Post on 25-Dec-2015
Integrating Shared Decision Making into Primary Care
Practice OHP Quality and Health Outcomes Committee
14 April 2014L.J. Fagnan, MD
Oregon Rural Practice-based Research NetworkOregon Health & Science University
Defining Shared Decision Making (SDM) Describe why SDM is a “hot” topic List conditions where SDM is likely to be of
use Learn where to find SDM resources/tools Describe models of implementing SDMo “From the trenches” report—the ORPRN Rural Study
Describe patient and practice SDM outcomes
Overview
Three Core Pillars of the Patient-Centered Medical Home
Moving from individual patient care to population-based care
Moving from physician-based care to team-based care
Using the Shared Decision Making concept to create an informed activated patient
A Multidimensional Framework for Patient and
Family Engagement in Health and Health Care
Carman K L et al. Health Aff 2013;32:223-231 ©2013 by Project HOPE - The People-to-People Health Foundation, Inc.
SDM and Health Reform Shared Decision Making to Improve Care and Reduce
Costs. NEJM, January 3, 2013 — “A sleeper provision of the Affordable Care Act encourages SDM…”
CAHPS PCMH Survey includes self-management support and shared decision making as a domain of care
Oregon PCPCH Standards’ Core Attribute of Person and Family-Centered Care
Milestone #7 of the CMS Comprehensive Primary Care Initiative
Makes the “Triple Aim” Possible—Better Population Health; Improved Experience of Care, Lower Per Capita Cost
Bottom Line: SDM is a standard of practice
Shared Decision Making: a Definition Integrative process between patient and clinician : Engages the patient
in decision-making Provides patient with
information about alternative treatments
Facilitates the incorporation of patient preferences and values into the medical plan
(Charles C, Soc Sci Med 1997; 44:681)Slide from Michael Barry, MD, IMDF President
BHM Healthcare Solutions
Better Patient Outcomes from Shared Decision Making
“No Decision About Me Without Me”
A central tenet of medicine and our approaches to treatment and diagnosis is its uncertainty
“Many doctors aspire to excellence in diagnosing disease. Far fewer, unfortunately, aspire to the same standards of excellence in diagnosing what patients want.”
Mulley A, Trimble C, Elwyn G. Patients’ preferences matter: stop the silent misdiagnosis. 367 London: King’s Fund, 2012
Medical Decision Making
Forces Sustaining Unwanted Practice Variation
Poor Decision Quality Unwanted Practice
Variation
Patients: Making Decisions in
the Face of Avoidable Ignorance
Clinicians: Less than optimal
“Diagnosis” of Patients’
Preferences
Slide from M. Barry. Informed Medical Decision Foundation
Patient Decision Aids (DAs)Tools that help patients make informed medical choices, consistent with their values and preferences
Three key elements:• Present balanced information about
treatment or testing options, specifying probabilities of outcomes
• Help people interpret the options in the context of what is important to them
• Encourage patients to collaborate with their clinicians when making decisions
Cochrane DA Review (n=86 trials)
Improve decision quality14% higher level of knowledge74% more realistic expectations25% better match of values and choices
Patients 39% less passive in decisions Reduce over-use of surgery-20%
PSA testing-15%HRT-27%
Stacey et al. 2011. Cochrane Review Patient Decision Aids
Introduced PDAs for hip/knee arthroplasty candidates in 2009
Reached 28% of eligible knee (N=3510)and 41% of hip patients (N=820)
Over 6 months:38% fewer knee replacements26% fewer hip replacements12-21% lower costs
Arterburn D, et al. Health Affairs 2012; 31(9)
Hip and Knee Decision Aids at Group Health
Consequences of Unresolved Decisional Conflict
59 times more likely to change mind (e.g. not showing up for colonoscopy)
23 times more likely to delay decision 5 times more likely to have regret 3 times more likely to fail knowledge
test (e.g. informed consent) 19% more likely to blame clinician for
bad outcomes
Sun, Q. (MSc thesis). University of Ottawa. 2005; Gattelari & Ward J Med Screen 2004; 11:165-169
Ottawa Personal Decision Guide©: A Tool for Implementing Decision Support
SDM is the “Pinnacle of Care”NEJM, March 1, 2012
“No care about me without me” Patients exposed to SDM DAs are big fans
and want this level of care The care team will develop an appreciation
for the value of SDM to enhance patient-centered care
SDM as the Right
Thing To Do
SDM is Difficult To Do
SDM implementation as the Triple Axel of patient-centered care
Push back from clinicians, staff, and patients
Demonstration Site ProgramObjective: to demonstrate that the use of
patient decision aids and the process of shared decision making can effectively and efficiently become part of day-to-day care
© Informed Medical Decisions Foundation 2013
Four year study Funded by
Informed Medical Decision Making Foundation (IMDF)
Facilitated by ORPRN
Implemented SDM in six sites in rural Oregon
Study Objective and Background
The mission of ORPRN is to improve the health of rural populations in Oregon through conducting and promoting health research in partnerships with the communities and practitioners we serve.
