person centered care - hospital quality institute · what is person-centered care? in 2015, the...
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Person Centered Careit’s
Not Just About Hospitals!
Carol Peden MB ChB, MD, MPH
Twitter @PedenCarol Email [email protected]
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E. C. Schneider, D. O. Sarnak, D. Squires, A. Shah, and M. M. Doty, Mirror, Mirror: How the U.S. Health Care System Compares Internationally at a Time of Radical Change, The
Commonwealth Fund, July 2017.
AUS UKNETH
NZ N…
SWE
SWIZGER
CAN
FRA
US
Note: Health care spending as a percent of GDP.
Source: Spending data are from OECD for the year 2014, and exclude spending on capital formation of health care
providers.
Health Care System Performance Compared to Spending
Higher health system performance
Lower health system performance
Eleven-country average
Higher health care spendingLower health care spending
Why disrupt the status quo?
Why do we need to change?
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http://www.health.org.uk/sites/health/files/PersonCentredCareMadeSimple.pdf
What is Person-Centered Care?
In 2015, the American Geriatric Society (AGS)
defines Person Centered Care as follows:
“Person-centered care requires that an
individual’s values and preferences be
elicited and once expressed guide all
aspects of their healthcare, supporting
their realistic health and life goals”
Let’s look at key characteritics of
Person-Centered Care
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“I get it.
Person-centered Care is important.
Everyone’s talking
about social determinants.
But how do we do this?” © 2015 Rishi Manchanda/ Health Begins
What gets in the way of care?
Hospitals Can Lead………..
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What happens to the Frail Older person in hospital?
“With each hospitalization spell, the frail older person is prone to an increased risk of hospital-acquired infections; deconditioning (functional loss following a period of bed rest/inactivity); falls; pressure ulcers; malnutrition; incontinence; and adverse effects. The older and more frail the patient, the more likely it is that they will experience functional deficit during hospitalization. Length of stay in hospital is a further contributory factor that can predispose frail older persons to an increased risk of adverse outcomes.” Zabien and Amin. Healthy Ageing Research 2016
Average annual rate of change of the global population aged >60 and >80 year 1980 -2050http://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2015_Report.pdf
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Frazer Underwood
Consultant Nurse for Older Peoples Services
Associate Director of Nursing
Royal Cornwall Hospitals NHS Trust
Assessment Units for
Older People
www.bgs.org.uk/pdf_cms/nurses/Frailty%20Units.ppt
Multi-factorial Inter-
professional Assessment
Frail
Older
Person
Triage Trajectory Transfer
• Diagnostics
• Treatment
initiation
• Liaison
• Negotiation
• Plan
• Co-ordination
• Communication
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Wrapping the system around…
Unit set-up and evaluation
Criteria• Over 70 years old plus one of the following:
Presence of delirium or dementia (AMTS)
Fracture as presenting problem but medically
unstable (not NOF)
Care home resident
ED frailty score ≥ 25 (Waterlow+)
University Hospitals of Leicester
Frailty Unit
Unit set-up • Single front door = shrinking MAU bed base (OPAL
Unit on MAU ward template)
• Establishing bed base from ED and MAU frailty data –
Frailty Tool (Waterlow+) (19 beds and ALOS = 72
hours)
• One geriatrician on unit 7/7 (plus 0.5 for OPAL Team
5/7)
• Specialist nursing and AHP team on unit
Royal Cornwall Hospitals
OPAL Unit
Outcome measure: 34% increase in discharge within 1 day
Frailty Unit
opens
Length of stay for frailty unit patients reduced by more than 4 days
Frailty Unit
opens
Slide Courtesy of Dr. Tom Downes, Sheffield Royal Infirmary
In-hospital mortality dropped by over 13%
Frailty Unit
opens
Slide Courtesy of Dr. Tom Downes, Sheffield Royal Infirmary
A complex system problem
Slide Courtesy of Dr. Tom Downes, Sheffield Royal Infirmary
McIsaac et al Association of Frailty and 1-Year Postoperative Mortality Following Major Elective Noncardiac Surgery: A Population-Based Cohort Study. JAMA Surgery 2016;151:583-45
Hazard greatest on post-op day 3
OPTIMAL PERIOPERATIVE
MANAGEMENT
OF THE GERIATRIC PATIENT:
Best Practices Guideline from ACS
NSQIP®/American Geriatrics Society
• Identify patients at high risk for delirium: provide tools for simple preoperative screening for cognitive impairment and risk factors
• Encourage providers to talk with patients about delirium and promotion of orientation through hearing aids, glasses, family/ friends’ bedside presence.
• Educate anesthesiologists regarding peri-operative anesthetic sedative and analgesic drug choices, including medications to be avoided.
“We only wish someone had educated us before the surgery—the emotional toll on the family was overwhelming and much of it could have been avoided with a little bit of information up front.”
The Big Room (Oobeya)Slide Courtesy of Dr. Tom Downes, Sheffield Royal Infirmary
The Big Room in Action
Physiotherapist gives an
account of the test of change
to get a patient home on the day they
were discharged by the GSM
consultant
Fellow
General
Manager
For
MedicineGSM
Matron
Service
Improvement
Social
Services
Manager
Community
Services
managerPhysiotherapis
t
Secretary
Discharge
Liaison
Slide Courtesy of Dr. Tom Downes, Sheffield Royal Infirmary
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www.rcplondon.ac.uk/projects/future-hospital-programme
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https://my.rcn.org.uk/__data/assets/pdf_file/0003/618231/02.15-The-Buurtzorg-Nederland-home-care-provider-model.-Observations-for-the-UK.pdf
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NEJM Catalyst Round Table Capturing the Patients Voice October 2017
https://catalyst.nejm.org/measuring-matters-capturing-patient-voice/Mohta, Prewitt, Volpp, Hiesler, Niehaus, Peden and Wagle.
• Bundled care• Focus on value based care• Enhanced recovery after surgery
(ERAS) approaches• Patient and family advisory councils
• Bundled care 90 day and > outcomes
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11/9/2017
What is Value in Health Care. Porter NEJM 2010;363:126Quality and Outcomes that matter to patients!
ERAS in the US
Increased Productivity
Increased Quality
Increased Patient Satisfaction
Reduced Cost
www.enhancedrecovery.org
www.enhancedrecovery.uk
Concept of pre-habilitationConsider how much more we could be doing to help patients get prepared for elective surgery.
Br J Anaesth. 2015 Feb;114(2):244-51 West et al.
Effect of prehabilitation on objectively measured physical fitness after neoadjuvant treatment in preoperative rectal cancer patients:
a blinded interventional pilot study.
6 weeks exercise training returned patients to pre-adjuvant chemotherapy fitness levels before surgery – no change in normal care group
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WIIFM?
Facilitate your strategic plan
Strengthens your
community partnerships
Control cost of care
for older adults
Person-centered Care
Initiative
Creation and
maintanence of local continuum
of care network
Person -centered
care planning to
include Palliative
Care
Quality of Life and
Functional Status
monitoring tools
Shared learning
alongside other
participating
communities
Using an ROI
formula to demonstrat
e effectiveness of each
care model
Risk assessment
in discharge
planning to identify special needs
Three Year Project
Year One: Design and recruitment
Year Two: Create networks, conduct tests
of change, implement care model
Year Three: Monitor and measure outcomes-
functional status, quality of life
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