Suzie Burke-Bebee DNP MSIS MS RN

Senior Health Informatician

Department of Health & Human Services/OS/ASPE

Diana R. Jolles CNM MS

Texas Woman’s University, Houston

PhD Student, Nursing Research

Unwarranted Variations in care

1 • Identify and understand the Shared Decision

Making Model as applied to clinical practice

2

• Recognize the benefits and challenges when implementing SDM throughout the patient’s life cycle (birth to end-of-life)

3

• Describe the impact of shared decision making in the context of providers and two elderly patients seeking care at the end of life

Landscape

Supreme Court

Patient Protection and Affordable Care Act (ACA)

Affordable, effective commerce

Impact Better care

Healthy people and

communities

Affordable care

1. Improve patient, family and caregiver experience

Quality Safety Access across settings

2. In partnership with patients, families and caregivers- and using a shared decision-making process- develop culturally sensitive and understandable care plans.

3. Enable patients and their families and caregivers to navigate, coordinate and manage their care appropriately and effectively.

Wide variation Safe

Effective

Affordable

Unwarranted Variations in Care

Supply Sensitive

Preference Sensitive

CHF

HIV

Dementia

Knee or hip osteoarthritis

Preventive screenings: breast, prostate, cervical

Family / Person Centered Care

Family/ Person centered

Satisfaction

Experience of care

Client engagement

Shared decision making

Values

Goals

Balance both clinical guidelines and family preferences.

Kim

• 1983

• Collaborative Decision Making

Hamilton

• 1995

• Therapeutic Partnership

Elwyn

• 2012

• Shared Decision Making

Deliberation

Initial Informed Preferences Preferences

Decision Support

Brief as well as Extensive

Decision

Talk

Option

Talk

Choice

Talk Decisions

Elwyn, G., Frosch, D., Thomson, R., Joseph-Williams, N., Lloyd, A., Kinnersley, P., Cording, E., Tomson, D., Dodd, C., Rolilnick, S.,

Edwards, A., and Barry, M. (2012). Shared decision making: a model for clinical practice. Journal of General Internal Medicine, 27 (10),

1361-1367. doi: 10.1007/s11606-012-2077-6.

Evidence

Research

Mortality risk

Optimal

NICE guidelines

Guidelines.gov

Practice

Lack of guidance to implement SDM25

“gray zone” (Kon)

Facultative rather than directive

Lack of communication

Accountability

NQF endorsed measures

Joint Commission

Hospital compare

DUALISM DISEASE VS PERSON FOCUS

Person centered

Access

Appropriate

Effective

Cultural humility

Values Based

Seamless

Understandable

Information sharing

Corr

ect qu

estio

n

• Perception

• Awareness R

ealit

ies

Patt

ern

s

• Directives

• Emergence

• Validation

Birth Payer

“choice” Death

Birth plan

Values

Needs

Culture

Death plan

Values

Needs

Culture

“Hospitals can also treat people inappropriately because staff do not recognize that the person is dying”

(Committee on Public Accounts, 2009)

70% prefer to die at home, 70% die in a facility

80% say that if seriously ill, they would want to talk to their doctor about end-of-life care, though 7% reported having a conversation. 60% report acknowledgement of their goals

40 % part of decision making team

Wide variation in informed consent (20%- 80%)16,24

COMMUNICATION AND ACCOUNTABILITY

INFRASTRUCTURE

TOOLS TO COMMUNICATE CLINICAL HISTORY, PREFERENCES, PROGNOSIS, VALUES

INFRASTRCTURE

ENVIRONMENT OF CARE, APPROPRIATE USE,

THE CULTURE OF MEDICINE

“developing an awareness of one’s own existence, sensations, thoughts and environment without letting it have an undue influence on those from other backgrounds;…..accepting and respecting cultural differences; adapting care to be congruent with the client’s culture”

(Flowers, 2004)

NURSING

TOOLS

ACCOUNTABILITY

LEADERSHIP

COLLABORATION

PRACTICE IMPROVEMENT

Interprofessional Teamwork

EHRs

Decision Aids

Mobile Apps

Tools Cultural Awareness Assessment Tool

Interproffesional Teamwork

Technocratic holistic spectrum

Patient Centered Care Improvement Guide (2008) Planetree.org

Liverpool Care Pathway

Decision Aids Cochrane (treatment or screening decisions)

