carrying out shared decision making in a changing world · harms, and risks of each option ... •...
TRANSCRIPT
Carrying Out Shared Decision Making in a Changing World
Candy Hanson, BSN, PHN, LHIT-HPStratis Health
April 3, 2018
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Stratis Health
Independent, nonprofit, Minnesota-based organization founded in 1971
• Mission: Lead collaboration and innovation in health care quality and safety, and serve as a trusted expert in facilitating improvement for people and communities
Working at the intersection of research, policy, and practice
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Lake Superior Quality Innovation Network (Lake Superior QIN)
The Lake Superior Quality Innovation Network (Lake Superior QIN) is comprised of three quality improvement organizations:
• Stratis Health in Minnesota• MetaStar in Wisconsin • MPRO in Michigan
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Objectives
• Understand shared decision making and its potential for our health systems in a rapidly changing care delivery and payment environment
• Learn the questions you should ask to analyze and improve your shared decision making efforts
• Identify the steps needed to apply these principles to your measurement and improvement priorities
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Let’s Start with a Question…
A. Not at all familiarB. Somewhat familiarC. Very familiarD. I could teach it
How familiar are you with shared decision-making?
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What Is Shared Decision Making (SDM)?
DEFINITION
A model of patient-centered care that enables and encourages people to play a role in the medical decisions that affect
their health − Agency for Healthcare
Research and Quality (AHRQ)
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Shared Decision Making –Two Foundational Principles
• Consumers armed with good information can and will participate in the medical decision making process
• Clinicians will respect patients’ goals and preferences and use them to guide recommendations and treatments
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Shared Decision Making
IHI Open School 2-part interview with Dr. Victor Montorifrom Mayo Clinic, “What is Shared Decision Making?”
http://www.ihi.org/education/ihiopenschool/resources/Pages/Activities/VictorMontoriSharedDecisionMaking.aspx
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How Is SDM Different from Informed Consent?
• Shared decision making happens “upstream” from informed consent, before the patient commits to an intervention― Shared decision making is the ethical
approach to gather information and gain the knowledge needed to shape the decision
― Informed consent is the legal process used to promote patient autonomy
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The Evidence Supports That It Works
• Growing body of research and evidence, showing significant positive effect in patient involvement and knowledge of options
• Systematic Review of Patient Decision Aides− An ongoing systematic review of trials of patient decision
aides for treating or screening decisions using Cochrane review methods: https://decisionaid.ohri.ca/cochsystem.html
• MN Shared Decision Making Collaborative− Annotated bibliography of peer reviewed articles about SDM:
http://msdmc.org/19-key-articles/
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How Much Time Will SDM Add to My Visit?
• Mayo Clinic Shared Decision Making National Resource Center studies indicate that incorporating SDM only adds 10% of time to a patient visit to a clinic.
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Question #2
Is Shared Decision Making called out in either the certification or re-certification process for the MN Health Care Home Model?
A. NoB. Yes – Certification OnlyC. Yes – both Certification and Re-
Certification
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Where SDM Intersects with the MN HCH Model – Certification
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Where SDM Intersects with the MN HCH Model – Certification (continued)
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Where SDM Intersects with the MN HCH Model – Certification (continued)
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Where SDM Intersects with the MN HCH Model – Recertification
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What SDM Looks Like in Action in Clinical Practice• One-time treatment decisions. Example: initial
treatment of breast cancer• Possible serial treatments. Example: low back pain• Preventive care or screening. Example: PSA test,
mammogram• Lifestyle decisions. Example: smoking cessation• Chronic care decisions. Example: diabetes
management• Life stage decisions. Example: assisted living,
hospice
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AHRQ’s SHARE Approach
• A five-step process for shared decision making • Includes exploring and comparing the benefits,
harms, and risks of each option• Occurs through meaningful dialog about what
means the most to the patient• The innovation of “evidence based tools”, known
as patient decision aides inform patients and help them set their own goals and clarify their values
• https://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.html
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What’s a Decision Aid?Osteoporosis – High Risk (Mayo)
http://centerforinnovation.mayo.edu/decision-aids/
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Decision Aid for Osteoporosis – High Risk (Mayo)
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AHRQ’s SHARE Approach (continued)
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What SDM Looks Like In Action?
Example #1: • SDM and cardiovascular prevention – using a
decision aid with a patient about taking statins• https://statindecisionaide.mayoclinic.org/
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What SDM Looks Like In Action
Example #2: • Breast and prostate cancer treatment – a case study
which describes a nurse care coordinator role in using decision aides to review treatment options, risk and benefit, and fit with their personal preferences and values.
• Initial skepticism about how it would fit into workflow and priorities, but now, “The shared decision-making bug is highly contagious.”
• http://msdmc.org/top-five/
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How Can I Align SDM Efforts With Other Measurement Requirements?
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Quality Payment Program Measure ID #350
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TOTAL KNEE REPLACEMENT: Shared Decision Making: Trial of Conservative (Non-surgical) Therapy
DESCRIPTION: Percentage of patients regardless of age undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical therapy (i.e., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure
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What Should Be Included In Your Documentation
Each of these points are documented in the medical record:• Patients report that they told the clinician about their
personal preferences and relevant values or goals• Patients report that they were told and fully
understand the risks and benefits of each option (including the conservative therapy)
• Patients are provided written information + an opportunity discuss with clinician before a decision is made
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Quality Payment Program Measures ID# 390
Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options
DESCRIPTION: Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient
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What Should Be Included In Your DocumentationEach of these points are documented in the medical record:• Patients report that they told the clinician about their
personal preferences and relevant values and goals• Patients report that they were told and fully
understand the risks and benefits of each option (based on genotype)
• Patients are provided written information + an opportunity to discuss with their clinician before a decision is made
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Considerations
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An Example of Making it Work
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What Is the Current State of SDM?
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What Is the Current State of Minnesota SDM?
• We want organizations to move from “dabbling” in SDM to having SDM systematically embedded more widely and deeply in practice
• We are no longer fighting the efficacy battle (what is SDM? is it proven to be effective?), and are now needing to address the time and attention battle
• We also recognize many clinicians already thing they are already doing SDM, so there is a misperception or misunderstanding of what SDM is and whether it is actually occurring
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How Do You Get Started With Shared Decision Making?
https://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/workshop/about-shareworkshop.html
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Getting Started - continued
https://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/workshop/about-shareworkshop.html
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Getting Started - continued
https://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/workshop/about-shareworkshop.html
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Getting Started - continued
https://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/workshop/about-shareworkshop.html
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Resources and Tools
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Additional Resources
• Ottawa Personal Decision Guide, and Ottawa Personal Decision Guide for Two:
• https://decisionaid.ohri.ca/decguide.html1-PatientDecsion• Massachusetts General Health Decision Sciences Center Tools
and Training• http://www.massgeneral.org/decisionsciences/research/Choice_
Report.aspx• All Massachusetts General Decision Aids• http://www.massgeneral.org/decisionsciences/assets/pdfs/1-
PatientDecisionAids.pdf• AHRQ SDM SHARE Web Site:
https://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.html
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Let’s Hear From You!
• Is anyone currently performing Shared Decision Making?
• Would you share your experiences?A. Describe your SDM EffortsB. Tell us how you got startedC. How it’s goingD. Successes and Challenges
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Questions?
This material was prepared by Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-D1-18-13 021318