Oregon SDM Decision Aids (DAs) Lessons
Bayshore Family Medicine
Winding Waters Clinic
Pioneer Memorial Clinic
Lincoln City Medical Center
SDM DA Implementation Overview(model used with permission from the Informed Medical Decisions Foundation)
Engage Providers and
Staff IdentifyEncourage
ViewingMeasure Impact
Practice Facilitation
Six Steps of Shared Decision Making
1. Invite patient to participate
2. Present Options
3. Provide information on benefits and risk
4. Assist patient in evaluation options based on their goals and concerns
5. Facilitate deliberation and decision making
6. Assist with implementation
Invite Patient to Participate “There’s a decision to make about your
treatment (or testing) and I’d like to make it with you. Knowing what’s important to you will help us make a better decision.”
OR “Sometimes things in medicine aren’t as
clear as most people think. Let’s work together so we can come up with the decision that’s right for you.”
How Did We Do with SDM DA Implementation in Routine Practice?
DA Selection By Clinic
A B C D
Living withDiabetes
Living with Diabetes
Living with Diabetes
Acute Low Back Pain
ManagingMenopause
Managing Menopause
Chronic Pain Management
Managing Menopause
PSA Testing PSA Testing Coronary Artery Disease
PSA Testing
Colorectal Cancer Screening
Knee Osteoarthritis
Growing Older To be determined…
Peace of Mind Peace of Mind
ORPRN: Questionnaires Distributed & Returned
Coronary Artery Disease (33%)
Spinal Stenosis (100%)
Coping with Depression (47%)
Knee Osteoarthritis (75%)
Chronic Low Back Pain (44%)
Acute Low Back Pain (51%)
Colon Cancer Screening (67%)
Peace of Mind: Advance Directives (65%)
Chronic Pain Management (59%)
PSA Testing (63%)
Managing Menopause (65%)
Managing Diabetes (62%)
TOTAL (61%)
-100 100 300 500 700 900 1100 1300 1500
1
3
15
15
17
29
40
46
47
57
66
87
423
3
3
32
20
39
57
60
71
80
90
101
141
697
Questionnaires dis-tributed
Topic (response rate*)
How important for providers to give DAs to patients?
Data submitted to Illume data warehouse as of 17-Mar-2011. IMDF Demonstration Sites.
N=194
N=1382
Patient Responses after Viewing DA:
Managing Diabetes
Managing Menopause
PSATesting
Chronic Pain Manage-
ment
Advance Directives
Colon Can-cer Screen-
ing
60%
45%
65%
44%
64%72%72%
59%
74%
57%61% 61%
ORPRN Other Sites
% v
ery
or
extr
em
ely
ORPRN: Decision Aid Usefulness Ratings
Question: “How useful was the program in helping you prepare to talk to your healthcare provider?”
[not at all / somewhat / very / extremely]
SDM Successes: The Winding Waters Story▶ Established highly functional SDM
team Clinic staff (front desk, MA, office
manager)Clinicians
▶ High performing practice facilitator (PERC)Develop implementation protocolsProvide at the elbow supportRespond to clinic requests
Facilitators: Within the Clinic
▶ Developing team based distribution strategies
▶ Creating system level protocols
▶ Clinician champion and identifying a staff data liaison
▶ Identify DAs for “common” conditions
Clinic stability essential to DA implementation
Care Team
Facilitators: Outside the Clinic
▶ Patient buy-in for DAs▶ Sharing patient feedback (i.e.,
Patient Advisory Council)▶ External support through
practice facilitation (ORPRN PERCs)Implementation protocolsDistribution processInterpretation of clinic level
data reports
Script pad designed by Winding Waters Patient Advisory Council
Shared Decision Making Toolkit
DA implementation guideUsing Decision Aids
(DAs) to facilitate SDM in routine care
Step-by-step guide based on lessons learned from our practices
Feedback from clinicians and staff
Ready-to-use resources http://sdmtoolkit.org/