The Dr. Robert Bree Collaborative: Working together to improve health care quality, outcomes, and...
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The Dr. Robert Bree Collaborative: Working together to improve health care quality, outcomes, and affordability in Washington State
Ginny Weir, MPHProgram DirectorBree Collaborative
April 15th, 2015 | Home Care Association of Washington Preconference
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Background
Slide 2
House Bill 1311
Health Plans
Public Purchasers
QI Organizations Hospitals
Employers
Others
Identify health care services with
high:• Variation• Utilization
Without producing better outcomes
Physicians
22 Stakeholders
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Process
Slide 3
Data Transparency
Provider Feedback Reports
Shared Decision Aids
Financial Incentives
Evidence-Based Guidelines
Centers of Excellence
Public Reporting
Public Comment Recommendations
to improve health care quality,
outcomes, and affordability in
Washington State
Clinical Committee
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Process
Slide 4
Workgroups meet for ~9 months - year
Updates at all Bree meetings
Public comment
Adoption by the Bree Collaborative
Approval by the Health Care Authority
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Reports
What is the problem? Is variation unwarranted? Does it contribute to patient harm?
What does it look like in Washington State?What are solutions within the medical system?Focus areasStakeholder-specific recommendations
How do we get there?
Slide 5
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Topics
Slide 6
Obstetrics
Cardiology
Elective Total Knee and Total Hip Replacement Bundle and Warranty
Elective Lumbar Fusion Bundle and Warranty
Low Back Pain and Spine SCOAP
Hospital Readmissions
End-of-Life Care
Addiction and Dependence Treatment
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New Topics
Slide 7
Coronary Artery Bypass Surgery Bundled Payment Model and Warranty
Prostate Specific Antigen Screening
Opiate Prescribing
Oncology Treatment
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Implementation
Agency Medical Directors Group (AMDG) reviews and approves recommendations which are then forwarded to the Director of the Health Care Authority (HCA)HCA Director reviews and decides whether to apply to state-purchased health care programs
Slide 8
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Implementation
Legislation does not mandate payment or coverage decisions by private health care purchasers or carriers
Delivery systems and providers not required to implement recommendations
Bree Implementation Team (BIT):Design and implement strategies to successfully encourage stakeholders to implement the recommendations
Slide 9
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Presentation from topic expert
Development of change strategy
Implementation of change strategy
Implementation Team: General Strategy
Formation of sub-group, if
needed
After adoption by the Health Care Authority:
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11
End-of-Life Care
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Inpatient Days per Medicare Decedent during the Last Six Months of Life, 2007
Slide 12Source: End of life Care. Dartmouth Atlas of Health Care. Accessed: July 2014. Available: www.dartmouthatlas.org/data/topic/topic.aspx?cat=18.
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Goal for all Washingtonians:
To be informed about end-of-life options Communicate preferences in actionable
terms Receive end-of-life care aligned with goals
and values
Slide 13
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Slide 14
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Focus Areas
Slide 15
1. Awareness
2. Advance care planning
3. Record end-of-life care wishes and goals
4. Accessibility of forms
5. End-of-life care choices are honored
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“It’s always too early until it’s too late.”
