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Similar a Patient Reported Outcomes (PROs) in Care Managed Patients: Potential and Challenges
Similar a Patient Reported Outcomes (PROs) in Care Managed Patients: Potential and Challenges (20)
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Patient Reported Outcomes (PROs) in Care Managed Patients: Potential and Challenges
- 1. Patient Reported Outcomes (PROs) in Care Managed Patients: Potential and Challenges Jennifer Tabler, MS, PhD Candidate Debra L. Scammon, PhD Knut Hoversten, MD student Michael K. Magill, MD And the Care by Design Research Team
- 2. Care Management Program • Care Managers as member of care team • Target Population – Patients with chronic conditions (DM, CAD, CHF) • Care Manager Tools – Goal Setting – Patient Reported Outcomes (PAM, PHQ9, RAND 36) • Patient Self-Management Tools – Weight --Exercise – Blood Glucose --Blood Pressure
- 3. Clinically Relevant Measures • General – Health-related quality-of-life – Satisfaction with care or treatment – Dimensions of patient experience • (e.g., depression and anxiety) • Disease-specific – Health status assessments – Symptom reporting
- 4. PRO data to clinician Improved Clinician-Patient Communication • Shared treatment plan/goals • Monitor treatment response and health status Clinician changes patient management Patient changes behavior Improved patient satisfaction Improved health outcomes Adapted from: Chen, Ou and Hollis 2013 BMC Health Services Research, 13:211
- 5. Patient Reported Outcome Measures • PAM - Patient Activation Measure – Beliefs, motivations, actions for self-care • PHQ-9 – Depression severity • RAND 36 Health quality of life – Perceived well-being in physical, mental, and social domains; functional limitations to daily life
- 6. Methods for obtaining PRO data – Initial Responses were on paper-based instruments – Follow up responses either paper-based or entered via My Chart (EMR Patient Portal)
- 7. Quantitative Assessment of PROs • Assess changes over time in PROs & health outcomes (two-tailed T-tests) • Link assessments to clinical outcomes (OLS regression)
- 8. Completed at least 1 time Completed 2 times Completed 3 times or more PAM 45.8% 8.8% 2.2% RAND36 37.2% 3.8% 0.7% PHQ9 44.8% 5.9% 1.2% All sites combined, n = 1,381 Utilization of PROs
- 9. PRO Measure Earliest Score (S1) Mean/Std Dev Most recent Score (S2) Mean/Std Dev T-Test Change S1 to S2 t- stat prob PHQ9 (n=78) Functional Impairment 1.09 (1.09) 0.944 (1.00) 0.93 0.352 Severity Score 2.05 (2.38) 2.15 (2.25) -0.27 0.786 Depression Score 0.57 (1.14) 0.59 (1.21) -0.09 0.923 RAND 36 (n=52) General Health Score 48.14 (21.84) 43.56 (19.81) 1.11 0.267 Social Functioning Score 73.56 (29.57) 68.63 (29.28) 0.858 0.393 Energy/Fatigue Score 47.06 (25.46) 42.60 (22.46) 0.944 0.347 PAM (n=122) Activation Score 63.98 (15.96) 62.74 (15.31) 0.619 0.537 Repeated Measures (Consented Patients)
- 10. Coeff P-value PAM 1 and First BMI (N=369) -0.08 0.015 PAM 1 and First LDL (N=389) 0.026 0.822 PAM 1 and First HbA1C (N=389) 0.004 0.531 •OLS Regression results (controlling for gender, age, and race/ethnicity) Relationship between Initial PAM scores and Initial Clinical Outcomes
- 11. Coeff P-value PAM 1 and Final BMI (N=325) -0.003 0.673 PAM 1 and Final LDL (N=344) -0.068 0.489 PAM 1 and Final HbA1C (N=337) 0.007 0.254 •OLS Regression results (controlling for gender, age, and race/ethnicity, as well as initial health outcome score Relationship between Initial PAM scores and Final Clinical Outcomes
- 12. Coeff P-value Change in PAM and Change in BMI (N=82) -0.012 0.45 Change in PAM and Change in LDL (N=93) 0.143 0.461 Change in PAM and Change in HbA1C (N=89) -0.021 0.042 •OLS Regression results (controlling for gender, age, and race/ethnicity) Relationship between Change in PAM scores and Change in Clinical Outcomes
- 13. Qualitative Assessment of PROs • Care Manager experience with PROs – Semi-structured interviews with 6 Care Managers • Incorporation of PROs into workflow • Perceived value of assessments to patient care
- 14. Care Managers’ Experiences • Complex patient population – Low literacy – refugees, prisoners, non-native English speakers – Mental illness – patients in crisis – Patient motivation – “no shows”, not ready to change • Perception of value of assessments – PAM easier to administer and of more value – RAND 36 long and redundant – Already using PHQ-2; don’t see incremental value with PHQ-9
- 15. • Challenges – Developing capacity to collect and use PROs effectively • Consider using alternative methods to acquire PRO data (Smart Phones, electronic monitoring devices) – Obtaining PROs during first care management visit increases opportunity for re-assessment • Develop system to obtain PROs early and often • Room for improvement – Education & re-education of care managers, patients Discussion
Notas del editor
- Assessment of the impact of care on patients has traditionally relied on clinical outcomes. Patient reported outcomes (PROs) offer another important source of information. Patient-centered outcomes research (PCOR) recognizes the importance of including the patient’s perspective in understanding health-related outcomes. Patients’ reports of their perspective on their health status are the only valid source for some types of information. There is growing evidence that the routine collection of PRO enable better and more patient-centered care.Data from PROs can be very helpful in delivering personalized healthcare. PROs can facilitate goal-setting and monitoring, as well as inform strategies to enhance patient engagement.Our aims are to document our experience with developing the capabilities to capture and use patient reported outcomes, examine trends in the collection of PROs over time and changes in assessments in relation to health status, and assess the experiences of care managers in using PROs to gain an understanding of obstacles to and benefits of their use in practice.
