Goal-Directed Health Care: Enhancing Value

James W. Mold, M.D., M.P.H.Department of Family and Preventive MedicineUniversity of Oklahoma Health Sciences Center

Objectives

Explain and then generate discussion about a different way to view health and health care.

Speculate on how this new conceptualization might alter our concepts of quality and thereby impact value.

Mr. Waldrin

Mr Waldrin is a 76 year old man of Northern European descent, married, a retired psychology professor who enjoys reading and writing (essays and articles for magazines). He is active politically, and also likes walking and traveling. His grown children and grandchildren are scattered throughout the country Trips to visit them often involve driving long distances. He is a non-smoker and drinks only 3 glasses of wine weekly.

For him, “states worse then death” would include all permanent conditions that prevented him from thinking clearly.

Mr. Waldrin

He has the following medical conditions and risk factors for adverse health outcomes:

• Type 2 DM for 11 years (rx: glipizide)• HTN for 20 years (rx: HCTZ)• Hypercholesterolemia for 11 years (rx: atorvastatin)• Osteoarthritis of knees for 8 years (rx: prn Tylenol)• A family history of colon cancer (mother at age 70)• Sedentary lifestyle

His current BMI: 32; BP: 150/90; A1c: 7.5%; LDL: 140

Goals, Objectives, and Strategies

Goals are aspirations for which it makes little sense to ask, “Why would you want that?” (e.g. prevention of premature death)

Objectives are those measurable steps along the way. (e.g. prevention of stroke)

Strategies are the methods used to get there. (e.g. keep BP less than 140/90)

Goals of Health Care

Prevention of premature death and disability

Enhancement of current quality of life Support of personal growth and

development

Assumption #1

All patients want to avoid death above all other goals up to the point when life becomes intolerable or loses its meaning That point is different for each person People’s opinions about this may change

somewhat over time

Assumption #2

Quality of life depends primarily upon the ability to do things that give life meaning Those things will be very different for

different people They will change over time

Assumption #3

Personal growth and development proceeds through a series of predictable stages, each one building upon the previous ones.

Full development in human beings requires learning, including learning from experience. Facing and overcoming adversity may be essential for maximal development.

Healing Relationships

Healing relationships are relationships built upon trust that nourish the inborn psychological needs of individuals for:

1. Connection to other human beings2. Development of competence to manage life events and

opportunities3. A sense of autonomy (personal control) in decision-

making

Self Determination Theory (Deci and Ryan) www.psych.rochester.edu/SDT

Four Models of Clinician-Patient Relationship

Paternalistic – clinician chooses interventions most likely to restore the patient’s health and well-being

Informative – clinician describes options, let the patient choose

Interpretive – clinician elucidates patients’ values and helps them select interventions that realize those values

Deliberative – clinician helps the patient choose the best health-related values that can be realized, given the situation

Emanuel EJ and Emanuael LL. Four models of the physician-patient relationship. JAMA 1992; 267(16): 2221-2226.

The Need to Prioritize

We have reached a point in the evolution of health care where there are many more things that can be done than any patient is able to do. (This will get dramatically worse once we all have our DNA sequenced at birth.)

We (clinicians and patients) must therefore learn how to prioritize available interventions based upon personal goals, values, preferences, resources, and action constraints and the potential impact of each intervention.

Diseases as Risk Factors

All health problems are associated with real or potential adverse outcomes Therefore, they can all be considered to be

risk factors for these outcomes

All health care interventions are intended to improve outcomes Therefore, they can all be considered to be

strategies

Initial Visit

Mr. Waldrin was seen initially by a nurse practitioner for an episode of bronchitis.

• His specific concerns and questions were addressed. • He was given advise about management of the acute

problem, and • He was taught how to reduce his risk of future infections

and how to know when to seek medical assistance for similar episodes.

Initial Visit

He was also asked to • Schedule a comprehensive visit (90-minute appointment) • Complete an online medical history and health risk

appraisal (HRA) either at home or in a kiosk in the clinic• Obtain and bring in copies of all relevant outside medical

records (generic list of examples provided)• Come in for fasting blood tests one week prior to the

comprehensive visit (types of tests determined from general assessment by NP)

Medical History/HRA

Socio-demographic informationLifestyle and health habitsPast medical historyFamily historyReview of systemsMental health symptoms/concernsValues and preferencesHealth-related quality of lifeOther health care professionals involved in care

Decision Support

After completing the questionnaire/HRA, he was directed to several decision-support tools that helped him understand his current health risks and the interventions available to address them.

