substance abuse
38 / 32 / 42
28 / 23 / 8
Overweight/obesity
18 / 18 / 21
33 / 5 / 5
Changed the way they addressed:
PCPs’ Main Concerns
OpenNotes impact on patients Pre -intervention % BIDMC / GHS / HMC
Post-intervention % BIDMC / GHS / HMC
Find notes more confusing than helpful
48 / 54 / 43
13 /21 / 12
Worry more
50 / 58 / 45
15/42 / 12
Feel offended
33 / 8 / 29
18 / 8 / 2
PCPs think patients who read their notes will:
Patients’ Experience
Among Patients with Notes (visits) • 84% of BIDMC patients opened at least one of their notes • 82% of GHS patients opened at least one of their notes • 47% of HMC patients opened some or all (new portal users) • 20-42% of patients reported sharing notes with others
Reports from Patients Post Intervention
• 70 - 72% of patients across the 3 sites reported taking better care of themselves • 77-85% reported better understanding of their health and medical conditions • 76-84% reported remembering the plan for their care better • 69-80% felt better prepared for visits • 77- 87% felt more in control of their care • AND, among those taking medications, 60-78% reported “doing better with taking my medications as prescribed.”
Reports from Patients Post intervention
• 1-8% of patients across the 3 sites reported that the notes caused confusion, worry, or offense • 26-36% had privacy concerns
Comments and
The Bottom Line
Doctor Comments I had to have better documentation, which is a good thing. My fears: Longer notes, more questions, and messages from patients. In reality, it was not a big deal. For me the most difficult thing was having to be careful about tone and phrasing of the notes knowing the patient would be reading them. I felt like my care was safer, as I knew that patients would be able to update me if I didn't get it right. I also felt great about partnering with my patients, and the increased openness. Patients should not have access to their notes. The note already serves far too many purposes such as billing, research, etc, and adding one more is not a good idea. They are not intended as a vehicle for patient communication.
Patient Comments Weeks after my visit, I thought, "Wasn't I supposed to look into something?“ I went online immediately. Good thing! It was a precancerous skin lesion my doctor wanted removed (I did). In his notes, the doctor called me "mildly obese." This prompted immediate enrollment in Weight Watchers and daily exercise. I didn't think I had gained that much weight. I’m determined to reverse that comment by my next check-up. If this had been available years ago I would have had my breast cancer diagnosed earlier. A previous doctor wrote in my chart and marked the exact area but never informed me. This potentially could save lives. It really is much easier to show my family who are also my caregivers the information in the notes than to try and explain myself. I find the notes more accurate than my recollections, and they allow my family to understand what is actually going on with my health, not just what my memory decides to store.
The Bottom Line for PCPs After a year of experience with OpenNotes, PCPs were asked: Taking all considerations into account, I would like my patients to continue to be able to see my visit notes online. Some said no: 26% of BIDMC PCPs 17% of GHS PCPs 19% of HMC PCPs On the other hand, when offered the option of turning off open notes at the end of the year-long intervention, not one doctor asked to do so.
The Bottom Line for Patients After one year, 99% of BIDMC patients 99% of GHS patients 99% of HMC patients wanted to continue to be able to see their visit notes online. When given a choice of doctors or health plans in the future, 86% of BIDMC patients 85% of GHS patients 89% of HMC patients said availability of open notes would have an important effect on their decisions.
Some Implications • Trust • Safety • Better use of resources • Should all patients really see everything? • 20-42% of patients shared notes
The Inexorable Rise of Online Access and Transparency Retailing Consumer finance and banking Providers: lab results, open disclosure, patient portals, VA Blue Button, MD Anderson Consumers: • “I don’t know if I want to read my entire medical record, but I want to have it.” • ONC direct-to-consumer promotion of HIT • Give Me My DaM Data • Consumer pressure will only intensify!
Want to learn more?
www.myopennotes.org
OPENNOTES: Exploring best practices in small groups Imagine using OPENNOTES as a patient/parent/caregiver in partnership with your primary care team. SUGGESTED DISCUSSION SCENARIOS PATIENT: reviewing information about me and my health from a recent primary care appointment PARENT: sharing information with partner from a recent pediatric visit with child CAREGIVER: helping aging parent make sense of health information and follow-up items What are the opportunities and challenges of making OPENNOTES a standard of care in our community? OPPORTUNITIES:
CHALLENGES:
OPENNOTES: Exploring best practices in small groups TABLE POLLING As a patient/parent/caregiver…. What is the potential value of OPENNOTES as a standard of care in our community? What is a key reflection from your small group discussions on OPENNOTES? pollev.com/pcmh
What might happen if patient engagement became a standard of care?
