human centered design & pace · 2019-12-18 · insight - design - innovation evolve. better....

Post on 14-Aug-2020

2 Views

Category:

Documents

0 Downloads

Preview:

Click to see full reader

TRANSCRIPT

The Perfect Match! OCTOBER, 2018

Human Centered Design & PACE

my name isHello.

insight - design - innovationevolve

Better. Not more. We create meaningful experiences with lasting value.

Confidential © Evolve Collaborative 2015

Kathleen

Our story starts with

Knowing Me “He’s a caring doctor - he listens and understands my needs.”

Perception of Boundaries “It’s not a friendship but not just surface either . We’re acquainted on a deeper level.” (relationship with female social worker)

Trust and Isolation “I keep all my aches and pains to myself. I’m friendly but people don’t know me. Even though you’re in a group of people, you’re still lonely.”

ElderPlace Glendoveer November 2017

Elderplace - Cully

November 2017

7

John, Hillary, Joan, & Amanda

“It’s hard not to swoop in and save people.” Learning to put independence back on participants.

Its about… Setting boundaries

9

“Foster kids get a mom.” How can we offer a ‘care mom’?

Its about… Building relationships

10

“We matchmake a care provider with a participant.”

Its about… Finding the right match

11

“We learn a lot when someone lives here for a

month but by that point we are already in it.”

Its about… Responsive planning

“Be on their turf.” respect, trust, humility, active listening

Its about… Building Empathy

12

13

Its about… small, non hierarchal teams

“Team-based model flattens the hierarchy.

Even drivers provide feedback on resident changes.”

14

Cadence of meetings: Daily stand-ups Quarterly conferences 6 month evaluations Live care planning Interdisciplinary teams

Goal: Develop a human-centered framework for care coordination

Using HCD techniques • Evaluate current state of care coordination • Identify opportunities for new services • Define key principles for delivering an ideal participant journey

Care Management Integration Council

Building the Ideal Participant Experience

Elder Place Population - Stable / Serious Disability

CM Acute Care Population - Acute Illness

Women & Children's Population - Maternal & Infant

Elder at Home Population - Long Term Frailty

Palliative Care Services Population - Advanced Organ System Failure

Home Health Services Population - Failing Health / Near Death

Proactive Outreach Team Population - Other (behavioral health, substance abuse)

PMG Care Management Population - Chronic Stable Conditions

Participant & Caregiver Interviews across all populations

Good design practice is to learn from extremes to

improve the universal experience

PACE and Pro-Active Outreach were the most

extreme & inspirational for care delivery

We can apply learnings and insights from PACE

to all populations we serve

Why was PACE involved

ElderPlace Coordination

of Care

CARE MANAGEMENT INTEGRATION COUNCIL (CMIC) Inpatient

Pharmacy

Emergency Department

Palliative Care

Medical Groups

Senior Health

Health Plan

Providence ElderPlace Locations

PACE • Currently serving 1448 frail elders in five counties • 97% are dually eligible – Operational for 28yrs • Approximately 500 PACE employees • 9 PACE Centers, 1 Alternative Care Setting

Housing • 1 Assisted Living and 2 Residential Care Facilities

Scope of Providence ElderPlace

Where%We%Serve%– Home%and%Community%Care

ALASKAAssisted'LivingHome'HealthHospiceSkilled'Nursing'Facility

CALIFORNIA%< NorthernHome'HealthHospiceInfusion'PharmacySupportive'Housing

CALIFORNIA%< SouthernHome'HealthHospiceInfusion'PharmacySkilled'Nursing'FacilityPalliative'CarePersonal'Home'Care'Services

TEXASHospiceInfusion'Pharmacy

MONTANAAssisted'Living

OREGON%< NorthernAssisted'LivingHome'HealthHome'Medical'EquipmentHospice

OREGON%< SouthernHome'HealthHospiceInfusion'PharmacyPalliative'Care

Infusion'PharmacyPACESkilled'Nursing'FacilityPalliative'CareSupportive'Housing

AK

CANorth

CASouth

TX

MTWASHINGTON%<EasternAssisted'LivingHome'HealthInfusion'PharmacyPersonal'Home'Care'Services'Skilled'Nursing'FacilitySupportive'Housing

