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Measuring the Patient Experience in a Medical Home

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Measuring the Patient Experience in a Medical Home QI/PCMH Roundtable March 14, 2013, Seattle, WA – PowerPoint PPT presentation

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Title: Measuring the Patient Experience in a Medical Home


1
Measuring the Patient Experience in a Medical
Home
  • QI/PCMH Roundtable
  • March 14, 2013, Seattle, WA

2
Radical Patient Centeredness
  • (1) The needs of the patient come first.
  • Mayo Clinic
  • (2) Nothing about me without me.
  • IHI
  • (3) Every patient is the only patient.
  • Harvard Community Health Plan Hospital

3
Why Focus on Patient-Centered Interactions?
  • Without a deliberate focus on integrating the
    patients perspective and the patient and
    families desires/goals, practice changes may
    create efficiency, but miss entirely the changes
    that would have come from patients experience of
    care.
  • Without involving patients and family members in
    quality improvement, we are only guessing at what
    they want and need.

4
  • The big ASK routinely asking patients about
    their experience of care to guide teams in the
    improvement and redesign aspects of achieving
    patient-centered medical home-ness
  • Methods to capture our patients experiences
  • Regularly host focus groups
  • Have patient representatives on the improvement
    team
  • Ask patients about their experience at the point
    of service
  • Routinely conduct patient surveys and review the
    results immediately

5
Radical Patient Centeredness
  • A never-ending inquiry to those we serve
  • What do you want and need?
  • What is your way?
  • How am I doing at meeting your needs?
  • How could I do that better?
  • How can I help you?

6
Patient-centered care as a quality dimension.
  • Ask the following question at the end of most
    interactions
  • Is there anything at all that could have gone
    better today from your point of view in the care
    you experienced?
  • And then, listen and learn.
  • For quantitative ratings, ask patients to rate on
    a 15 scale disagreement to agreement with the
    assertion
  • They gave me all the care I needed and wanted,
    exactly when and how I needed and wanted it.
    Seek 5s and study the low raters.
  • L. Gordon Moore, MD

7
Data for Improvement, Accountability, Research
Aspect Improvement Accountability Research
Aim Improvement of care Comparison, choice, reassurance New knowledge
Test Observability Test observations Evaluate current performance no test Test blinded
Bias Sample Size Consistent bias just enough data Measure and adjust to reduce bias 100 of data Design to eliminate bias just in case data
Flexibility of hypothesis Improvement of care No hypothesis Fixed hypothesis
Testing strategy Sequential tests No tests 1 test
Is change an improvement? Run or control charts No change focus Hypothesis tests (F-test, T-test, Chi-squared, P-value)
Confidentiality of data Only used by those involved in improvement Available for public consumption Identities protected Tammy Fisher, MPH Director, Quality Performance Improvement San Francisco Health Plan
8
Collecting Patient Experience Data
Purpose Data Collection Tools/strategies
Improvement Point of service surveys Telephonic surveys Comment cards Patient exit surveys Focus groups Patient (and family) Walkabouts Kiosks, via web
Accountability/Research Mailed surveys Telephonic surveys
9
Common Reasons for Using an Existing Instrument
  • So normative comparisons can be made
    (benchmarking)
  • To replicate or maintain continuity with previous
    studies
  • Existing measure is state-of-the-art
  • The time and expense of developing new measure is
    prohibitive

10
Examples of Existing Patient Experience Surveys
  • CAHPS (consumer assessments of health plans
    survey)
  • http//www.cahps.ahrq.gov
  • PCAT (primary care assessment tool)
  • http//www.jhsph.edu/pcpc/pca_tools.html
  • Cassady CE et al., Pediatrics (J Ambul Pediatr
    Assoc) 2000105998-1003.
  • ACES (ambulatory care experience survey)
  • http//160.109.101.132/icrhps/resprog/thi/aces.asp
  • Safran DG et al., Medical Care. 1998. 36
    (5)728-739.
  • IPC (interpersonal processes of care)
  • Stewart et al., Health Serv Res. 2007 June 42(3
    Pt 1) 12351256.
  • PACIC (patient assessment of chronic illness
    care)
  • http//www.improvingchroniccare.org/index.php?pPA
    CIC_Surveys36
  • Glasgow RE, et al., Med Care  2005 43(5)436-44

