leveraging shared-decision making to manage population … · • this activity has received no...

Leveraging Shared Decision Making to Manage Population Health – Partners HealthCare’s Lessons Learned

Gloria Stone Plottel, MS, MBA, Founder and CEO, GSPsquared LLCAdam Licurse, MD, MHS, Associate Medical Director,

Partners Population HealthCare Management and the Brigham and Women's Physician Organization

Defining Patient Experience

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- The Beryl Institute

PX Continuing Education Credits

• In order to obtain patient experience continuing education credit, participants must attend the program in its entirety and return the completed evaluation.

• The planning committee members and presenters have disclosed no relevant financial interest or other relationships with commercial entities relative to the content of the educational activity.

• No off label use of products will be addressed during this educational activity.

• This activity has received no sponsorship or commercial support. No products are available during this educational activity, which would indicate endorsement.

Today’s Presentation

Leveraging Shared-Decision Making to Manage Population Health – Partners HealthCare’s Lessons Learned In this session, we'll take an in-depth look at Shared-Decision Making and learn why it is key to managing population health, improving patient outcomes, increasing patient engagement, and reducing healthcare costs. Partners HealthCare Population Health Management will share lessons learned from its work to expand and implement Shared-Decision Making in Partners HealthCare’s 10 hospitals and hundreds of physician practices. Participants will learn how to use Shared-Decision Making to increase patient engagement, best practices for running a Shared-Decision Making program and key considerations for expanding a Shared-Decision Making program throughout an integrated health system.

Gloria Stone Plottel, MS, MBA Founder and CEO GSPsquared LLC

Adam Licurse, MD, MHS Associate Medical Director

Partners Population HealthCare Management Brigham and Women's Physician Organization

Leveraging Shared Decision Making to Manage Population Health – Partners

HealthCare’s Lessons LearnedGloria Stone Plottel, MS, MBA

GSPsquared LLC

Adam Licurse, MD, MHSPartners HealthCare Population Health Management

Brigham and Women’s Physician Organization

December 3, 2015

Introductions

Gloria Stone Plottel, MS, MBAFounder and CEOGSPsquared LLC

Adam Licurse, MD, MHSAssociate Medical Director

Partners HealthCare Population Health Management and


Today’s Objectives

• Tell the story of scaling Shared Decision Making across the Partners HealthCare System

• Shared Decision Making best practices• How Shared Decision Making contributes to:

o Managing population healtho Improving patient outcomeso Increasing patient engagemento Reducing healthcare costs

• Key considerations when scaling Shared Decision Making throughout a health system

Setting the stage

Partners HealthCare System

• Founded in 1994 in Boston, Massachusetts by Massachusetts General Hospital and Brigham and Women’s Hospital

• Includes:• 2 Academic Medical Centers• Community hospitals• Specialty hospitals• Managed care organization• Community health centers• Physician network• Home care services• Long-term care services

• Several hospitals are teaching affiliates of Harvard Medical School

Emerging regulatory landscape

Pre 2006

•Pre 2006 state HC law

•Many without health insurance

•Fee for service•Focused on

volume•Rapidly increasing

healthcare costs

2006-2012

•Passed: 2 MA healthcare laws & national ACA

•Expanded access; 98% of Mass residents with health insurance

•Need to reign in healthcare expenditures

•Very focused on quality & measuring quality

Emerging landscape

•Global payments•Managing health

of populations•Improve

outcomes•Improve quality•Reduce costs•Reimbursement

contracts changing at federal and state levels putting more risk on providers

Partners HealthCare covers ~500,000 lives in accountable care contracts

Medicare Commercial Self Insured•Example: Pioneer ACO

•Covered lives: ~52k

•Example:Alternative Quality Contract

•Covered lives: ~350K

•Example: Partners Plus

•Covered lives: ~90k

21 3

Patient engagement strategic goals for population health management

To increase patients participating in their own health care treatment so as to contribute to:

• Improving quality of care • Improving patients’ experience of care• Improving outcomes • Reducing costs• Meeting contractual risk obligations

Shared Decision Making (SDM)

Interactive process between patient (and family) and clinician(s)

Engages patient in decision making

Gives accurate information about options and outcomes

Tailors treatments to patient’s goals and concerns

Source: Massachusetts General Hospital and Health Decision Sciences Center

What’s the purpose?

Match the right treatment to the right patient at the right time,

every time


• Chemoprevention for breast cancer: “Clinicians should inform patients of the potential benefits and harms of chemoprevention.”

• Screening for osteoporosis: “… clinicians also should consider each patient's values and preferences and use clinical judgment when discussing screening with women...”

• Coronary revascularization: “Shared patient/physician decision making for many scenarios would be expected and may result in the patient deferring coronary revascularization while maintaining medical therapy.”

