Comprehensive Patient and FamilyCentered Care :

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• Comprehensive Patient and Family-Centered Care
• The Breast Care Center Experience

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Learning Objectives

• Describe the evolution of the integration of
  evidence-based medicine patient centered care
  in a clinical microsystem approach at the Walter
  Reed Army Medical Center Breast Care Center
• Compare and contrast program outcomes before and
  after implementation of evidence-based,
  patient-centered care using a microsystem
  approach at Walter Reed Army Medical Breast Care
  Center

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Published and On-Line References used in this talk

• http//www.clinicalmicrosystem.org
• http//cms.dartmouth.edu/greenBook.htm
• Collins PM Hidden in Plain View. Navy Medicine,
  March-April 2007
• http//www.improvingchroniccare.org/change/model/c
  omponents.html
• http//www.familycenteredcare.org
• http//www.hjf.org/research/cbcp_web.html

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Synopsis

• Walter Reed took a clinical microsystem approach
  when integrating an evidence-based and
  patient-centered care approach in its Breast Care
  Center. Attendees can compare and contrast
  program outcomes before and after implementation
  of this methodology and consider its implications
  for use at their facility.

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Military relevance

• Excluding skin cancer, Breast cancer is the most
  common cancer among women in the United States.
• More than 15 of active duty military personnel
  are women. Add to that the number of Armed
  Services family members who are women and it
  becomes apparent that breast cancer is both a
  civilian and a military concern.

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Multi-faceted approach CBCP employs.

• Clinical Microsystem
• Chronic Care Illness Model
• Patient- and Family-Centered Care

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• Principles
• And
• Practice

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Multi-faceted approach CBCP employs.

• Clinical Microsystem

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A Clinical Microsystem Approach the CBCP way

• Clinical Microsystems defined
• Front-line units that provide most health care to
  most people
• Places where patients, families, and care teams
  meet
• Includes support staff, processes, technology,
  and recurring patterns of information, behavior,
  and results
• The patient is central

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• A clinical microsystem is a group of
  interdependent people who come together for a
  common aim.
• The patient is at the center of any microsystem,
  but a given patient is not fixed within a single
  microsystem.

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What occurs at a clinical microsystem?

• Care is made
• Quality, safety, reliability, efficiency, and
  innovation are made
• Staff morale and patient satisfaction are made

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• A microsystem approach to improvement requires
  the involvement and investment of all frontline
  players, including patients and families.

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5 things that make a microsystem successful

• Focused on patient
• Focused on staff
• Each individual important and their work valued
• Excellent leadership
• Always more than one
• Doctor Nurse Administrator
• Emphasis on providing good care
• On outcomes and the processes that produce the
  outcomes
• Effective communication and innovative, usable
  information technology
• Communication between everyone Staff, Patients,
  Families

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• Every clinical microsystem is unique.

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Multi-faceted approach CBCP employs.

• Clinical Microsystem
• Chronic Care Illness Model

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Chronic Care Model instituted at CBCP

• Developed by the MacColl Institute for Healthcare
  Improvement Innovation at the Center for Health
  Studies, Group Health Cooperative
• Institute derived from Ed Wagners Improving
  Chronic Illness Care Model
• Proven success in improving physician and patient
  satisfaction and positive clinical outcomes

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• There are many definitions of  "chronic
  condition", some more expansive than others. We
  characterize it as any condition that requires
  ongoing adjustments by the affected person and
  interactions with the health care system.
• 133 million people, or almost half of all
  Americans, live with a chronic condition. That
  number is projected to increase by more than one
  percent per year by 2030, resulting in an
  estimated chronically ill population of 171
  million.

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Present system deficiencies in treating chronic
health conditions include

• Rushed practitioners not following established
  practice guidelines
• Lack of care coordination
• Lack of active follow-up to ensure the best
  outcomes
• Patients inadequately trained to manage their
  illnesses

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• Overcoming these deficiencies will require
  nothing less than a transformation of health
  care, from a system that is essentially reactive
  - responding mainly when a person is sick - to
  one that is proactive and focused on keeping a
  person as healthy as possible. To speed the
  transition, Improving Chronic Illness Care
  created the Chronic Care Model, which summarizes
  the basic elements for improving care in health
  systems at the community, organization, practice
  and patient levels.

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Chronic Care Model elements

• Community
• Health System
• Self-management support
• Delivery System Design
• Decision Support
• Clinical Information Systems

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Chronic Care Model themes

• Patient safety (within the health system)
• Cultural Competency (in delivery system design)
• Care Coordination (in Health System and Clinical
  Information Systems)
• Community policies (in Community Resources and
  Policies)
• Case management (in Delivery System Design)

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Chronic Care Model benefits

• Healthier patients
• More satisfied Providers
• Cost savings

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Multi-faceted approach CBCP employs.

• Clinical Microsystem
• Chronic Care Illness Model
• Patient- and Family-Centered Care

http//www.familycenteredcare.org
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• In its Six Quality Aims for Improving Care, the
  IOM report defines patient-centered care as care
  that is respectful of and responsive to
  individual patient preferences, needs and values,
  and ensuring that patient values guide all
  clinical decisions.
• Partnerships amongst professionals, patients,
  and families are essential to such a caregiving
  process.