11
Approaches to measuring patient experience with
care
  • Patient surveys
  • Proprietary tools
  • Public domain instruments (CAHPS)
  • Focus groups and interviews
  • Walkthroughs
  • Mystery shopping participant observation by
    trained informants
  • Web-based user-generated reviews

12
Sampling Issues
  • Patient population
  • General population
  • Specific subgroups (e.g., chronic illness)
  • Timeframe
  • Visit-based
  • Over the prior 6 or 12 months
  • Frequency
  • Annual monitoring
  • Continuous sampling for improvement
  • Sample size
  • Internal use for improvement
  • External use for public reporting, P4P

13
Traditional Data Collection Modes
  • Mail administration
  • 3 waves of mailing (initial mail, postcard
    reminder, second mail)
  • Telephone administration
  • At least 6 attempts across different days of the
    week and times of day
  • Mixed mail and telephone administration
  • Boost mail survey response by adding telephone
    administration

14
Alternative Modes
  • Internet/Web
  • Email distribution
  • Web response option
  • Interactive Voice Response (IVR)
  • Touchtone IVR
  • Active Voice IVR
  • In-office distribution
  • Paper survey
  • Mail return
  • Internet returns
  • Drop box on site
  • Kiosk or other electronic modes

15
Comparison of Mail, Web, and IVR Modes
Mail Web Web Mail IVR IVR Mail
Response Rates 50.8 18.4 48.6 34.7 53.7
Respondent Characteristics Younger More ed Healthier Less ed Less ethnic More use
Survey Scores (adjusted and unadjusted) Same Same Lower Lower
Total Costs (per completed response) 5.19 13.94 8.01 9.04 8.06
Rodriguez, et al. Evaluating Patients
Experiences with Individual Physicians. Medical
Care. Vol. 44, No. 2, February 2006.
16
Cultural Competence Missing from CAHPS
  • Communication
  • Use of complementary and alternative medicine
  • Respect for Patient Preferences/Shared Decision-
    making Empathy and emotional support
  • Linguistic Competency Access to language
    services Health literacy aspects
  • Experiences Leading to Trust/Distrust Level of
    trust, caring, truth-telling
  • Experiences of Discrimination Due to
    race/ethnicity, insurance, language, etc.

17
Point of Service
  • Good for measuring the effect of changes tested
  • Focus on meaningful measures
  • Document collection methodology train staff
    collecting information
  • Collect just enough data
  • Have at least 15 completed surveys
  • Easy to develop reports
  • Data collection is burdensome!

18
Sample Comment Card
  • Comment Card
  • We would like to know what you think about your
    visit with Doctor X.
  • ? Yes, Definitely ? Yes, Somewhat, ? No
  • Did Dr. X listen carefully to you?
  • Did Dr. X explain things in a way that was easy
    to understand?
  • Is there anything you would like to comment on
    further?
  • Thank you.
  • We are committed to improving the care and
    services we provide our patients.

19
Telephonic Surveys
  • Good for measuring the effect of changes
  • More rapid feedback than mailed surveys
  • Typically less expensive
  • Outside vendors do it and provide reports
  • Easy to manipulate data for reporting
  • Less frequent monthly data at best

20
Patient Exit Interviews
  • Rapid feedback on changes tested
  • Not burdensome to collect data
  • Uncover new issues which may go unreported in
    surveys
  • Requires translation of information into
    actionable behaviors
  • Providers see the feedback
  • Include 3-5 questions, mix of specific measures
    and open ended questions
  • Receptionist or non-clinic member obtains
    feedback (HP or IPA staff)

21
What is patient-centered care?
  • Health care that establishes a partnership among
    practitioners, patients, and their familiesto
    ensure that decisions respect patients wants,
    needs, and preferences and that patients have the
    education and support they need to make decisions
    and participate in their own care.