Slide 16
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Advance Care Planning
Slide 17
Adapted from: Butler M, Ratner E, McCreedy E, Shippee N, Kane RL. Decision Aids for Advance Care Planning: An Overview of the State of the Science. Ann Intern Med. 2014 Jul 29
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Advance Directives VS POLST
Slide 18
Advance Directive Physician Orders for Life-Sustaining Treatment
(POLST) Durable Power of Attorney for
Health CareLiving Will/Health Care Directive Written Personal
Statement
Appropriate Population
All adults All adults All adults Those with advanced progressive chronic conditions
Timeframe Future care Future care Future care Current careWhere Completed Any setting Any setting Any setting Medical setting
Product Legal designation of a health care decision-making surrogate that is part of an advance directive in alignment with Washington State law RCW 11.94.010
Description of an individual’s health care wishes for the end of life for a time when that individual is unable to communicate those wishes that is part of an advance directive in alignment with Washington State law RCW 70.122.030
Summary of personal values and goals of care relating to end-of-life care wishes
Medical orders
Surrogate Role Surrogate cannot complete Surrogate cannot complete Surrogate responsible for presenting to health care provider
The designated surrogate can consent to POLST on behalf of an incapacitated patient
Responsible for Portability
Currently patient or family/friends
Currently patient or family/friends Currently patient or family/friends
Provider/Health System
Responsible for Review
Patient or family/friends Patient or family/friends Patient or family/friends
Provider/Health System
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Seek to empower WashingtoniansDraw from the work of many efforts across our StateWork to align end-of-life care with patient’s wishes, goals, and values
Do not endorse a specific advance care planning program or initiative or a specific advance directive as many are being used successfully in our state Slide 19
Recommendations
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1. Awareness
Community-wide discussions Advance directive that includes:
1. Living will/health care directive2. Durable power of attorney for health care 3. Written personal statement
Difference between POLST and an advance directive
Slide 20
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Ex: Whatcom Alliance for Health Advancement
Slide 21Source: Whatcom Alliance for Health Advancement. End of Life Choices. Accessed: August 2014. Available: http://whatcomalliance.org/end-of-life-care/.
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2. Advance Care Planning
Educate health care professionals Evidence-based tools and programsInvolve family members and friends Appropriate timing
Slide 22
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2. Advance Care Planning
Reimbursement Hospice Advance care planning facilitators
Slide 23
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Ex: Honoring Choices: Pacific Northwest
Slide 24Source: Honoring Choices: Pacific Northwest. Copyright 2015. Available: http://www.honoringchoicespnw.org/
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3. Record Wishes and Goals
AccurateEasily understandable ActionableCulturally appropriateEngage low-literacy patients
Slide 25
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A Closer Look at Advance Directives
A living will/health care directiveConsistent with section 030 of the Washington State Natural Death Act.
Signed by the declarer in the presence of two witnesses“Artificially provided nutrition and hydration” if “diagnosed to be in a terminal condition or in a permanent unconscious condition”
Stipulates specific treatment preferences (if known and applicable to the situation)
A durable power of attorney for health careNames a surrogate Indicates the amount of leeway for surrogate in decision-making
A written personal statement Patient’s values and goals regarding end-of-life care
Slide 26
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Ex: prepareforyourcare.org
Slide 27
Source: The Regents of the University of California. Prepare for your Care. 2013. Accessed: August 2014. Available: www.prepareforyourcare.org
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4. Increase Accessibility
Advance directives and POLST registryDriver’s license
Slide 28
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Ex: Oregon POLST Registry
Slide 29 Source: Oregon POLST Registry. History of the Oregon POLST Registry. Accessed: August 2014. Available: www.orpolstregistry.org/oregon-polst-registry/about-opr/
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5. End-of-Life Care Choices Are Honored
Quality improvement programsHospitalsNursing homesOther settings
Measure family satisfaction Legal immunity to health care providers who honor a patient's POLST
Slide 30
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Ex: Interventions to Reduce Acute Care Transfers (INTERACT)
Slide 31 Source: INTERACT: Interventions to Reduce Acute Care Transfers. Accessed: August 2014. Available: https://interact2.net/
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RecommendationsHospitals
Education on having empathetic, realistic, and patient- and family- centered advance care planning conversations
Using lower literacy materials if appropriateDocument advance directives and/or POLST in medical record
Communicate with patient and primary care provider
Quality improvement for greater adherence to patients’ wishes
Support patients and families during times of crisis Slide 32
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RecommendationsHealth Plans
Reimbursement for end-of-life care counseling and discussion regarding advance directives with patients and surrogate decision makersEncourage hospitals, nursing homes, and other applicable settings to implement a quality improvement program Inclusive and comprehensive benefits for care of patients with serious illness at the end of life allowing them to receive care consistent with their wishes and goals