WASHINGTON%<WesternAssisted'LivingHome'HealthHospice'Infusion'PharmacyPACESkilled'Nursing'FacilitySupportive'Housing

WAWest

WAEast

OR%North%

OR%South%

PACEServing,over

2000,Participants,/,day

HospiceServing,over

22k,patients

Home,HealthServing,over

65k,patients

Skilled,Nursing,&,Transitional,Care

1,130,beds

Infusion,and,Pharmacy

253k,prescriptions,filled

Home,Medical,EquipmentServing,over

9000,clients,

Supportive,Housing

784,units

Personal,Home,Care,Services

633,886hours,of,service

Service,Line,Volume Accelerators

The$US$Infusion,market$is$expected$to$reach$$25B by$2024$with$growth$rates$of$10%$during$this$period.$We$are$2X outpacing$this$rate$of$growth$in$markets$today.

The$US$Hospice market$is$expected$$to$grow,by,20%,between$2017$and$2022.$We$are$2X,outpacing$this$rate$of$growth$in$markets$today.$

US$Home,Health,spending$is$$103B,,expected$to$grow$to$$173B,by$2026$or$6.7%,growth,per,year.,We$are$3Xoutpacing$this$rate$of$growth$in$markets$today.$

2018%Home%and%Community%Care%3 OregonMission As people of Providence, we reveal God’s love for all, especially the poor and vulnerable, through our compassionate service.

Core Values Respect Compassion Justice Excellence Stewardship

Promise Together, we answer the call of every person we serve: Know me, care for me, ease my way.

Strategic Intent We will excel at population health while providing personalized and compassionate care. Population health means that we are accountable for improving the health outcomes, experience and affordability for people who choose Providence.

STRENGTHEN OUR CORE

BE OUR COMMUNITIES’

HEALTH PARTNER

TRANSFORM OUR FUTURE

•Caregiver(engagement•Quality•Patient(experience•Value(&(affordability•Referral(relationships•Philanthropy

•Integration(across(the(care(continuum•Behavioral(health•Holistic(care(models•Social(determinants

•Digital(experience•Research•Awareness(and(advocacy

The Providence

Innovation Fellowship Program2015 - Present

• Fellows are mixed front line & mgmt

• The program lasts one year

• Evolve deliver four core HCD modules

• Fellows design, develop and launch live

pilots in Oregon

• Fellows work in collaborative cross

disciplinary teams

PROVIDENCE INNOVATION FELLOWSHIP PROGRAM

On track to touch over

45,000 people in Oregon

with new care approaches

IMPACT TO DATE

Collaborated with

over 50 community

organizations and

emerging companies

80 caregivers trained

over the last 4 years

IMPACT TO DATE

new services for future moms

helping families build resiliency

the ideal participant journey

fun, vibrant, approachable & easy

ADVERSE CHILDHOOD EXPERIENCES

CARE MANAGEMENT INTEGRATION COUNCIL

MEDICAL WEIGHT LOSS

WOMEN'S & CHILDREN’S HEALTH SERVICES

What is this HCD thing? Sounds fancy…

It is all about empathy. Connecting people with brands they love.

Field interviews help us…

Generate insights Provide context Inspire the team

34

Agile in approach.

Collaborative by design.

Harness the power of play.Workshop lead process

Develop a human-centered framework for care coordination.

Using HCD techniques • Evaluate current state of care coordination • Identify opportunities • Define the key principles for creating an ideal participant journey

CARE MANAGEMENT INTEGRATION

BUILDING THE IDEAL PARTICIPANT EXPERIENCE

37

FIELD RESEARCH METHODOLOGY

Patients/ Family - 60 mins

• A Typical Week • Care Journey Overview • Barriers, Resources & Services Card Sort • Your Dream Care Team • Looking Forward

Care Providers - 60-75 mins

• Tour/ shadow (15 mins if possible) • Care Journey Overview • Support & Teamwork • Patient Collaboration • Looking Forward

FIRST MEETING UNDERSTANDING MY NEEDS

MAKING A PLAN AND SETTING GOALS

STAYING ON TRACK

ADAPTING AS THINGS CHANGE

UNIVERSAL CARE JOURNEY

Elder Place Population - Stable / Serious Disability

CM Acute Care Population - Acute Illness

Women & Children's Population - Maternal & Infant

Elder at Home Population - Long Term Frailty

Palliative Care Services Population - Advanced Organ System Failure

Home Health Services Population - Failing Health / Near Death

Proactive Outreach Team Population - Other (behavioral health, substance abuse, diversity lens)

PMG Care Management Population - Chronic Stable Conditions

Participant & Caregiver Interviews across all populations

“I don’t like being so dependent.”