Institute of Medicine. Envisioning the National
Health Care Quality Report. Washington, DC
National Academy Press 2001.
22
(No Transcript)
23
Self-management Support Stepsto Build Skills and
Confidence
Necessary for special populations (Addictions, MH)
Expert Skills Techniques
Ex Cognitive Behavioral Therapy Dialectical
Behavioral Therapy
Addresses special situations
Advanced Skills Techniques
Adequate for majority of population
Motivational Interviewing Uncomplicated
Depression Group Interactions Training others in
Basics
Basic Skills
Goal Setting Action Planning Problem Solving
Source Connie Davis. RNP
24
The CareSouth Carolina Elements of SMS in the
Stepped Model
  • Care Teams with roles and responsibilities for
    SMS throughout the team
  • Care Managers for higher levels of need
  • Standardization of group and individual learning
    needs
  • Patient focus groups for re-design

25

26

27
Reliability Data for SMG Set
28
THE PATIENT PARTNER PROJECT
  • Betsy Stapleton, FNP Jessica Osborne-Stafsnes

29
  • The process of becoming an intelligent partner
    in the health process can be hard for people.
  • -- Toni M.

30
www.aligningforceshumboldt.org
About Aligning Forces Humboldt
  • Humboldt County AF4Q Alliance Part of RWJFs
    Aligning Forces for Quality
  • Humboldt Focus to generate meaningful
    opportunities for patient engagement in
    healthcare improvement, delivery, and design.

31
Patient Engagement in Humboldt County, Ca
CDSMP leaders act as faculty at PCR meeting to
discuss the patient perspective of living with a
chronic health condition 2009
PCR 3.0 kicks-off. Practices must recruit two
patient partners to participate. Patients
participate in collaborative and office
improvement meetings. 2012
HDNIPA participates in the IHI Quality
Allies Project 2005-2006
Implementation of the Chronic Disease
Self-Management Program (CDSMP) 2008
2011 PCR 2.0 launches with an emphasis on
PCMH. Recruitment of a patient partner team
member is a requirement of participation. Signific
ant infrastructure is built to support this
effort.
2009 HDNIPA adopts collaborative model to
improve primary care called Primary Care
Renewal (PCR) 10 PCP practices participate
2007 AF4Q initiative begins, citing patient
engagement as a key driver of quality
improvement
32
Patient Core Function Levels Recommended Patient Role Key Patient Characteristics Necessary Support Practice Readiness
1. Help individual patients better manage their own health Partner in care Willing to develop self-awareness about personal role in managing healthReceptivity to initiate better health care behaviors The ability to communicate with care team Offer peer-support resources, such as referrals to community-based chronic disease self-management programs (often available both in-person or online), group visits, etc. Starting to engage in viewing patients as partners in chronic condition management. Beginning practice redesign efforts. Willingness to explore new models of care. Leadership support
2. Becoming a leader beyond personal health. Support others in better managing their own health. Partner in care Desire to become peer leader and provide support to others. Able to work cooperatively and effectively with others Access to training for peer leader roles. Starting to implement internal self-management support. Practice open and receptive to chronic disease peer leaders. Leadership support
3. Assist individuals to weigh in on patient experience (resulting in weighing in on quality improvement efforts, office workflows, and patient experience). Advisor Communication skills Can collaborate with diverse individuals Desire to increase knowledge Can contribute and provide collective pt. perspective comfortably Focused on improving care related to the team goals Offer information and training on key focus areas. Ask specific questions. Create a culture that values patient insight. Significant investment in resources. Link into external support that will aid your practice in working with patients in a quality improvement setting. Leadership support.
4. Foster and support champion patients as equal core members of committees that drive redesign efforts at the highest levels Advisor and Champion Skills listed above andCan articulate pt. insight and bring pt. feedback to the forefront Functions in a fast-paced and technical setting Problem-solves in inclusive ways Create roles for a patient/patient advocate on committees. Solicit patient feedback. Offer educational and training opportunities. Significant investment in resources. Link into external support that will aid your practice in working with patients in a quality improvement setting. Leadership support. (Stapleton Osborne-Stafsnes, 2011)
33
AFH Patient Engagement Model
CDSMP Shared Decision- Making
CDSMP Leader Training Community Health- Campaign
Surgical Rate Project Leadership Team
Patient Partners Focus Groups Surveying
Osborne-Stafsnes Stapleton, 2013
34
The Patient Partner Project
Practices often struggle with the 'fires' of the
day , making it difficult to focus on larger
constructs such as patient-centered care. The
participation of Patient Partners on practice
improvement teams keeps the importance of
improving patient care at the forefront of
discussion. Rosemary DenOuden, Chief Operating
Officer, HDNIPA
35
Primary Care Renewal
  • QI collaborative
  • 10 Practices/20 Patient Partners
  • Collaborative meetings every two months
  • Practice meetings 2X/month
  • Each team is assigned a practice coach
  • Patient Partners receive training and support
  • Ambassadors and advocates