• Shared Decision Making and patient engagement are key facets of Patient-Centered Medical Homes

SDM and Guidelines


Evidence Base: Decision Aids

2014 Cochrane Systematic Review contains 115 RCTs:Decision aids increase decision quality: increase in knowledge increase in realistic expectations increase in value-choice concordance

Decision aids engage patients less passive (RR 0.66) Fewer who remain undecided (RR 0.59)

Decision aids address over- and under- use reduction in major invasive elective surgery (RR 0.79) reduction in PSA testing (RR 0.87) and HRT use (0.73)

Stacey et al. Cochrane Database of Systematic Reviews, 2014

From Massachusetts General Hospital to Partners HealthCare system-wide

SDM at MGH: 15 PC practices + clinics; 4,000 shared dec’s/yr.; about 2% of patient volume

Strategic options and scaling tactics

SDM used at Partners’ 10 hospitals and 100s of physician

practices

Clinician training

IT and the electronic medical record

Patient portal

Mail services

Patient decision points and clinical office protocols

Leadership

Advisory group

How are we doing?

• Implementation• Process• Outcome

Collaboration

MGH Stoeckle Center for Primary Care InnovationMGH Health Decision Sciences Center

• Susan Edgman-Levitan, PA; Executive Director, Massachusetts General Hospital The John D. Stoeckle Center for Primary Care Innovation

• Karen Sepucha, PhD; Director, Massachusetts General Hospital Health Decision Sciences Center

• Leigh Simmons, MD; Massachusetts General Hospital Health Decision Sciences Center and The John D. Stoeckle Center for Primary Care Innovation

Use of patient decision aids at MGH

Top Programs Overall:

1. PSA testing2. Advance Directives3. Colon Cancer Screening4. Knee Osteoarthritis5. Insomnia

Cumulative distribution of decision aidsBy the numbers: • 22,000+ decision aids distributed since 2005

• 500+ orders/month

• >800 unique clinicians and staff have prescribed programs

0

5000

10000

15000

20000

25000

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Most Popular Patient-Triggered Program Ordersa) Insomniab) Anxietyc) Depressiond) Low back paine) Living with Chronic Pain


Some challenges we face

• Some clinicians very interested, others rarely use decision aids

• Ordering system very clinician-driven; but they are busy and forget, and might not always know what patients want

• How to identify patients at decision points outside of visits

• Balance between clinician time and conversation “quality”


Case 1: Clinician training

• Pilot project launched in 2005 at 1 practice and in 2006 spread to all 18 MGH adult primary care practices

• Clinician-driven ordering of video/booklet decision aids, during the visit, supported by EMR, with centralized distribution thru SDM Center.

Steady use (~100 orders/month) BUT not nearly what it could be, most orders were from a few physicians, and significant variation among clinics


Designed Training Course

• 1-hour session held during regular practice meeting• Overview of shared decision making (what, why, how)• Feedback: usage data (practice and provider level), patient

& provider comments• View video decision aid• Discussion

• 1 hour CME credit for physicians• 15/18 practices hosted course


Impact and Lessons Learned

• More than doubling orders

• Comparative data is a strong motivator• Providers enjoyed a little competition!

• Physician champion role important• Quarterly newsletter and biannual training


Case 2: Automating Delivery of Decision Aids

• Goal to take advantage of EMR/IT applications to help with delivery

• Early project: sent decision aids to patients based on problems in problem list (e.g. osteoarthritis, fibroids)• Easy and increased use of decision aids, but• Overall a disaster…not at a decision point (wasted time) and/or not

relevant (e.g. sent fibroid program to a woman who had already had a hysterectomy)

Need more nuanced approach to identify patients who actually need the decision aid


Mental Health Integration

• Interest: Providers open to using more decision aids in practice, but “low-prescribing” practice; nursing leader invested in improving patient education processes

• Workflow: MAs offered patients PHQ-2 at all annual visits; if PHQ-2 + for depression, patients were offered order form for mental health programs (depression, anxiety, and insomnia)


Enabling patient-directed ordering

• Pre-visit and during visit models

•10-fold increase in orders when opened up to patients

•Patients and clinicians order different programs


Measurement and feedbackPatient surveys to assess impact on knowledge, goals and decisions

Quarterly newsletters with practice- and provider- level reports


What’s next?

• Expand integration into primary care• PCMH and pre-visit preparation• In-visit tools

• Enhance referrals to specialty care • Orthopedics (hip & knee osteoarthritis and back) • Acute low back pain (urgent care, Occ Health and ED)

• Innovation and research• Evaluate impact of new decision aids, in-visit tools, web

based tools• Decision quality measurement


Making it happen:

• Key factors for successful implementation:o Receptive culture for clinicians, staff, administration

training and feedback, link to incentives and broader initiatives

o Engaged, prepared patients high quality toolso Infrastructure and resources EMR, IT


Today we focused on

• How Shared Decision Making contributes to managing population health, increasing patient engagement, improving patient experience

• Shared Decision Making best practices • Key considerations for scaling SDM in a health system• Partners HealthCare’s lessons learned

Q & A and Thank you

Gloria Stone Plottel, MS, MBAFounder and CEOGSPsquared LLC

[email protected]

Adam Licurse, MD, MHSAssociate Medical Director

Partners HealthCare Population Health Management and


[email protected]

mailto:[email protected]

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• In order to obtain PXEs, participants must attend the program in its entirety and complete evaluation.

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