Presentation given at the Foundation's Jan. 26, 2011 Research and Policy Forum by David Swieskowski, MD, MBA and Kelly Taylor, RN, MSN, CCM from Mercy Clinics in Des Moines, IA.

1. Foundation for Informed Medical Decision Making Research & Policy ForumJanuary 26, 2011Washington, D.C. A Care Setting Experience with Shared Decision Making David Swieskowski, MD, MBA - Chief Executive Officer, Mercy Clinics, Inc. Kelly Taylor, RN, MSN - Director of Quality, Mercy Clinics, Inc.

3. 70% Primary Care

4. 877,956 patient visits in FY10

5. Owned by Mercy Medical Center in Des Moines

6. MMC employs 325 physicians

7. MMC owned by Catholic Health Initiatives

8. Virtual Private Practice Comp Plan

10. Professionalism

11. Competitive advantage

12. How:

13. Joined IHI impact program in 2002

14. Joined Pilot Collaborative on Self-Management-Support in 2003

15. Started small in pilot clinics and spread successes throughout the system

16. Used the PDSA approach

17. Shift from Ad Hoc projects to a comprehensive plan to redesign care based on:

18. Wagner’s Care Model

22. Overdue for care

24. Monthly Clinic Level Quality Report

25. Delivery System RedesignThe Office Based Health Coach MCI has 27 full time Health Coaches At least one in every primary care clinic New job description Started as RN, CMA, LPN, Receptionist and was more data oriented New Health Coaches must be RNs and are more clinically oriented Group meeting for 2 hours twice a month Training & sharing of learning Formal 28 hour “Certification” Program

26. Five Essential Functions Of The Office Based Health Coach Oversees the disease registry database Conducts pre-visit chart review Works with patients & families on self-management support Coordination of care across the care continuum Involvement in QI activities

27. Pre-visit Review Audit Mercy West Medical Clinic

28. One Day of Charges from Pre-visit Chart Review Urbandale FP Clinic

30. Goal setting and action plans

31. Medication Adherence

32. Only 40% of Mercy Clinic patients are highly adherent

33. Patient Education

34. Provided or arranged by Health Coaches

35. Shared Medical Appointments

37. Systems Ensure Quality: Hypertension Process Map

38. Mercy Clinics BP run chart

40. Yields were 20% higher

41. Knowledge of a change is different than acceptance

42. Time lag of about 7 years between first knowledge and adoption

43. Acceptance is influenced by

44. Shared experiences of Early Adopters

47. Diffusion is fundamentally a social process

48. Exchange of personal experiences is at the heart of diffusion

49. Encourage the use of small tests of change (PDSA)

50. Resistors are irrelevant to the change process

51. Developing the critical mass with enough positive experiences is what counts

52. Work with the willing

55. Primarily physician employment

56. Create IT systems to measure value

57. Quality and Utilization

58. Integrated Care system

59. Guidelines across specialties and sites

60. Advanced Primary Care (Medical Home)

61. Wellness care – Healthy living center

62. Transition Coach project

65. Preference sensitive conditions are those that have multiple treatment options without clear evidence that one option is superior. Therefore the decision about which option to choose is based upon the preference of the physician and / or patient

66. Evaluate the Impact of decision aids on decision quality

67. Using before and after questionnaires

69. Implementation of Decision Aids and Current Status

71. Hip Osteoarthritis

72. Knee Osteoarthritis

73. Acute Low Back Pain

74. Chronic Low Back Pain

75. Spinal Stenosis

76. Herniated Disc

77. At FMU clinic

78. Abnormal Uterine Bleeding

79. Managing Menopause

80. Uterine Fibroids

81. In the Future

82. Spread DAs FMU clinic piloted to other 4 pilots

83. Diabetes

84. CHF

86. How we built this into existing models Basic philosophy: It takes a proactive, prepared practice team to effectively provide high quality chronic care (and SDM as well!) to our patients Health Coaches and provider champions are initially the key members of that practice team in each of the pilot sites

87. How we built this into existing models This is a new scope of work for coaches and providers closely aligns with our advanced primary care and ACO vision But the strategies used to test and implement are the same used to redesign the delivery of chronic care Senior level support and guidance from Clinic Administration PDSA cycles-Part of the job of the coach is to try new things Physician champions Monthly Team meetings Outcomes Data Review