“The doctor was the one who pushed for this place.”

“I do activities but it feels like I’m getting weaker.”

LOSING CONTROL

“Give me one person, I put my life on it, I would heal faster!”

“It’s tough to balance so many schedules. There’s always clashes. I feel like they all blame me.”

CONFUSING SYSTEM

“All services are planned week to week.”

“We text back and forth what I need to do. If I miss something, we’ll meet to discuss it.”

“My pain determines what I’m doing over the weekend.”

SHORT TERM OUTLOOK

PARTICIPANT INSIGHTS CHALLENGES (EDITED)

PARTICIPANT INSIGHTS CHALLENGES (EDITED)

UNCLEAR BOUNDARIES

“It’s hard not to swoop in and save people.”

“It’s challenging to know when to pass patients back to primary care.”

“We’re struggling with patients getting the right information at the right time when they’re willing to hear it.”

INEFFECTIVE COMMUNICATION

“Many patients are being talked to in a language they don’t understand.”

“We had to build bridges with PHP care managers to make sure they’re giving the right information.”

CONFLICTING GOALS

“Physicians are graded on their patients’ outcomes. Difficult patients create tension.”

“My problem is them not taking their meds. Their problem is they don’t like the meds.”

“We are not patient driven, we are patient oriented.”

CAREGIVER INSIGHTS CHALLENGES (EDITED)

Experience Principles

• Guide us when bringing service design to life • Principles should help both generate and evaluate new ideas • Principles are inspired by participant and caregiver insights

Empower People & Partnerships

Meet People Where They Are

Contribute to the Whole Team

UNIVERSAL CARE MGMT EXPERIENCE PRINCIPLES

Anticipate Needs, Now & Next

Remember the Impact of Human Connections

Practice Empathic Communication

Our Services How we meet the needs of our populations.

Our People How we behave, unified across all caregivers.

Our Tools How we engage, inspire and teach our participants. Physical, virtual and digital touch-points.

UNIVERSAL CARE MGMT EXPERIENCE PRINCIPLES

Building the Ideal Participant ExperienceWe generated universal ideas - Relevant for all populations Seed ideas, not final recommendations

Creative Workshop

PROVIDENCE + evolve | Content Confidential | November 2016

Future Focussed

Foster Relationships

CONSISTENCY

PARTICIPANT DRIVEN

Foster Relationships

COMMUNICATION

OPTIONS

IDEAL CARE JOURNEY SEED IDEAS FOR RECOMMENDATIONS

Foster Relationships

Personalized

Work as One

ADVOCACY TRAINING

Balance Goals

COLLABORATIVE

GOAL SETTING

Work as One

EXTENDED TEAM

ADAPTIVE REASSESSMENT

Leverage Experience

CELEBRATE WINS

SUPPORT HUB

Foster Relationships

Support Independence

Work as One

COMMUNITY CONNECTIONS

EDUCATION CONSENSUS

Tools for Relationships

SEAMLESS TRANSITIONS

Foster Relationships

Navigate the System

Work as One

COLLABORATIVE

GOAL SETTING

CO-CREATE

MY STORY

SINGLE

POINT OF

CONTACT

Foster Therapeutic Relationships Personalize Care Future Focused Support My Goals Navigate The System

Trust & Isolation Knowing Me

Expectations & Education Support Structure Confusing System

FOR PARTICIPANTS

Work as One Set Clear Expectations Balance System & Participant Goals Leverage Experience Tools to Support Care

Inconsistent Teamwork Unclear Boundaries

Conflicting Goals Wasted Resources

Technology Barriers

FOR CAREGIVERS

Average length of time in ElderPlace is 3.9 years

Interdisciplinary Teams

Panel sizes

Goals of care

Participant directed care

INSIGHTS TO OPPORTUNITIES HOW THESE RELATE TO PACE

Co-Create My Story

• Framework for capturing and co-creating participants’

stories during their first meeting.

