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/

Merci beaucoup!

LJ FagnanORPRN

fagnanl@ohsu.edu