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Institute for Family-Centered Care (IFCC)

• A leader in innovative health care delivery
• Its core concepts of patient and family-centered
  care
• Dignity and Respect
• Information Sharing
• Participation
• Collaboration

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IFCC unique feature

• Role of patients and family advisors to clinic or
  hospital staff on committees and programs to
  operationalize patient-partnerships
• Advisors have the potential to reflect a range of
  experiences within the unit, hospital, or clinic
  they serve and can provide valuable insights into
  process improvements

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Instituting patient-centered care within your
clinical microsystem

• At the clinical microsystem level Patients and
  family advisors should participate as full
  members of quality improvement and redesign
  teams, participating from the beginning in
  planning, implementing, and evaluating change.
  Design of the experience of care should respect
  the patient and family, optimize access to that
  care, allow for participation, and support and
  stimulate activation and commitment to achieving
  their clinical goals.

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• Ulrich, R., Zimring, C., Quan, X., Joseph, A.
  (2004). The role of the physical environment in
  the hospital of the 21st century A
  once-in-a-lifetime opportunity. Retrieved
  September 2004, from http//www.healthdesign.org/r
  esearch/reports/physical_environ.php
• Research teams from Texas AM University and
  Georgia Tech identified over 600 studies - most
  in top peer-reviewed journals - that establish
  how hospital design affects clinical outcomes. In
  comparison with multi-bed rooms, single-bed rooms
  reduced noise, improved lighting, improved
  ventilation, and enhanced ergonomic designs.
  Supportive workplaces and improved layout were
  found to be associated with reducing errors,
  stress, pain, and medication use and improve
  sleep as well as other positive effects including
  staff outcomes. The report states, A growing
  scientific literature is confirming that the
  conventional ways that hospitals are designed
  contributes to stress and danger, or more
  positively, that this level of risk and stress is
  unnecessary improved physical settings can be an
  important tool in making hospitals safer, more
  healing, and better places to work.

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• McWilliam, C. L., Brown, J. B., Stewart, M.
  (2000). Breast cancer patients' experiences of
  patient-doctor communication A working
  relationship. Patient Education and Counseling,
  39(2-3), 191-204.
• Women with breast cancer who reported positive
  working relationships and communication with
  their health care provider were more likely to
  also report more control and mastery of the
  illness experience than women who did not have a
  positive relationship.

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• Stewart, M. J., Brown, J. B., Donner, A., et al.
  (2000). The impact of patient-centered care on
  outcomes. Journal of Family Medicine, 49(9),
  796-804.
• In this study of 39 physicians and 315 patients,
  patients' perceptions of their physicians as
  patient-centered was positively associated with
  improved patients' health status and increased
  efficiency of care. This study of communication
  in outpatient visits revealed that when patients
  achieved common ground with physicians, health
  status and emotional health improved, while fewer
  referrals and diagnostic tests were needed two
  months after the visit. This study is part of a
  long-term program focusing on physician and
  patient relationships led by Stewart and
  colleagues

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• Sodomka, P. (2005, May). Leadership for
  Family-Centered Care. Presented at the Institute
  of Family-Centered Care's educational program for
  the Leadership Team, Womack Army Medical Center,
  Fort Bragg, NC.
• The MCG Health System in Augusta, Georgia has
  positive outcomes in clinical areas where they
  have made an explicit commitment to patient- and
  family-centered care and involved patients and
  families in planning, implementation, and
  evaluation of policies, programs, professional
  education, and facility design. For example The
  MCG Neuroscience Center of Excellence, reported
  positive outcomes over two to three years
  including
• Patient satisfaction increased from the 10th to
  the 95th percentile.
• Length of stay decreased by 50.
• Discharge rate (volume) increased by 15.5.
• Medical errors reduced by 62.
• Staff vacancy rate dropped from 7.5 to 0.
• A waiting list of staff wanting to work on the
  unit.
• Positive change in perceptions reported by
  physicians, staff, and house staff.
• The Breast Health Center's patient satisfaction
  scores went from the 40th percentile to the 74th
  in the first year of operations, and are now over
  the 90th percentile.

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Additional aspects of CBCPs multi-faceted
approach

• The program conducts a risk reduction clinic
  designed to identify those at increased risk of
  developing breast cancer, and to provide
  treatment, education and counseling. CBCP staff
  also provide comprehensive clinical care in a
  specially designed and nurturing environment.
  Their "nurse navigator" program ensures that
  patients receive personalized care and support
  throughout their treatment.

http//www.hjf.org/research/cbcp_web.html
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Multi-faceted approach CBCP employs.

• Clinical Microsystem
• Chronic Care Illness Model
• Patient- and Family-Centered Care

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• Principles
• And
• Practice

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Windber / Walter Reed /USU Clinical Breast Care
Project (CBCP) Craig Shriver MD FACSLTC MC PI
Chair, Steering Committee April 2000
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TEMPLATE

• Total
• Evaluation and
• Management
• PLAnning of your
• Treatment
• Experience
• Where the Clinical Microsystem, Chronic Care
  Illness Model, and Patient- and Family-Centered
  Care all come together !

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CBCP-WRI Research Workflow?
Johnstown Malcolm Grow AF Landstuhl AAMC
Clinic Domain
WWW/Internet Domain
Research Domain
Translational Clinical Trials (eg. TAILOR-Rx)
Fire wall
Fire wall
DoD Serum Repository
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CBCP patient accruals to research, cumulative
annual total (as of 31 December 2007)
3591
2893
2150
1200
764
317
2002 2003 2004 2005
2006 2007
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CBCP Biologic Specimens (as of 31 December 2007)
2003 2005 2007
Number of patients 3,591
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Multi-faceted approach CBCP employs.

• Clinical Microsystem
• Chronic Care Illness Model
• Patient- and Family-Centered Care