population health and best practices for serious illness · · 2017-10-10chuck’s end of life...

Materials developed by Respecting Choices®. © Copyright 2017 GLMF, Inc. All rights reserved.

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Sandra E. Schellinger, MSN RN NP‐CSenior Faculty Consultant

October 11, 2017St. Cloud, MN

Population Health and Best Practices for Serious illness:

A Team Approach to Align Care with What Matters Most


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No Financial Disclosures or Conflicts of Interest

The national Respecting Choices® program was developed with support from Gundersen Medical Foundation in La Crosse, WI.

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Respecting Choices Mission and Vision

Mission:We guide organizations and communities worldwide to effectively implement and sustain evidence‐based systems that provide person‐centered care

Vision:To transform healthcare culture by integrating and disseminating best practices to achieve person‐centered care

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U.S.A. and Canada

Australia BelgiumDenmark GermanyItaly SingaporeSlovenia SpainThe Netherlands United Kingdom

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Objectives6

oDescribe key components of a person-centered culture of care for serious illness.

o Identify the components of an ongoing process of goals of care discussion using the Respecting Choices Next and Last Steps® advance care planning (ACP) and “Shared Decision Making in Serious Illness” (SDMSI) programs.

oDescribe organizational strategies to promote engagement, dissemination, and sustainability of a person-centered care (PCC) approach.


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“…Our most cruel failure in how we treat the sick andaged is the failure to recognize they have prioritiesbeyond merely being safe and living longer; that thechance to shape one’s story is essential to sustainingmeaning in life; that we have the opportunity torefashion our institutions, our culture, and ourconversation in ways that transform the possibilitiesfor the last chapters of everyone’s lives.”

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What matters most?

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A Life’s Journey9

Chuck was 81 years old: a father, a veteran, a man of strong faith.

In his last year of life, Chuck and his wife faced many challenges.


Chuck’s End of Life Experience

HospicePalliative Care

Home CareER visits

Clinic VisitsHospital Days

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https://www.bing.com/images/search?view=detailV2&ccid=BWG3L5c3&id=B6DCB7DCCB1FEE8CBFC29061F14365A6A79DE48D&thid=OIP.BWG3L5c3zfcVVtMSXKI‐fgEgDY&q=serious+illness+trajectory&simid=608037632787155875&selectedIndex=12&ajaxhist=0

(Murray, 2007, Fry, 2016)

“Organ System Failure” Trajectory

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Serious Illness

‘Serious illness’ a condition that carries a high risk of mortality, negatively impacts quality of life and daily function, and/or is burdensome in symptoms, treatments, or caregiver stress.

‘Serious illness’ care include medical and nonmedical issues, whole person goals and transition from disease specific to preference sensitive care and treatment options.

‘Serious illness’ Care Increase demand, fragmentation, disease oriented, over‐under treatment, too late access to End of Life care.

(Murray, 2007,, Kelley, 2014), Schellinger, 2017)


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Serious Illness Care: A Call to Action

1. Person‐Centered Family‐Oriented Care2. Shared Decision Making in Support of

Patient Goals3. Comprehensive Coordinated Care4. Accessible 5. Provide Value

(IOM Crossing the Quality Chasm, 2001, IOM Dying in America Report, 2014, Kelley, 2014, Hammes, 2012, National Academy of Medicine, 2017, NQF Strategies for Change, 2017)

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“Doctor Knows Best”

The shifting patient‐provider relationship

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Person‐Centered Care:Are we ready for prime time?

Characteristics Medical Model

Patient‐Centered

Person‐Centered

Person‐Directed

Centrality of Physician High Moderate Moderate Moderate

Role of individual in decision making

Low Moderate Moderate High

Role of non‐medical issues in decision making

Very low Moderate High Very high

Education and empowerment of patient and family

Low Moderate Moderate Very high

Coordination between care settings

Low Low Moderate Very high

(Table adapted from Lines, 2015; Heidenreich, 2013)


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Person‐Centered Care

“Care that is respectful of and responsive to individual patient preferences, needs and values.”

Success Requires Patient, Provider and System Competencies

‐ Knowledge, Skills, Attitudes

(Crossing the Quality Chasm, Institute of Medicine Report 2001, Bernabeo, 2013)

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Advance Care Planning: A strategy to delivering Person‐Centered Care?

