Bree Collaborative Meeting

September 18, 2019 | Puget Sound Regional Council

AgendaChair Report, July 24th Meeting MinutesAction Item: Approve minutes

Implementation: 2020 and 2021Presentation for Public Comment: Shared Decision MakingAction Item: Approve Shared Decision Making Report and Recommendations for Dissemination for Public Comment

Presentation for Public Comment: Palliative CareAction Item: Approve Palliative Care Report and Recommendations for Dissemination for Public Comment

Workgroup Update: Risk of Violence to OthersBREAKLearning from Adriane LabsWorkgroup Update: Opioid PrescribingWorkgroup Update: Maternity BundleNext Steps and Close

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July 24th Meeting Minutes

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Implementation: 2020 and 2021

Ginny Weir, MPHDirector, Bree Collaborative

September 18th, 2019 | Bree Collaborative Meeting

Implementation Funding ESHB 1109

(31) $300,000 of the general fund—state appropriation for fiscal year 2020 and $300,000 of the general fund—state appropriation for fiscal year 2021 are provided solely for the Bree collaborative to support collaborative learning and targeted technical assistance for quality improvement initiatives. The collaborative must use these amounts to hire one full-time staff person to promote the adoption of Bree collaborative recommendations and to hold two conferences focused on the sharing of best implementation practices.

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Welcome Amy!

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Targeted technical assistance

Building AwarenessAssessmentGap Analysis Barriers Facilitators

Facilitating adoption Conjunction with conferenceSharing best practices

Save the DateMarch 25th, 2020

First Implementation Conference SeaTac Conference CenterFocus on:Behavioral Health Integration Bundled Payment Models

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Presentation for Public Comment: Shared Decision Making

Ginny Weir, MPHDirector, Bree Collaborative

September 18th, 2019 | Bree Collaborative Meeting

Workgroup Members

Chair: Emily Transue, MD, MHA, Associate Medical Director, Washington State Health Care Authority David Buchholz, MD, Medical Director, Premera Sharon Gilmore, RN, Risk Consultant, Coverys Leah Hole-Marshall, JD, General Counsel and Chief Strategist, Washington Health Benefit Exchange Steve Jacobson MD, MHA, CPC, Associate Medical Director, Care Coordination, The Everett Clinic, a DaVita

Medical Group Dan Kent, MD, Medical Director, United Health Care Andrew Kartunen, Program Director, Growth and Strategy, Virginia Mason Medical System Dan Lessler, MD, Physician Executive for Community Engagement and Leadership, Comagine Health Jessica Martinson, MA, Director of Clinical Education and Professional Development, Washington State

Medical Association Karen Merrikin, JD, Consultant, Washington State Health Care Authority Randy Moseley, MD, Medical Director, Quality, Confluence Health Michael Myint, MD, Medical Director, Population Health, Swedish Hospital Martine Pierre Louis, MPH, Director, Interpreter Services, Harborview Medical Center Karen Posner, PhD, Research Professor, Laura Cheney Professor in Anesthesia Patient Safety, Department

of Anesthesiology & Pain Medicine, University of Washington Angie Sparks, MD, Family Physician and Medical Director, Clinical Knowledge Development, Kaiser

Permanente of Washington Anita Sulaiman, Patient Advocate Slide 9

Today’s Goal

Review content of recommendationsVote to disseminate for public comment

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Focus Areas

A common understanding and shared definition of shared decision making and the benefit of shared decision making.Ten priority areas as an initial focus for the health care community.Highly reliable implementation using an existing framework customized to an individual organization.Documentation, coding, and reimbursement structure to support broad use.

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Defining Shared Decision Making

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Appropriateness

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Adapted from Neumann I, Akl EA, Vandvik PO, Agoritsas T, Alonso-Coello P, Rind DM, et al. Chapter 26: How to Use a Patient Management Recommendation: Clinical Practice Guidelines and Decision Analyses. Graves RS. Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. J Med Libr Assoc. 2002;90(4):483.

Workgroup Goal

State-wide movement toward greater use of shared decision making in clinical practice at a care delivery site and organizational level. All care delivery sites move toward greater adoption using a stages of change framework (i.e., precontemplation, contemplation, preparation, action, maintance). In some locations will be starting in the precontemplations (e.g.,

leadership engagement and buy-in) while others will be ready to start action (e.g., pilots of shared decision making in one health service area such as abnormal uterine bleeding), and others will be maintaining or spreading use.

