A Conversation about Missing Conversations or Engaging Patients and the Shared Care Plan

1
A ConversationaboutMissing ConversationsorEng
aging Patientsandthe Shared Care Plan

• Marc Pierson, MD
• Whatcom County
• Pursuing Perfection
• PeaceHealth

2
Who is We?Where is Home?Health broken
between our organizations.
3
Our time together

• Quick overview of Pursuing Perfection
• Three Innovations
• Patients on teams and governance--TRANSORMATIVE
• Clinical Care Specialists role
• Shared Care Plan
• Results
• Better clinical and cost outcomes
• Conversation (Q A)

4
A Confession

• The center has shifted for me in two ways.
• I see that patients homes are the center of any
  health system.
• I now see that social life originates from
  conversations about what we care about. From
  there we make commitments to one another.

5
Our Story in Whatcom

• Institute of Medicine
• Computer Based Health Record, 1990
• Community Health Record
• Whatcom Health Information Network (HINet)
• Most wired healthcare community in the US
• To Err is Human, 1999
• Crossing the Quality Chasm, 2000
• Robert Wood Johnson Foundation
• Pursuing Perfection (P2)Transform American
  Health Care

6
IOM

• Not an indictment of physicians, nurses, or,
  indeed any of the people who give or lead care.
• futile to seek the improvement by further
  burdening an overstressed health care workforce
  or by exhorting committed professionals to try
  harder.
• A redesigned health care system can offer the
  health care workforce what it wantsa better
  opportunity to provide high-quality care.

7
CONTEXT
8
Robert Wood Johnson FoundationTransform
American Health Care

• Give me a break!
• or
• Take it seriously?

9
P2 Participating Orgs

• Family Care Network
• Sea Mar Community Health Clinics
• North Cascade Cardiology
• St. Joseph Center for Senior Health
• St. Joseph Hospital
• Group Health Cooperative
• Community Health Plan of Washington
• AND LOTS OF PATIENTS

10
Two Strategies

• We worked on changing our organizations
• You all know how difficult that is.
• Slow going. Not transformative.
• We invited patients to participate
• They showed us what is transformative
• Give them what they need to navigate the
  non-system between our organizations (Clinical
  Care Specialist)
• Give them the information they need to
  participate and partner. (Shared Care Plan)
• Enable them communicate to HELP EACH OTHER and
  those they care about. (Shared Care Plan, group
  visits).

11
Involving Patients in the Process
12
Patient Action Advisory Committee
13
(No Transcript)
14
Chronic Care ModelA Useful Affordable
Approximation
15
Patient Involvement--context

• To Err is Human
• Quality Chasm Report
• McGlynn Report
• Whatcom County10 years of collaboration
• Chronic conditions
• Patients Social Network
• Activated patient/family units

16
Patient Involvement--Details

• RWJF/IHI Pursuing Perfection
• Whatcom-5 provider organizations, 2 payers,
  patients as co-designers
• Pts with DM and CHF
• Clinical Care Specialists (concierge)
• Navigator, coach, translator, lifeguard
• Shared Care Plan
• Print to talk
• Conversations change behavior
• In the home
• In the office
• In the field
• Screen shots
• Satisfaction
• Patient Activation

17
PATIENTS EXPERIENCE
18
Rebecca Brysons Conditions and Virtual Care Team
Pursuing Perfection in Whatcom CountyApril 2003
19
Rebeccas Communication Burden
Pursuing Perfection in Whatcom CountyApril 2003
20
Rebeccas Communication Burden

Shared Care Plan
Pursuing Perfection in Whatcom CountyApril 2003
21
Information for a Care System
Patient centeredness -Personal preferences
-Personal goals -Next steps to those goals
-Care team members including fm fr -Patient
possession of accurate medication list -Useful
measures for patient-centered approach Patient
activation Health status -Depression
-Physical functioning -Health related
QOL Virtual team functioning
development Quality of care transitions Lab
values Demographics Diagnoses Medications Images
Transcriptions, orders, coding, billing, etc
PHR (Shared Care Plan) for Virtual Care Teams
Old Business EMRs
HInet (WAN)
22
Missing Conversations

• The focus shifts
• from EMR
• (organization specific business medical records)
• to include PHR
• (patient health records)

23
Screen Shots
24
Patient Designed Features

• Control of access
• Audit trail
• Advanced directives
• Printing for refrigerator, purse and glove
  compartment
• Printing for wallet
• Connection to EMR medications for
  reconciliation
• AHRQ single accurate medication list

25
(No Transcript)
26
Effects

• Saved and average of 3,000 per person per year
  on ED and hospital stays.
• Had better clinical outcomes for diabetes
• Even though they were the sickest.
• Had high patient and family satisfaction
• High acceptance by providers

27
Debilitating Assumptions

• Chronic care and prevention is like acute care
• Patients and old people are incompetent
• Doctors and hospitals are the center of health
  caring
• People cannot get access to the web
• Business medical records must be adopted before
  personal health records/support systems
• Everyone must adopt PHRs before they are useful
• Its OK for every business to provide a
  different personal health record

28
Engaging Patients

• Lets just talk about this.
• Experiences?
• Concerns?
• Hopes?
• Beliefs?
• Actions?
• Commitments!

29
Engaging Communities?!

• Communities of
• EMS
• Schools
• Churches
• Hair dressers
• Parish Nurses
• .

30
Shared Care Plan

• Who already knows something about it?
• What do you think?
• What do you want to know?

31
Lets Give Them a Chance

• With the devastating knowledge from the McGlynn
  reports.
• Lets empower patients and their social networks
  in order to get this nation above 55 reliability
  in health care
• Lets let them help us make it safer
• Lets let them help us with the very difficult
  job of delivering health care
• Lets invite them in as full partners
• It is virtually free

32
Screen Shots
33
Screen Shots
34
Screen Shots
35
Screen Shots
36
Screen Shots
37
Screen Shots
38
(No Transcript)
39
(No Transcript)
40
Screen Shots
41
Screen ShotsAudit Trail
42
Screen ShotsAudit Trail
43
(No Transcript)
44
Activated PatientsBetter for Everyone
45
(No Transcript)
46
(No Transcript)
47
(No Transcript)
48
(No Transcript)
49
(No Transcript)
50
(No Transcript)
51
(No Transcript)
52
(No Transcript)
53
(No Transcript)
54
(No Transcript)
55
PHR

• Will become much more than a record or document
• Home support platform
• Communication and messaging platform
• Base for home monitoring devises
• Workflow and decision support features build in
  and under control of users.

56
Interesting Policy Facts

• Source code instructions available for free
  from PeaceHealth _at_...
• Support for instillation and adaptation available
  elsewhere. Talk with me.
• Washington State Healthcare Information
  Infrastructure Advisory Board is recommending
  something very similar to the Shared Care Plan
  for everyone in the state.
• An more advanced Shared Care Plan (Personal
  Health Management System) is underdevelopment for
  general availability

57
What would you want the SCP to do for you your
patients and friends?
58
My Recommended Links

• http//www.wwpp.org/media/fla/whatcomProf/whatcomP
  rof.html
• http//www.wwpp.org/media/fla/BonnieWWPP2/TestVid.
  html
• https//www.peacehealth.org/apps/Forms/Default.asp
  ?FormID1191
• http//www.wwpp.org/users/0000002/
• www.sharedcareplan.org
• www.wwpp.org
• www.connectingforhealth.org/resources/wg_eis_final
  _report_0704.pdf

59
THANK YOU