Decrease hip and knee surgery and cost

Breast and prostate cancers

National Maternity Care

Caringinfo.org/stateaddownload/

AHRQ 10 Questions you should know

1. What is the test for?

2. How many times have you done this procedure?

3. When will I get the results?

4. Why do I need this treatment?

5. Are there any alternatives?

6. What are the possible complications?

7. Which hospital is best for my needs?

8. How do you spell the name of that drug?

9. Are there any side effects?

10. Will this medicine interact with medicines that I’m already taking?

SDM Resources

Ottawa Personal Decision Guide (OPDG)

International Patient Decision Aids Standards (IPDAS) Collaboration

Mayo Clinic SDM National Resource Center

MAGIC Program

Shared Decision Making Resource Centre

Informed Medical Decisions

Foundation

40 Court Street

Suite 300

Boston, MA 02108

National Quality Forum Endorsed Measures

NQF 0469: Elective Delivery (Joint Commission)

NQF 0480: Exclusive Breast Milk Feeding (Joint Commission)

NQF 1626: Patients admitted to the ICU who have care preferences documented (RAND) NQF palliative care endorsement summary

NQF 1641: Hospice and palliative care- treatment preferences: percentage of patients with chart documentation of preferences for life sustaining TX

NATIONAL QUALITY FORM

ENDORSED MEASURES

Family-Centered Shared Decision Making

Effective Access

Shared decision making

Accountability

values

prognosis

goals

transformation

Effective Communication

MJ CASE STUDY SYSTEMS ROOT CASE

LC CASE STUDY SYSTEMS ROOT CAUSE

Family-Centered life course approach

Systems level failure and systems level solutions DNP opportunity

DNP/PhD collaborations

INTERPROFESSIONAL education

1. Jost, T. The Supreme Court on the individual mandates constitutionality: an overview. Health Affairs Blog; June 12, 2012. http://healthaffairs.org/blog/2012/06/28/the-supreme-court-on-the-individual-mandates-constitutionality-an-overview/. Accessed March 13, 2013.

2. Triple Aim IHI http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx

3. Triple Aim IOM http://www.iom.edu/~/media/Files/Activity%20Files/Quality/VSRT/Core%20Metrics%20Workshop/Core%20Metrics_1pager_13Mar12.pdf

4. Intent of moving from FFS to VBP

5. Roades, C. What the Supreme Court’s ACA ruling will mean for providers. Health Affairs Blog; June 28, 2012. http://healthaffairs.org/blog/2012/06/28/what-the-supreme-courts-aca-ruling-will-mean-for-providers/. Accessed March 13, 2013.

6. Millenson, M. & Macri, J. Will the Affordable Care Act move patient-centeredness to center stage? Urban Institute. March 2012. http://www.urban.org/UploadedPDF/412524-will-the-affordable-care-act.pdf. Accessed March 13, 2013.

7. Frampton, S., Guastello, S., Brady, C., Hale., & Horowitz, S., et. al. Patient-Centered Care Improvement Guide. October 2008. http://planetree.org/wp-content/uploads/2012/01/Patient-Centered-Care-Improvement-Guide-10-28-09-Final.pdf. Accessed March 13, 2013.

8. Emanuel, E. & Emanuel, L. (1992). Four models of the physician-patient relationship. The Journal of the American Medical Association, 267 (16), 2221-2226.

9. Allen, A., Stevenson, l., Grady, K., Goldstein, N., Matlock, D., Arnold, R., Cook, N., Felker, G., Francis, G., Hauptman, P., Havranek, E., Krumholz, H., Mancini, D., Riegel, B.,& Spertus, J. Decision making in advanced heart failure: a scientific statement from the American Heart Association, 125, 1928-1952. doi: 10.1161/CIR.0b013e31824f2173

10. Frosch, D. & Kaplan, R. (1999). Shared decision making in clinical medicine: past research and future direction. American Journal of Preventive Medicine, 17 (4), 285-294.