Share insights and feedback explicitly focused
on collaborative topics
36
Conceptual Framework
Stapleton Osborne-Stafsnes for AFH, 2013
37
Collaborative Coaching Model
Patient Partner Project Managers
Practice Coaches
Practice Team
Patient Partners
Effective QI Team
Stapleton Osborne-Stafsnes for AFH, 2013
38
Collaborative Meetings
  • Techniques
  • Standing agenda item that starts meeting and sets
    tone
  • Prep patient for presentation
  • Vary presentation mode to keep interest
  • Evaluate

39
Patient Partner Meetings
  • Introduce meeting topics and curriculum
  • Practice updates, brainstorming, and
    problem-solving
  • Sharing of best-practices
  • Capture patient recommendations and perspective
    on meeting subjects.

40
Team Meetings
  • Patients attend one practice improvement
    meeting at their office each month.
  • Some offices have standing agenda items
    specifically for their patient partners.
  • Patients offer insight and work on projects
    specific to the practice.
  • Sample Projects
  • Practice brochure
  • Patient-friendly language
  • Practice ombudsman
  • Testing patient portals
  • Process development

41
Challenges
As a consumer we are often treated like we
don't know anything or the staff doesnt want us
involved. They feel that staff can represent
the consumer instead of us consumers.
Osborne-Stafsnes Stapleton, 2013
42
Addressing Challenges
43
Whose Home Is It?
  • Patients Home
  • Patient-centered
  • Staff uses comprehensible language
  • Ultimately, patient is in control
  • Provider/Staff home
  • Office-centered
  • Patient Partners learned Medicalese
  • Ultimately, Provider/Staff are in control

Medical Home
Practice Home
Providing Medical Care Patient Experience
Doing Business QI Practice Redesign
Productive Interactions
(Stapleton, 2012)
44
Recognizing Success
They keep our focus centered where it should be
on the patients. -- Participating Clinician
45
Recognizing Success
  • Focus Groups
  • Surgical Rate Project
  • Empanelment
  • Process Development
  • Backlog reduction

They keep our focus centered where it should be
on the patients. -- Participating Clinician
46
Foundational Engagement Elements
  1. Didactic orientation and training
  2. Clear role expectations and focus
  3. Structured solicitation of input
  4. Transparent and continuing feedback loop

An Observation Success occurs more often when
patient activation level, staff activation level,
and complexity of the project align.
47
Thank you!
Tools in PCI Implementation Guide http//www.safet
ynetmedicalhome.org/practice-transformation/implem
entation-guides
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