Slide 33
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RecommendationsThe State of Washington
Reimbursement for end-of-life care counseling and discussion regarding advance directives with patients and surrogate decision makersState registry for advance directives and POLST Promote use of the registryLegal immunity for health care providers honoring POLST Slide 34
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More Information
Ginny Weir, Program [email protected] (206) 204-7377www.breecollaborative.org
Recommendations available here: www.breecollaborative.org/about/reports
Slide 35
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Comments/Questions
Slide 36
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37
Appendix
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Topics
Slide 38
Obstetrics
Cardiology
Elective Total Knee and Total Hip Replacement Bundle and Warranty
Elective Lumbar Fusion Bundle and Warranty
Low Back Pain and Spine SCOAP
Hospital Readmissions
End-of-Life Care
Addiction and Dependence Treatment
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Obstetrics
Elective DeliveriesEliminate all elective deliveries before the 39th week of pregnancy (for which there is no appropriate documentation of medical necessity)
Elective Inductions of LaborDecrease elective inductions of labor between 39 and up to 41 weeks
Primary C-sectionsDecrease unsupported variation among Washington hospitals in the C-section rate for women who have never had a C-section
Slide 39
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Cardiology
Clinical Outcomes Assessment Program (COAP), a neutral, third-party quality improvement program of the Foundation for Health Care Quality
All hospitals in Washington State who perform open-heart surgery and PCIs participate in COAP
Ask to publicly disclose hospitals’ insufficient information reports and the appropriateness of PCI procedures
Realistic and aggressive timeline
Slide 40
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Bundles and Warranties
Health care currently pays physicians and other providers for the number of services provided rather than the quality of careGoal to tie payment to an entire episode of care including potential complications resulting from poor care
Slide 41
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Total Knee and Total Hip Replacement
High volume of proceduresVariation in way procedures are done
Readmission Rates by hospital on website: http://www.breecollaborative.org/topic-areas/apm/
Slide 42
Source: Readmission Rates for TKR/THR Procedures in Washington State:Summary of Findings from 2011 CHARS DataBree Collaborative – Accountable Payment Model SubgroupOctober 2013. Available: http://www.breecollaborative.org/wp-content/uploads/bree_summary_CHARS_Analysis.pdf
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Warranty
A contract between provider and purchaser/payer whereby…Provider will correct failure of their product…At no additional cost to purchaser
Slide 43
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Warranty Cont.
7 days Acute myocardial infarction Pneumonia Sepsis
30 days Death Surgical site bleeding Wound infection Pulmonary embolism
90 days Mechanical complications related to surgical procedure Periprosthetic joint infection
Slide 44
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Bundle: Four Components
1. Document disability despite conservative therapy
2. Ensure fitness for surgery3. Provide all elements of high quality surgery4. Facilitate rapid return to function And transparent quality metrics
Slide 45
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Quality Standards
AppropriatenessEvidence-based surgeryRapid and durable return to functionPatient care experiencePatient safety and affordability
Slide 46
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Low Back Pain
Appropriate evaluation and management of patients with newly diagnosed and persistent acute low back pain and/or nonspecific low back pain not associated with major trauma in primary care
Early identification and management of patients diagnosed with low back pain that is not associated with major trauma but have psychosocial factors (e.g., anxiety) that place them at a high risk for developing chronic low back pain and disability
Awareness of low back pain management among individual patients and the general public
Slide 47
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Spine SCOAP
All hospitals participate in the Spine Surgical Care and Outcomes Assessment Program (SCOAP) to improve surgical outcomes for chronic low back pain patients
SCOAP is a provider-led program of the Foundation for Health Care Quality that collects data on select surgical procedures for quality improvement
Results unblinded
Slide 48
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Hospital Readmissions
Build community-collaborativesAdopt the Washington State Hospital Association's Care Transitions Toolkit
For patients with diagnoses of acute myocardial infarction, heart failure, community acquired pneumonia, chronic obstructive pulmonary disease, or stroke measure and report whether:
Patient discharge information was provided to the primary care provider or aftercare provider within three days of discharge
A follow-up phone call to the patient or caregiver occurred within three business days
Slide 49
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Addiction and Dependence Treatment
Reduce stigma associated with alcohol and other drug screening, intervention, and treatment
Increase appropriate alcohol and other drug use screening
Increase capacity to provide brief intervention and/or brief treatment for alcohol and other drug misuse
Decrease barriers for facilitating referrals to appropriate treatment facilities
Address the opioid addiction epidemic Slide 50