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Drivers of Shared Decision Making Implementation

Skills-based Education/TrainingPatient Decision AidsPatient/Family EngagementSystems-Based

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Selected Health Care Services

Surgical/Procedural: Knee and Hip Osteoarthritis (HCA certified) Spine Surgery (HCA certified) Abnormal Uterine Bleeding Trial of Labor After Cesarean Section (HCA certified)

Advanced Care Planning (HCA certified) Screening:

Prostate Specific Antigen Testing Breast Cancer Screening

Behavioral health: Depression Treatment Attention Deficit Hyperactivity Disorder Treatment Opioid Use Disorder Treatment

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Implementation Framework

National Quality Partner’s Playbook: Shared Decision Making in Healthcare = implementation fundamentals with basic, intermediate, advanced steps Leadership and culture Patient education and engagementHealthcare team knowledge and training Action and implementation Tracking, monitoring and reporting Accountability The Agency for Healthcare Research and Policy (AHRQ) developed the SHARE (Seek, Help, Assess, Reach, and Evaluate) approach

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http://www.qualityforum.org/National_Quality_Partners_Shared_Decision_Making_Action_Team_.aspx

Health Care Delivery Organizations and Systems

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Stage of Change StepsPrecontemplation

• Review your organization’s mission, vision, and values.

• Define how shared decision making can help advance your organizational goals and align with regional, state-wide, and Federal programs, expectations, and contracting.

Contemplation • Define/select a framework with which to implement shared decision making.

• Identify clinical champions who will be willing to help educate their peers, and administrative champion to support necessary operational changes.

• Select an appropriate training for your providers and staff about shared decision making. Preparation • Spread awareness about shared decision making broadly within your organization. Use the

definitions and materials within this report.

• Work with your clinical champion(s) to educate providers about the value of shared decision making and how to have a good conversation that uses the patient decision aid or references the patient decision aid if the aid will be distributed to patients prior to the visit.

• Select one of the 10 clinical areas to pilot (e.g., breast cancer screening).

• Select a patient decision aid or aids to integrate into the care stream. If using a patient decision aid that has not been certified by the HCA, the workgroup recommends using the IPDAS-based criteria adapted by the HCA within Appendix G.

Health Care Delivery Organizations and Systems

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Stage of Change

Steps

Preparation • Define where in the care stream to use the aid (e.g., prior to visit via email).

• Clearly identify roles for care team members. Non-clinical staff can have a shared decision making conversation.

• Providing templates for documentation of use of shared decision-making.

• Conduct clinic- or system-wide training.

Action • Implement your shared decision making pilot.

• Implement performance metrics outlined on page 16.Maintenance • Evaluate use of the shared decision making process including feedback on the specific patient

decision aid.

• Decide whether to change any components within the pilot if not working.

• Spread to other sites or adopt shared decision making within another clinical area.

• Review new evidence on a regular basis to update the shared decision making options based on the most current evidence.

Health Plans and/or Professional Liability Carriers

ReimbursementValue-based care standardsMetrics Availability of patient decision aidsPrior authorization requirement Continuing education Discounts or other incentives Documentation templates

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Documentation, Coding, Reimbursement

Documented like any other clinical encounterSome limited existing codes (e.g., G0296 Counseling)Development of additional coding for added shared decision making reimbursement. Prior authorizationIncluded as part of some alternative payment models (e.g., total joint replacement bundles)

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Next Steps

Adopt Shared Decision Making Report and Recommendations for adoption for public comment

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Presentation for Public Comment: Palliative Care

John Robinson, MD, SMChief Medical Officer, First Choice Health

September 18th, 2019 | Puget Sound Regional Council

Workgroup Members

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Chair: John Robinson, MD, SM, Chief Medical Officer, First Choice Health Lydia Bartholomew, MD, Senior Medical Director, Pacific Northwest, Aetna George Birchfield, MD, Inpatient Hospice, EvergreenHealth Raleigh Bowden, MD, Director, Okanogan Palliative Care Team Mary Catlin, MPH, Senior Director, Honoring Choices, Washington State Hospital Association Randy Curtis, MD, MPH, Director, Cambia Palliative Care Center of Excellence, University of Washington Medicine Leslie Emerick, Legislative Consultant, Home Care Association of Washington Ross Hayes, MD, Palliative Care Program, Bioethics, Rehabilitation, Pediatrician, Seattle Childrens Greg Malone, MA, MDiv, BCC, Palliative Care Services Manager, Swedish Medical Group Kerry Schaefer, MS, Strategic Planner for Employee Health, King County Bruce Smith, MD, Medical Director of Providence Hospice of Seattle, Providence Health and Services Richard Stuart, DSW, Psychologist, Swedish Medical Center - Edmonds Campus Stephen Thielke, MD, Geriatric Psychiatry, University of Washington Cynthia Tomik, LICSW, Manager, Palliative Care, Evergreen Health Gregg Vandekieft, MD, MA, Medical Director for Palliative Care, Providence St. Peter Hospital Hope Wechkin, MD, Medical Director, Hospice and Palliative Care, EvergreenHealth