Patients and families engaged in practice improvement • Participate in quality improvement activities • Participate in patient/family advisory councils or other regular meetings • Provide feedback through surveys • Help in development of patient materials • Participate in focus groups • Do “walk-through” to give staff a patient perspective of practice workflow Share learning from… The Impact Health Improvement Action Society of British Columbia (ImpactBC)
Share learning from… Aligning Forces for Quality in South Central Pennsylvania
Source: Engaging Patients and Families in the Medical Home, Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, June 2010
Patient Partners Initiative Start-up
Recruit Patient Partners • 1-2 patient partners per practice Patient and Provider Orientation • educate participants • clarity on expectations & roles
Monthly
Patient Partners part of Primary Care Team • patients are meaningfully engaged in quality improvement projects • measure project results
Twice a year
Collaborative Learning • patent partners, providers, and staff from all practices • learning about quality improvement • learning about working together
Please click on links below to view IMPACTBC videos: IMPACT BC Video #1 IMPACTBC Video #2
PATIENT PARTNERS INITIATIVE ACTIVELY INVOLVING PATIENTS AS PARTNERS IN PRACTICE DESIGN AND REDESIGN
BENEFITS Increased
level of empowerment for patient partners. Process improvements New ways to deliver patient education Improved patient experience Community benefit-patient partners volunteering to help with other patient education programs.
PRACTICES’ BENEFITS The
voice of the patient is included in practices process improvement efforts. Improves practices understanding about health literature and how to improve comprehension with diverse group of patients. A perspective on what is considered important to a patient as a patient.
CHALLENGES/SOLUTIONS
Challenge Keeping teams engaged in improvement efforts. Practices & patients at different stages of development. Measuring outcomes – changes in patient engagement level.
Solution Enduring Learning Forum Mentor program for both patient partners & practices. Patient Activation Measure.
LESSONS LEARNED Recruiting
patient partners can be challenging. Provide as much support as possible to practices during this phase. Keeping teams motivated to continue seeking improvement is an ongoing process. Ask for feedback. Leverage successes and proactively plan the next steps.
PATIENT PARTNERS INITIATIVE: Exploring best practices in small groups Imagine participating in a PATIENT PARTNERS INITIATIVE as a patient/parent/caregiver with your primary care team. SUGGESTED DISCUSSION SCENARIOS Based on your experiences and observations, what could be better at your primary care practice/doctor’s office? Potential improvements before the primary care visit Potential improvements during the primary care visit Potential improvements after the primary care What are the opportunities and challenges of making PATIENT PARTNERS INITIATIVE a standard of care in our community? OPPORTUNITIES:
CHALLENGES:
PATIENT PARTNER INITATIVE: Exploring best practices in small groups TABLE POLLING As a patient/parent/caregiver…. What is the potential value of a Patient Partner Initiative as a standard of care in our community? What is a key reflection from your small group discussions on the Patient Partner Initiative? pollev.com/pcmh
Today’s Objectives As a patient/parent/caregiver…. AWARENESS on value of improving Provider-based Patient-Engagement EXPLORE promising best practices from around the country -- a good place to start! IDENTIFY commitments to advance patient engagement as a standard of care in Central Ohio
WHAT CAN I DO TO ADVANCE THESE BEST PRACTICES? Access HealthColumbus intends to invite primary care practices to participate to pilot provider-based patient engagement (best practices) over the next two years. We would like to include the names of patients/parents/caregivers on the invitation that is used to engage leadership from local primary care organizations. As a patient/parent/caregiver, can we include your name (not organizations) on the invitation used to engage primary care? Your Name: OPENNOTES
YES, Access HealthColumbus can include my name on an invitation to secure commitments of participation to pilot OPENNOTES as a standard of care in Central Ohio?
PATIENT PARTNERS INITIATIVE
YES, Access HealthColumbus can include my name on an invitation to secure commitments of participation to pilot PATIENT PARTNERS INITIATIVE as a standard of care in Central Ohio?
Next Steps Access HealthColumbus will apply learning today into the design for collaborative improvement project(s) We will send you a link to the presentations and videos We will send you a record of learning from today’s session Thank you for your time and participation! Thank Nationwide for sponsoring today’s learning session and our other public-private funding partners!
Patient-Centered Primary Care Collaborative of Central Ohio Q1 2013 Learning Session TOPIC: Provider-based Patient Engagement
Please save the following dates for 2013 learning sessions (7:30-10:30AM): • Friday, May 31 • Friday, September 27 • Friday, December 6
Learning Session Sponsored by Nationwide
www.accesshealthcolumbus.org Lead Support
Major Support
Additional Support 100% Access HealthColumbus Board & Staff Individual & Corporate Donations