ACP is a process of communication for planning for future medical decisions. To be effective, this process includesReflection on goals, values, and beliefs (including cultural, religious, spiritual, and personal);Understanding of possible future situations and decisions as well as the value of planning;Discussion of these reflections and decisions with those who might need to carry out the plan.

Does Advance Care Planning Help?

ACPHospice

Palliative CareHome Care

ER visitsClinic Visits

Hospital Days


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Advance Care Planning (ACP) is

To know and honor an individual’s informed plans byCreating an effective planning process, including

– Selecting a well‐prepared healthcare agent or proxy, when possible

– Creating specific instructions that reflect informed decisions geared to the person’s state of health

Making plans available to treating health professionalsAssuring plans are incorporated into medical decisions, when needed

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(Agency for Healthcare Research and Quality, 2003, National Academy of Sciences, Institute of Medicine, 2014, Rand Corporation, 2007, Wilkinson, Wenger, Shugarman, 2007)

consistently fails to improve careThe prevalence of ADs is low.

– General population 20‐30% – End‐stage illness < 50%

ADs are often unavailable at the place of treatment (available to the physician only 25% of time)ADs are often not helpful to decision making (i.e. too vague)ADs are often not followed

– Unavailable or ambiguous– Not understood/supported by loved ones

Statutory AD Does Not Work”

Healthy Adults Or Those Who Have Not Planned

Adults With Progressive Lifelimiting Illness, Suffering Frequent Complications

Individuals Whom It Would Not Be A Surprise If They Died

In The Next Year

First StepsCreate an AD that

identifies healthcare agent and goals of care

for permanent brain injury.

Shared Decision Making in Serious illnessDiscern goals (or use documented goals from previous ACP conversations) when using the decision‐making framework for any decision.

Palliative CareDiscern goals (or use documented goals from

previous ACP conversations) to assist with symptom management and other treatment decisions.

Next StepsCreate/update anAD that identifies

healthcare agent and goals of care if illness complications resultin “bad outcomes.”

Last StepsCreate/update anAD that identifies

healthcare agent and identify goals of care, expressed as medical

orders using POLST paradigm.

Review prior documentation of goals, values

Document and create plan to honor decisions


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Culture Change: Medical Oriented to Person‐Centered Care

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Why are Shared Decision‐Making Conversations Not Happening?

ProviderSystemProvider

System

Patient and Family

Provider

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Patients Do Not Have

Well‐Formed Goals and Values (Stacey et al., 2011)

Why change to Shared Decision‐Making?


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Informed Consent to Shared Decision‐Making5

Common Approach• First, identify all

options.• Present options for

intervention to patient. FAQsRisk: Benefit statistics

• Work with patient to make a treatment decision.

SDMSI Approach• First, identify and understand

patient’s priorities and goals for care.

• Present options consistent with patient’s goals.

• Frame “benefits and burdens” in context of patient’s views of unacceptable outcomes.

• Explore non‐intervention as a viable option.

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Unique Features of SDMSI

1) Includes soliciting patient goals…and more2) Fosters self‐awareness through reflection on

individual provider biases that impact decision making conversations with patients

3) Solicit patient goals first and then use them in a shared decision making framework to reach a treatment decision

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SHARED DECISION MAKING IN SERIOUS ILLNESS

(SDMSI)ALIGNING CARE WITH

WHAT MATTERS MOST TO PATIENTS


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SDMSI Development:A Collaborative Process

• Partnership between a Respecting Choices user (Spectrum Health) and Respecting Choices Program Development Teamꟷ Carole Montgomery, MD, FHM, MHSA; Vice President,

Clinically Integrated Pathways; Respecting Choices SDMSI Faculty, Independent Contractor

ꟷ Respecting Choices Program Development Team: Director of Program Development & Research, Materials Specialist, Respecting Choices Faculty

• Advisory Committee: Physicians and ACP experts from 5 organizations

• Testing and evaluation at 3 organizations (Spectrum, Dartmouth‐Hitchcock, Gundersen Heath System)

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Program Development Core Concepts

• Education alone does not change behavior.• Integration of Respecting Choices program

development Best Practice Strategies:ꟷ Leadershipꟷ Systems redesignꟷ Skills‐based trainingꟷ Quality improvementꟷ Instructor mentoring and certification

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Shared Decision Making in Serious IllnessImplementation Workflow