11. Frosch, D., Moulton, B., Wexler, R., Holmes-Rovner, M., Volk, R., & Levin, C. (2011). Shared decision making in the United States: policy and implementation activity on multiple fronts,

12. Lee, E. & Ezekiel, E. (2013). Shared decision making to improve care and reduce cost. New England Journal of Medicine, 368 (1), 6-8.

13. Godlee, F. interview with J. Wennberg. (2011). Time to tackle unwarranted variations in practice. British Medical Journal, 342, 687-690.

14. Arterburn, D., Wellman, R., Westbrook, E., Rutter, C., Ross, T., McCulloch, D., Handley, M., & Jung, C. (2012). Introducing decision aids at Group Health was linked to sharply lower hip and knee surgery rates and costs. Health Affairs, 31 (9), 2094-2104. doi: 10.1377/hlthaff.2011.0686

15. Ricciardi, L., Mostashari, F., & Murphy, J. (2013). A national action plan to support consumer engagement via e-health. Health Affairs, 32 (2), 376-384.

16. Alston, C., Paget, L., Halvorson, G., Novelli, B., Guest, J., McCabe, P., Hoffman, K., Koepke, C., Simon, M.,

Sutton, S., Okun, S., Wicks, P., Undem, T., Rohrbach, V., & Von Kohorn, I. (2012).

Communicating with patients on health care evidence. Discussion Paper, Institute of Medicine, Washington, DC.

http://www.iom.edu/evidence. Accessed March 17, 2013.

17. Beach, M., Duggan, P., & Moore, R. (2007). Is patients’ preferred involvement in health decisions related to

outcomes for patients with HIV? Health Decisions, 22, 1119-1124.

18. Smebye, K., Kirkevold, M., & Engedal, K. (2012). How do persons with dementia participate in decision making

related to health and daily care? A multi-case study. BMC Health Services Research, 12 (241), 1-12.

19. Givens, J., Kiely, D., Carey, K., & Mitchell, S. (2009). Health care proxies of nursing home residents with

advanced dementia: decisions they confront and their satisfaction with decision-making. Journal of the American

Geriatric Society, 57 (7), 1149-1155. doi: 10.1111/j.1532-5415.2009.02304.x.

20. AHRQ Health Care Innovations Exchange: Shared decision making for breast cancer patients leads to high

levels of patient satisfaction, and comfort with decisions and treatment preferences. Dartmouth-Hitchcock Medical

Center. (2010). http://www.innovations.ahrq.gov/content.aspx?id=2811 Accessed March 20, 2013.

21. Sepucha, K., & Belkora, J. (2007). Putting shared decision making to work in breast and prostate cancers: tools

for community oncologists. Community Oncology, 4 (11), 685-691.

22. Volk, R., Cass, A., & Spann, S. (2009). A randomized controlled trial of shared decision making for prostate cancer screening. Archival Family Medicine, 8, 333-340.

23. Millenson, M. (2012). Building patient-centeredness in the real world: the engaged patient and the accountable care organization. http://www.nationalpartnership.org/site/DocServer/ACO-Report-HQA-NPWF.pdf?docID=10481

Accessed March 20, 2013.

24. Zikmund-Fisher, B., Couper, M., Singer, E., Ubel, P., Ziniel, S., & Fowler, F. (2010). Deficits and variations in patients’ experience with making 9 common medical decisions: the DECISIONS Survey, 30, 85S-95S. doi: 10.1177/0272989X10380466

25. Elwyn, G., Frosch, D., Thomson, R., Joseph-Williams, N., Lloyd, A., Kinnersley, P., Cording, E., Tomson, D., Dodd, C., Rolilnick, S., Edwards, A., and Barry, M. (2012). Shared decision making: a model for clinical practice. Journal of General Internal Medicine, 27 (10), 1361-1367. doi: 10.1007/s11606-012-2077-6.

26. Coylewright, M., Montori, V., & Ting, H. (2012). Patient-centered shared-decision making: a public imperative. The American Journal of Medicine, 125 (6), 545-547. doi: 10.1016/j.amjmed.2011.12.007

27. Kon, A. (2006). Answering the question: “Doctor, if this were your child, what would you do?” Pediatrics, 118, 393-397. doi: 10.1542/peds.2005-2655.