Today’s Goal

Review content of recommendationsVote to disseminate for public comment

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Focus Areas

Defining palliative care using the standard definition developed by the National Consensus Project including appropriateness of primary and specialty palliative care. Spreading awareness of palliative care.Clinical best practice provision of palliative that is:

Responsive to local cultural needs Includes advance care planning Incorporates goals of care conversations into the medical record and

plan of care

Availability of palliative care through revision of benefit structure such as a per member per month (PMPM) benefit. Slide 26

Definitions

Serious illness is a condition that “negatively impacts quality of life and daily function, and/or is burdensome in symptoms, treatments, or caregiver stress… [and] carries a high risk of mortality.” “Palliative care focuses on expert assessment and management of

[symptoms including] pain…assessment and support of caregiver needs, and coordination of care [attending] to the physical, functional, psychological, practical, andspiritual consequences of a serious illness. It is a person-and family-centered approach to care, providing people living with serious illness relief from the symptoms and stress of an illness.”

Source: Kelley AS. Defining "serious illness". J Palliat Med. 2014 Sep;17(9):985.Source: National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative

Care, 4th edition. Richmond, VA: National Coalition for Hospice and Palliative Care; 2018. www.nationalcoalitionhpc.org/ncp.

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http://www.nationalcoalitionhpc.org/ncp

The power of metaphor

Weir Slide 28

Primary V Specialty Palliative Care

Primary palliative careDelivered within primary and relevant sub-specialty careMeets physical, functional, psychological, practical, and spiritual

consequences of a serious illness Refer patients to specialty palliative care when needs cannot be met

Specialty palliative care Interdisciplinary team Includes or has access to a care coordination function and is able to

meet medical, psychological, and spiritual care needs Access (e.g., telemedicine) to 24/7 specialty expertise highly

recommended

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Interdisciplinary Team

The National Consensus Project defines the interdisciplinary team as a “team of physicians, advanced practice registered nurses, physician assistants, nurses, social workers, chaplains, and others based on need” and breaks out professions by the following roles:

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Physicians and/or advanced practice providers

Nurses

Social workers

Chaplains

Clinical pharmacists

Illness trajectory, prognosis, and medical treatments

Assessment, direct patient care, serving as patient advocate, care coordinator, and

educator

Family dynamics, assess and support coping mechanisms and social determinants of health, identify and facilitate access to resources, and mediate

conflicts

Spiritual care specialists, assess and address spiritual issues and help to facilitate continuity with the patient’s faith community as requested

Medication management, adjustment and deprescribing

Initial Assessment and Ongoing Assessment and Management

Goals of care conversations including around hospitalization Advance care planning Cognitive impairmentFunctional needsSymptom management and medical carePharmacy managementCaregiver needsBehavioral health and psychosocial (i.e., depression, anxiety, suicidality, others)Spiritual care needs+ Care Coordination + Urgent Issues Slide 31

Benefit Structure

A per member per month (PMPM) palliative care benefit for seriously ill patientsOpen to all agesFollows a patient across settings (e.g., if hospitalized)Does not require the patient to be homebound or to stop curative or active therapy Setting of provision of specialty palliative care services (e.g., hospital) as accountable entity

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Benefit Structure

Identification: Develop an agreed-upon strategy to identify seriously ill patients (e.g., such as with the PACSSI Eligibility and Tiering Criteria outlined in Appendix D). Interdisciplinary: Require an interdisciplinary approach to care that

does not require a physician to lead the interdisciplinary team. Payment structure: Offer a larger payment for the initial intake visit, a

PMPM payment, and a smaller per-in-person visit payment. Services: Use recommendations on the following pages to define the

included specialty palliative care services and which services are excluded (e.g., hospitalizations). Measure: Measure success using at least one metric related to (1)

potentially avoidable complications and (2) patient-specific quality of life. See page 18 for options under each of these categories. Metrics may be tied to gainsharing.

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Stakeholder Groups

Washington State Health Care Authority and Department of HealthHealth PlansHealth Care Purchasers (employers and union trusts)Patients and Family MembersSpecialty Palliative Care TeamsPrimary Care Providers and Sub-specialty ProvidersHealth Systems

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Next Steps

Adopt Palliative Care Report and Recommendations for adoption for public comment

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Implementing TeamBirth to Promote Effective Communication,

Safety, & Dignity in Childbirth

@neel_shah

Healthy People 2000: 15% CD Rate

United States Cesarean Delivery Rate (%)

0

5

10

15

20

25

30

35

1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

Baby’s safety

Mom’s safety

Best long term health for both

Simplicity

Teamwork

Permission

Opportunity

Structure

Labor and Delivery Planning Board

Team

Preferences

Plan

Next Assessment

FEASIBILITY EFFECTIVENESS EFFICACY

ACCEPTABILITY

FIDELITY

SAFETY

DIGNITY

CASE MIX

RURALITY

FEASIBILITY

ACCEPTABILITY

FIDELITY0% 20% 40% 60% 80% 100%

Nurse (n=220)