Prioritized Interventions List

Life Extension:

Aerobic exercise 30 min 3 times/wk 3 yrs

Take aspirin 81mg every day 2.5 yrs

Reduce highway miles driven by 50% 2 yrs

Yearly flu shot 6 mo

Reduce BP to below130 systolic 6 mo

Reduce LDL cholesterol to below 70 3 mo

Take an ACE inhibitor 2 mo

Take high dose niacin 1 mo

Take metformin 1 mo

Take a beta blocker 1 mo

Home portable defibrillator 3 wk

Prioritized Interventions List

Pneumococcal vaccination 3 wkFloss teeth daily 3 wkCheck smoke alarm every 6 mo 2 wkSee dentist once a year 2 wksIncrease intake of soluble fiber 2 wksIncrease intake of insoluble fiber 2 wksWash hands after being out in public 2 wksLower A1c to 7% 2 wksColonoscopy 1 wkCPR Training for spouse 1 dayTetanus shot 2 hrs Weight reduction 1 hr

Prioritized Interventions List

Preservation of Cognitive Function:Reduce driving by 50% LargeAerobic exercise 30 minutes 3 times/wk LargeAspirin 81mg daily LargeReduce BP to below 130 systolic LargeReduce cholesterol to below 70 MediumIncrease social activities MediumMultivitamin/M tab once a day Small

Second Visit

Nurse:• Vital signs• Cognitive screening test• Review questionnaire (on-line) for completeness and

patient questions; download information into EHR

Physician:• Review of questionnaire data• Detailed history of current health problems• Complete physical examination• Review of prioritized lists and notes made by patient • Development of wellness plan

Prospective Assessment

Physician and Mr. Waldrin also review Mr. W’s life story, aspirations, values and preferences, strengths and resources, action constraints and limitations

Key questions:

What’s a typical day like for you?

What would you like to do that you can’t do now?

What are the things that make like worthwhile for you?

What conditions would be worse than death?

Wellness Plan

Physician and Mr. W agree upon a wellness plan to be completed over the next year

• 30 minutes of walking 3 times per week• Quadraceps strengthening exercises daily• Diabetes education classes• Aspirin 81 mg per day• Start HCTZ 25mg a day to lower BP to 130/80• Start metformin 500mg BID• Flu shot

Wellness Plan (cont.)

• Pneumococcal vaccination• More frequent hand washing• Dental appointment• Take a MVI/M daily• Eye appointment• Durable power of attorney incl. health care• Basic metabolic panel in 1 and 6 months• Diabetes/HTN visit with NP every 4 months• Wellness visit in 12 months

Between Wellness Visits

Mr. Waldrin works out a plan with the nurse for accomplishing the tasks in his wellness plan. They agree on:

• How and when they will communicate (e.g. phone, e-mail, mail)

• Who else needs to be involved (e.g. PT, pharmacist, dentist)

• Whether others will assist (e.g. spouse)• Whether additional informational resources would be

helpful

Between Wellness Visits

As Mr. W. completes the agreed upon tasks, his information in the Risk Processor is automatically updated from the EHR using the continuity of care record (CCR). It is also updated by changes in guidelines and population statistics.

He is encouraged to review this information periodically using the decision support tools provided.

HRA: Health Risk Appraisal CCR: Continuity of Care Record

Risk ProcessorPrioritizes available

interventions from clinical guidelines by outcome and size of effects

Prioritized Recommendations Lists

Wellness Plan

Decision Support Tool

Link to Resources

Task ManagerRegistry, reminder, and

recall system

Lab results, consults, referrals

Billing System

EHR

Personal attributes,

values,goals,

preferences,constraints

ClinicianPatient

Wellnessnurse

Evidence-based guidelines and population statistics

CCR

HRA

Value = Quality/Cost

How is health care qualitatively different from automobile maintenance?

Why should the conceptualization of quality be qualitatively different in health care than in industry?

Value = Quality/Cost

“Quality medical care can be defined as that care that has the capacity to achieve the goals of both the physician and the patient.”

Steffen GE. Quality medical care. JAMA 1988; 260(1): 56-61.

“Relational value” refers to the development, between a clinician and patient, of greater knowledge, understanding, common purpose, and trust.

Zubialde JP and Mold JW. Relational value: Bridging the worldview gap between patients and health systems. Fam Med 2001; 33(5): 393-398.

Value = Quality / Cost

As long as the cost of medical care is tied to the identification and correction of abnormalities, costs can be expected to rise along the same slope as medical discoveries.

But where is this path taking us? Toward the absence of health challenges, the perfect genome?

When cost is a concern, its usually best to have a clear idea of your goals and priorities and the cost-effectiveness of the available strategies by which to achieve them.

Pay-for-Performance

Suggestion:Incentivize actions that are most likely to achieve

the stated goals.

Until clinicians learn to specify goals, have them categorize patients into those for whom life extension is still a goal and those for whom it isn’t. Pay incentives for increases in patient life expectancy when life extension is still a goal.

Questions?

Cases

Patient with CHF and medication non-adherence

Patient with chronic rotator cuff problem Patient with arthritis of hips and knees My bad voice My anal fistula

What We Have Currently

Goal-directed care concepts

HRA concepts and rudimentary HRA tools

Models of HRA use in clinical practice

Models of practice that include wellness nurse

Task management software

EHRs

CCR for some EHRs