• Caregivers take the time to sit with participants and talk

about their lives before discussing their conditions.

• Documentation of what participants want caregivers to

know about them.

• Starting point for them to develop goals and a dynamic

plan of care.

OPPORTUNITY FOR PARTICIPANTS AT ELDERPLACE

Initial biopsychosocial assessment

MSW shares story with IDT members at initial care planning meeting

Live care planning

• Tiered care management system with a single point of

contact (could be a small team).

• Care coordinators and participants define which teams to

bring in and when.

• Each participant, no matter their condition, will have a point

of contact and baseline care plan.

• Plans can be easily built upon as needs change.

OPPORTUNITY FOR PARTICIPANTS AT ELDERPLACE

IDT

Coordination with outside specialists and caregivers

Single Point of Contact

Nursing Facility

Hospital Lab/ X-ray/ Pharmacy

IDT

Participant& FAMILY

Housing DME & Supplies

ELDERPLACE CARE MODEL

Specialty Care

SPOC

Goals of Care

• Longevity • Function • Palliative care

Collaborative Goal Setting

• Generative tools to aid shared decision-making with

participants.

• Facilitate conversations between care coordinators and

participants to identify strengths, delegate responsibilities,

address health related social needs and help participants

ask the right questions.

• Establish participants’ short, mid and long term goals.

OPPORTUNITY FOR PARTICIPANTS AT ELDERPLACE

We will not lose sight of the caregiver’s needs

Caregiver wellbeing is valued alongside patient care

We will support clinical and non-clinical needs

We are in service to more than just medicine

We will always have a navigator available

Information is shared quickly and consistently

We will work to ease transitions of care

Meaningful support for health and facility changes

We will ensure our staff is well educated

You get the best care, delivered with compassion

We will be a trusted source of information

We have the resources and partnerships you need

Dementia Care PathwaysExperience Principles developed using HCD techniques

6

“Deep%Dive”%)) Assess%and%Create%Inputs(July)Dec%2017)

Prioritization%and%Planning%

(Jan)April%2018)

Activating%the%Delivery%System%Care%Management%Plan%(Q3%2018)2019)

CREATE'INPUTS

• Human'Centered'Design:'patient'and'caregiver'interviews'+'Experience'Principles'Workshop

• Generate'recommendations'using'“Bridges'to'Health”'population'framework

DESIGN

• Design'new'systems'and'structures'guided'by'HCD'Experience'Principles

• Create'training'and'communication'plan

IMPLEMENT

• Optimize'current'resources'and'functions'

• Execute'on'portfolio'of'initiatives

• Integrate'new'resources'and/or'functions

We'are'here

Care'Management'Initiative'Timeline

Care Management Integration Council Building The Ideal Participant Experience

FINAL RECOMMENDATIONS MOVING FORWARD

• Longitudinal Plan of Care (LPOC) as the central place to capture a person’s story/goals in a way that is patient driven

• Clearly establish a single point of contact/care coordination

• Better capture and communicate Social Determinant of Health (SDH) challenges.

• Develop standard resources and education material to help participants and families understand their diagnosis and progression of disease and resources/programs available to them (including SDH)

• Better prepare caregivers to help patients and families navigate complex situations/options and end of life needs. Clearly define the roles of navigators and when specialty teams such as palliative care should be consulted.

• Optimize the Resource Line to help better leverage existing resources and manage population needs 24/7.

• Medication review and reconciliation across the continuum

• Provide Substance Use Disorder treatment for people of all ages including medication assisted treatment to minimize withdrawal issues

Care transitions are risky times for elders, when many things can unravel and lead to devastating problems.

Transitions of Care Better. Not more.

Empower People & Partnerships

Meet People Where They Are

Contribute to the Whole Team

Anticipate Needs, Now & Next

Remember the Impact of Human Connections

Practice Empathic Communication

UNIVERSAL CARE MGMT EXPERIENCE PRINCIPLES

Q&A How does Human Centered Design inspire you? How can PACE organizations leverage this approach?

• How can we ease or reduce transitions? • How can we deliver a single point of care? • How can we effectively share information with caregivers? • How can we be participant-driven, not clinician driven?

paul@evolvecollab.com

Cynthia.Noordijk@providence.org

top related