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SDMSI Course Objectives

1. Define the importance of shared decision making for patients with serious illness.

2. Identify communication skills that impact shared decision‐making conversations.

3. Identify shared decision‐making skills to discern what matters most to patients with serious illness.

4. Identify shared decision‐making skills to align care with what matters most to patients.

5. Participate in practice activities to integrate shared decision‐making skills.

6. Identify organizational practices to document the elements of shared decision‐making conversations.

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Cone of Learning (Edgar Dale)32

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SDMSI Program Activities

• Precourse learning material• Program engagement: Why are we doing this? How does it fit

with strategic initiatives?• Interactive classroom activities

ꟷ Interview guides, video demonstration of skills, role‐play practice with facilitated feedback, problem solving

• Systems redesignꟷ Identification of target population for SDM conversationsꟷ Documentation of SDM conversations and goals of care

• Postcourse program metricsꟷ Pre and post participant attitude and competencyꟷ Patient experience survey post SDM conversationꟷ SDM conversations documentation


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Curriculum Overview

• SDMSI unique in this patient population• Barriers to SDMSI• Role of the provider • Self assessment: Communication skills and biases• General interview skills• Explore and identify patients’ hopes, fears,

unacceptable outcomes• Define “goals of care”• Practice• Use patient goals as foundation of SDMSI• Decision‐making framework• Define the decision and unacceptable outcomes• Practice

Content

Discern “What Matters Most”

Align Care with “What Matters Most”

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SDMSI Versus Common Approach toDecision Making: What’s Different?

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Common Approach• First, identify all

options.• Present options for

intervention to patient. FAQsRisk: Benefit statistics

• Work with patient to make a treatment decision.

SDMSI Approach• First, identify and understand

patient’s priorities and goals for care.

• Present options consistent with patient’s goals.

• Frame “benefits and burdens” in context of patient’s views of unacceptable outcomes.

• Explore non‐intervention as a viable option.

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SDMSI: The Target Population

• Patients with advancing chronic illness as evidenced by:

ComplicationsCo‐morbiditiesIncreased clinical encountersFunctional decline

• Patients who we would not be surprised died in the next one to two years

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SDMSI Conversation

• Illness understanding –symptoms, complications• Sharing current state information• Explore Hopes for care – current and future,

Quality of life, fears and concerns about illness• Apply what matters most to a SDM discussion in

order to align goals with care

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Role of Provider in SDMSI Conversations

• Identify patients who would benefit from SDMSI conversations.

• Assist patients in aligning their goals and values with any treatment decision they may face.

• Utilize existing documentation and goals of care to inform the approach to SDMSI conversations.

• Document goals and decisions.• Create plans that assist to honor patient’s

decisions.

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Communications Skills

The Cornerstone of Person‐Centered Shared Decision Making

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Shared Decision‐Making Skills

• Setting the Stage• General Interview Skills• Skills to Discern What Matters Most• Skills to Align Care with What Matters Most

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Helping Patients Make Decisions that Align with What Matters Most

The decision‐making frameworkExample: CPRRole‐play demonstration

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Decision Aids/Fact Sheets

(videos, print, web‐

• Assist in delivering unbiased and current information.

• Help individuals form questions.

• Use during the SDMSI conversation or as a follow‐up activity.

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CPR Small Group Role‐Play3

• Partner with the person sitting next to you ---patient with heart failure and provider.

• Role model what you should say to help him make a decision about CPR.

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Decision Making Framework

• Identify Decision • Explore facts based upon current state of health• What is acceptable/unacceptable?• What are the patient’s goals?• Explore worries, concerns and fears? • Recommendations based upon individual goals

and values.(Weiner, 2013, Elwyn, 2012)

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One Organization’s Implementation

• ACP implementation for 3 years• System priority around “Heal the Whole

Person”• Increasing focus on “Value‐Based Care”• SDMSI integrated as means to meaningfully

engage providers (physicians and advanced practice practitioners)

• System‐wide conversion to one EMR


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Cumulative Participants

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60

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90

100

Q3 CY 2015 Q4 CY 2015 Q1 CY 2016 Q2 CY 2016 Q3 CY 2016 Q4 CY 2016 Q1 CY 2017 Q2 CY 2017

By Provider Type

attending residents APP

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Practicing Physicians and APPs

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Program Metrics

• Pre and post provider attitudes and competence

• Patient experience post SDM conversation• Documentation of goals of care from SDM

conversation


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(SDMSI)The Importance of a System