- Patients can also use the self-monitoring tools to track their own progress with regard to weight, exercise, blood glucose and blood pressure. Our goal is to have patients actively engaged in their own care by completing the assessments at least twice during their participation in the care management program and by making regular entries into the self-monitoring tools.
- PAM was selected as a tool for assessing patients’ readiness for change with regard to taking actions to improve their health. The scores provide guidance to CMs as to the interventions that might be most helpful to move individual patients toward higher levels of self-management. Scores on repeat assessments were expected to be correlated with improved health status measures. This provides a tangible demonstration to patients that their efforts are paying off. The other measures were used to obtain patient generated information about how they felt (RAND) and whether they were showing any signs of depression (PHQ9). Depression typically goes undetected. If it is diagnosed it can be treated and if improved may have positive relationship to improvements in other areas.
- During initial care management visits, care managers work with patients to complete these assessments entering data into the EMR. Repeat assessments, either during a care management visit or as patients complete the assessments electronically, help care managers track patients’ progress toward goals.
- As the completion rates for each of the PROs presented in Table 1 illustrate, tracking responses over time has presented some problems.
- Changes between the first and second administration of the PHQ9 and RAND 36 show significant improvement for some of the summary measures: PHQ9 severity and symptom scores decreased between first and second administration (t-test p<0.01); RAND 36 improved between first and second administration on general health (t-test p<0.001), social functioning (p<.004), and energy/fatigue (p<0.011). For the 46 consented patients who have had multiple PAM assessments, there has been a positive (but not significant) change in activation level between the first and most recent assessments (p=.057). Among the 73 care management patients who had taken the PAM two or more times as of March 2013, 41% had moved up at least one PAM level indicating an increase in their activation. patients in PAM Level 3 – “Beginning to Take Action.”. Essentially, we have moved patients from the bottom of Level 3 to the top of Level 3. If we continue in this vein we will soon break through to Level 4 – defined as “Maintaining Behaviors over Time”. Adopted new behaviors but may have difficulty maintaining them if faced with stresors or health crises
- SPLIT THESE SLIDES
- developing the infrastructure and capability to capture and integrate PRO into the EMR proved to be more time consuming and resource intensive that anticipated. Experience with the PRO was needed before the reporting capabilities could be developed to support CM access to and use the PRO. Reports had to be developed that helped CM interpret and use the results. Accelerate trend toward integration of data from Smart Devices***Pressure from Beacon—report to increase the number of PAM. It wasn’t fully integrated into the rutine.Recommended periodic testing based on the condition. When PROs were collected multiple times throughout the care management program, changes in the desired direction on all the assessments were observed and these changes were statistically significant (p<.05). It is important to ensure that the first care management visit is used to obtain baseline assessments as this increases the opportunity to obtain re-assessments.The PAM toolis particularly helpful in monitoring patients’ progress on self-management. With a baseline assessment, the CM can focus on techniques specifically designed to move a patient to the next level of activation.It appears that work flow and the time required to complete the various assessments are key factors that influence completion of the assessment tools. Thus, process redesign and CM and patient education can help improve completion of PRO. The protocol for the first care management visit is particularly important to ensure there is sufficient time and a clear process for PRO administration in order to increase PRO completion. Education, and re-education, of CM about the importance of using PAM scores to reinforce patient progress toward goals is needed as on-going operations may distract CM from this specific component of their roles.