88. Identifying the Denominatorfor Knee and Hip OsteoArthritis Original definition: Age > 50 Chronic knee or hip pain Over 6 months or 3 (or more) visits for this problem Any mention in the record or referral notes about possible joint replacement New definition (Sept. 2010): Identify the denominator by identifying all patients referred to Ortho who are over age 50 with chronic knee or hip pain We still distribute to both definitions

89. Senior Level Support Example: Decision Aid Distribution and Follow-up Process Map 8/09

90. PDSA Cycles Clinic Admin provides the high level process to be achieved Health Coaches utilize the Model for Improvement/PDSA cycles to achieve rapid process improvements Coaches are change agents in their individual clinics Have received training on the use of PDSA cycles

91. Physician Champions Absolute key to the spread of any quality initiative throughout the clinic and the clinic system Key Duties: Guinea pig-try PDSA tests with coaches Cheerleader-to their peers and their nurses Communicator-to all internal staff, clinic system and beyond!

92. Barriers to Physician Buy-in Perception that a significant portion of patients do not want share decision making Not current standard of care May undermine their recommendations Synvisc injections Bio-identical hormones Time to learn about the DA Time it takes to arrange a handoff

93. Monthly Team Meetings Key concepts Once a month every month 1 hour in length Clinic Administration sets agenda but always leaves time in the agenda for individual team planning Provider champs and coaches expected to attend Clinic managers encouraged to (and often do) attend

94. Outcomes Data Review Standing agenda item at each team meeting Data helps us see where we are doing well and where opportunities for improvement exist. Both are equally important!

96. Data Review Example

97. Data Review Example

98. How We Went From Numbers To Patient Satisfaction Our initial focus was on implementing a process to distribute the decision aids. Reviewed data distribution numbers at each team meeting. Once data distribution numbers were high enough, we also began to look at how satisfied our patients were with this program.

99. How We Went From Numbers To Patient Satisfaction Our data tells us that we have an opportunity to improve our patient satisfaction scores Why is it important to work on this? It’s all about providing value The satisfaction scores will help senior leadership evaluate the value of implementing, spreading and sustaining this program throughout all of Mercy Clinics Inc.

100. Current Strategies to Improve Satisfaction Collaborating within our own system as well as with the FIMDM research team, we have learned about many best practice ideas we are excited to try that are focused on: Physician and staff one-on-one engagement Patient engagement Warm handoffs Teaming with Physical Therapy

101. Patient Engagement Posters DAs in x-ray Educational displays with DAs DAs in the exam room DAs in the referral area Have notes on them: “Ask about this booklet if you have any questions”

102. Physician and Staff Engagement Internal marketing to the pilot physicians and staff Coffee bars Posters Clinic newsletter One-on-one Champion discussions Academic detailing CME/CEU events provided by project coordinator at each of the pilot clinics have been completed CME/CEU events are now planned by providers at each individual pilot clinic regarding a specific DA of their choice Increase in the number of DA topics

103. Efforts to Increase Warm Handoffs Coach pre-visit chart review Engage receptionists and schedulers Dr. Engagement PT referral plan Patient Engagement

104. SDM at Mercy Clinics Inc. Care Team Reactions Each of the 4 original pilot clinics were given the option to opt out of the pilot going in to the 2nd year-none of the clinics did. Patient Reactions “This hits it so on the head. I’m not the only one going through this.” “I wish I would have had this information when my symptoms first started. The DVD my doctor asked me to watch has been extremely helpful.”

105. SDM at Mercy Clinics Inc. Health Coach Reactions I had a patient write me a note thanking me for encouraging her to watch the DVD. When people take time to write you a note like that, you know you have made a difference and it feels great. Patients are happy when you take the time to do this. It doesn’t take too long. I’ve never had anyone be anything but positive. Provider Reactions Patients come back with really good questions. They are more focused and the visits are more productive and satisfying. They actually save me time during my busy day of seeing patients.

107. Who benefits most from DAs

108. Who should identify the patient

109. What is the best time to present the DA

110. Is Satisfaction higher if presented at time of referral

111. What is the best way to engage the patient

112. Is face-to-face better than mailing

113. What follow up should be done and by who

115. Will choose the best plan for themselves, yielding better outcomes

116. Will often choose less expensive options

117. Will improve patient satisfaction

118. SDM is patient centered and consistent with our values

119. It can free up physician time

120. Provide self-management support more effectively and at less cost