Patient Engagement: Impact on Disease Management & Population Health Innovation Care Partners Scottsdale, Arizona Karen R Vanaskie DNP, MSN, RN, Peggy Tyndall RN, MBA, & the ICP Clinical Team
Introduction: Innovation Care Partners is a physician-led Clinical Integration Network and Accountable Care Organization. We are dedicated to improving patient health and reducing healthcare spend through collaboration, coordination, and communication in the community. Our clinical integration allows for • Remarkable improvements in clinical outcomes and evidencebased care for patients • Coordinated care between physicians, hospitals and other healthcare professionals • Quality of care and performance reports • Delivery of the right care, at the right time, in the right place • Reduced healthcare costs for patients, employers and health plans Setting: Intensive Outpatient Care Program: Our Care Coordination Team collaborates with patients and their primary care physicians to assist in coordination of care helping to demystify the complexities of the healthcare system. Our Care Coordination services span from assisting in transitioning from the hospital, providing support and guidance, researching community programs, and helping patients establish health care goals. Intensive Outpatient Care Model (IOCP) Primary care based for predicted moderate to high risk patients • Specially trained care coordinators • Behavioral modification interviewing • “Supervisit” process • Medication Management • Assessment tools: • SF-12 (VR-12) – measure health related quality of life and estimated disease burden • Patient Activation Measure (PAM) - tool that measure patients engagement in their health care (Levels 1-4) • PHQ–2 & PHQ-9 – tool used to screen, diagnose, monitor, & measure severity of depression • Mutually agreed upon “Shared Action Plan” • High level (face to face) contact with patients and providers. •
Figure #2: Improved Levels of Depression
Methods: Behavioral Motivation Interviewing (BMI) Techniques: BMI- Is a way of activating a persons own motivation and resources for change. Effective BMI assists in motivating ambivalent and reluctant patients to change their behavior. BMI is a skill that is best used in the clinic setting and it does not have to take a long time. If done correctly it will lower a patients resistance (dissonance) and reduce everyone's frustration with not achieving compliance and goals.
% of Members by Depression Level Baseline and Follow-Up - March 2018 Mild depression 100% 90%
23.36%
13.70%
Minimal depression
80%
Establishing Change Partnerships- – Our Patient Partnership is based on a high level of Acceptance by helping the patients sense the following: 1- Absolute worth, 2- Autonomy, 3- Accurate Empathy, and 4- Affirmation. Our Care Coordinators are trained to utilize the fundamental steps in BMI – these steps include: 1- Express Appreciation - Offer Praise (guiding / Inviting) 2 – OARS- Deepening reflections while maintaining conversational tone (Oaffirming, A- reflective listening, R- summarizing, S- Show an understanding of the patients point of view.. 3 - Recognize Change Talk – including patients desire, ability, reason, and need for change 4 – Draw out & strengthen change talk - Use strategies to boost change 5- Roll with Resistance- (redirecting / reframing) 6 – Consolidating the Commitment- What is next 7 - Change Plan – Let patient take the lead in planning process – use both written and verbal. 8 – Switch - Adjusting approach to patients stage of change (Miller, B. 2006) Our team attends a two day BMI training session with many opportunities to role play and act on their new communication skills. We also have many aids to assist in structuring their questions to patients both in the Patient Activation Measure(PAM) software and in our BMI training. The Shared Action Plan allows care coordinators to monitor the change in achieving their health care goals.
70% 60%
51.22%
72.42%
Moderate depression
50% 40% 30% 20% 10%
12.95% 8.16% 4.32%
8.07% 4.32% 1.50%
0% Baseline
Follow-Up
Moderately severe depression Severe depression
Results: Innovation Care Partners continues to have success applying the principles of the IOCP Model to enhance patients level of engagement in their own health care. After six months in the program patients have demonstrated: • % Of Patients with Severe Depression: 7% lower • Patients highly engaged in their own care: 10% increase A happier more engaged patient is a positive impact on population health. Yielding better results for our utilization metrics. All of these efforts assist us in lowering health care costs. ICP saved CMS money and earned shared savings for the 3rd year in a row. ICP’s ACO has the following state wide outcomes:• The only Arizona-based MSSP that earned revenue for 2016 • The first Arizona MSSP to earn revenue in 2014 • Only Arizona-based MSSP to earn revenue each year since inception (2014) • Performed in the top 5% of MSSPs nationally in terms of total dollars received • Had the highest savings rate in the country at 9%
Data and Figures: Figure #1: Improved Levels of Patient Engagement % of Members by PAM Level for Baseline and Follow-up - March 2018
Conclusion: Innovation Care Partners care management model supports coordinated, high touch, patient centered care of the highest quality and value. Improving the patients levels of engagement is a key factor in improving population health. Utilization of the IOCP model and behavioral modification interviewing techniques yield a strong benefit for our patients. References:
100% 90%
30.36%
35.34%
80%
Patient Activation Measure® (PAM)® assesses the underlying knowledge, skills and confidence integral to managing one’s own health and healthcare. PAM segments consumers into one of four activation levels along an empirically derived continuum. Each level provides insight into an array of health-related characteristics, including attitudes, motivators, behaviors and outcomes. Level one being least engaged and level four being highly engaged. PAM is a unidimensional, interval level, Guttman-Style 10-13 questions scale developed by Dr. Judith Hibbard & Dr Bill Mahoney and Colleagues at University of Oregon.(Insignia Health, 2014-All rights reserved.)
70% 60%
27.77% 33.16%
50% 40%
19.48% 15.75%
30% 20%
22.28% 15.75%
10% 0%
Baseline
Innovation Care Partners
Follow-Up
Level IV Level III Level II Level I
• Bynum, J. P., W., & Ross, J. S. (2013). A measure of care coordination? Journal of General Internal Medicine, 28(3), 336-8. doi:http://dx.doi.org/10.1007/s11606-0122269-0 • Kazis, L.E.; Miller, D.R.; Skinner, K.M.; Lee, A.; Ren, X.S.; Clark, J.A.; Rogers, W.H.; Spiro III, A.; Selim, A.; Linzer, M. Payne, S.M.; Masell, D.; Fincke, B.G.; Applications of Methodologies of the Veterans Health Study in the VA Health System: Conclusions and Summary. J Ambulatory Care Management 2006a 29:2 182-188. • Miller, W. R.; Rollnick, S. (2013) Motivational Interviewing: Helping People Change.3rd ed. Guilford Press, New York, NY • Hibbard, J. H.; Greene, J.; Tusler, M. (2009) Improving the Outcomes of Disease Management by Tailoring Care to the Patient’s Level of Activation. The American Journal Of Managed Care. Vol. 15 (6:353--‐360). • Hibbard, J.H.; Greene, J. & Overton, V : Patients With Lower Activation Associated With Higher Costs; Delivery Systems Should Know Their Patients’ ‘Scores’. HEALTH AFFAIRS 32,NO. 2 (2013): 216–222 www.postersession.com