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3. Community Engagement– Materials that engage– Strategies to engage– Special population groups

4. Continuous System Management– The Five Promises– Implementation project plan– Ongoing QI plan

1. Health System Redesign– Team approach and supporting

workflows– Standardized documentation

processes– Storage & retrieval processes

2. Staff Education & Facilitator Certification– Train the trainer Model– Team education– Other stakeholder education

(Hammes & Briggs, 2011)

an Effective SDMSI Program

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(SDMSI)Measuring Person‐Centered Care


52Retrieved from: www.ihi.org/Engage/Initiatives/

Aim

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Measurement Person‐Centered Family‐Oriented Care

Three aspects of care• Communication• Decision Making• End of life Care

Outcomes and Core Concepts• Individualized Care• Family• Respect Dignity and compassion• Information sharing and

Communication• Shared Decision Making• Self‐Management• Access and Convenience

https://www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/personcentered/personmeasures.html,http://www.qualityforum.org/Publications/2014/08/Priority_Setting_for_Healthcare_Performance_Measurement__Addressing_Performance_Measure_Gaps_in_Person‐Centered_Care_and_Outcomes.aspx,

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Summary54

Advance directive completion alone will not ensure we are honoring and respecting individual goals and wishes.

A Person Centered Care for Serious Illness can be realized through….

• Ongoing process of advance care planning that aligns with a persons goals values and beliefs and current state of health.

• Intentional shared decision making opportunities that align care with what matters most.

• Adoption of to adopt strategies to promote engagement, dissemination, and sustainability by providers, systems and patients


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www.respectingchoices.org

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1. Gwande A. Being Mortal: medecine and what matters in the end. First edition ed. New York, NY: Metropolitan Books, Henry Holt and Company; 2014.2. Murray SA, Kendall M, Boyd K, Sheikh A. Illness trajectories and Palliative Care. British Medical Journal. 2005;330(April 30):1007-1011.3. Fry M, McLachlan S, Purdy S, Sanders T, Kadam UT, Chew-Graham CA. The implications of living with heart failure; the impact on everyday life, family support, co-morbidities and access to healthcare: a secondary qualitative analysis. BMC family practice. 2016;17(1):139.4. Kelley AS. Defining "Serious Illness". Journal of Palliative Medicine. 2014;17(9):985.5. Schellinger SE, Anderson EW, Frazer MS, Cain CL. Patient Self-Defined Goals: Essential of Person-Centered Care For Serious Illness. American Journal of Hospice & Palliative Medicine. 2017.6. (IOM) Institute of Medicine (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC.7. IOM (Institue of Medicine). 2014. Dying in America: Improving quality and honoring individual preferences near the end of life. Washington, DC: The National Academies Press.8. Kelley AS, Meier DE. Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform. New York, NY: Springer Science. New York, NY: Springer Science; 2014.

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9. Hammes BJ. Having Your Own Say: Getting the Right Care When it Matters Most.Washington, DC: CHT Press. (Available at www.respectingchoices.org); 2012.10. (NAM) National Academy of Medicine (2017) Community-Based Models of Care Delivery for People with Serious Illness. Discussion Paper www.nam.edu/perspectives. In.11. National Quality Forum (NQF). National Quality Partners (NQP): Strategies for Change - A Collabortive Journey to Transform Advanced Illness Care. Washington, DC: NQF; 2016. Available at http://www.qualityforum.org/Events/Education_Programs/2016/National_Quality_Partners_(NQP)__Strategies_for_Change_-_A_Collaborative_Journey_to_Transform_Advanced_Illness_Care.aspx.12. Topol E. The Patient Will See You Now. The Future of Medicine is in Your Hands. New York, NY: Basic Books; 2015.13. Lines LM, Lepore M, Weiner JM. Patient-centered, Person-centered, and Person-directed Care. They are Not the Same. Medical care. 2015;53(7):561-563.14. Heidenreich PA. Time for a Thorough Evaluation of Patient-Centered Care. Circulation Cardiovascular Quality Outcomes. 2013;6:2-4.15. Bernabeo E, Holmboe ES. Patients, providers, and systems need to acquire a specific set of competencies to achieve truly patient-centered care. Health affairs. 2013;32(2):250-258.16. Stacey D, Legare F, Col NF, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014(1):CD001431.

population health and best practices for serious illness · · 2017-10-10chuck’s end of life...

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