Midwife (n=22)

Obstetrician (n=79)

Definitely Probably Maybe Probably not Definitely not

81%

91%

85%

Clinicians recommend the project

FEASIBILITY

ACCEPTABILITY

FIDELITY0% 20% 40% 60% 80% 100%

Improves TeamCommunication

Improves Care

Clarifies Non-UrgentCesareans

Yes, definitely Yes, somewhat Don't know / no opinion No

80%

92%

95%

Clinicians report benefits for decision-making and communication

0% 20% 40% 60% 80% 100%

Believed preferencesinfluenced care

Had preferredrole in care

Understoodconversations

Yes, definitely Yes, somewhat Don't know / no opinion No

FEASIBILITY

ACCEPTABILITY

FIDELITY

99%

98%

90%

People in labor report being involved in their care

FEASIBILITY

ACCEPTABILITY

FIDELITY

0%

20%

40%

60%

80%

100%

Baseline Launch Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7

At Least One Huddle Multiple Huddles

People in labor report increasing frequency of huddles

FEASIBILITY

ACCEPTABILITY

FIDELITY

27%

31%

35%33%

26% 26%

31% 29%26%

28% 28%

23% 22%25%

0%

5%

10%

15%

20%

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May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

2018 2019

% of

Pat

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NTSV Cesarean Rate (EvergreenHealth)

HealthyPeople 2020 Target

FEASIBILITY EFFECTIVENESS

ACCEPTABILITY

FIDELITY

SAFETY

DIGNITY

Community of Practice

Regional Effectiveness

Trial

Workgroup Update: Opioid Prescribing: Supporting Patients on Chronic Opioid Therapy

Gary Franklin, MD, MPHMedical Director, Washington State Department of Labor and Industries

September 18th, 2019 | Bree Collaborative Meeting

Workgroup Members

Co-Chair: Gary Franklin, MD, MPH, Medical Director, Washington State Department of Labor and Industries

Co-Chair: Charissa Fotinos, MD, Deputy Chief Medical Officer, Washington State Health Care Authority

Co-Chair: Andrew Saxon, MD, Director, Center of Excellence in Substance Abuse Treatment and Education (CESATE), VA Puget Sound Health Care System

Rose Bigham and Cyndi Hoenhous, Co-chairs, Patient Advocates Washington Patients in Intractable Pain

Katharine Bradley, MD, MPH, Senior Investigator, Kaiser Permanente Washington Research Institute Malcolm Butler, MD Chief Medical Officer Columbia Valley Community Health Pamela Stitzlein Davies, MS, ARNP, FAANP Nurse Practitioner Departments of Neurology & Nursing,

University of Washington Andrew Friedman, MD Physical Medicine and Rehabilitation Virginia Mason Medical Center Kelly Golob, DC Chiropractor Tumwater Chiropractic Center Dan Kent, MD Chief Medical Officer UnitedHealthcare Kathy Lofy, MD Chief Science Officer Washington State Department of Health Jaymie Mai, PharmD Pharmacy Manager Washington State Department of Labor and Industries Joseph Merrill, MD, MPH Associate Professor of Medicine University of Washington Anne Blake-Nickels Patient Advocate Gregory Rudolph, MD Addiction Medicine Swedish Pain Services Jennifer Davies-Sandler Patient Advocate Mark Stephens President Change Management Consulting Mark Sullivan, MD, PhD Psychiatrist University of Washington David Tauben, MD Chief of Pain Medicine University of Washington Medical Center Gregory Terman MD, PhD Professor Department of Anesthesiology and Pain Medicine and the

Graduate Program in Neurobiology and Behavior, University of Washington John Vassall, MD, FACP Physician Executive for Quality and Safety Comagine Health Michael Von Korff, ScD Senior Investigator Kaiser Permanente Washington Research Institute Mia Wise, DO Medical Director, Collaborative Healthcare Solutions Premera Blue Cross Slide 2

Recap: Patient-Centered Approach to Chronic Opioid ManagementVancouver, WA Conference August 9th

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250-300 attendees

GuidelinesBackground

Help primary care and other providers support patients in managing chronic pain Follow National Pain Strategy:

Patient-centered, accounting for individual preferences, risks, and social contexts Comprehensive, meeting biopsychosocial needs Multimodal and integrated, using evidence-based treatments

Focus on goals of clinically meaningful improvement in function, as well as improved quality of life, and greater patient functional independence rather than on pain relief Priority = safety and avoidance of serious adverse outcomes

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https://iprcc.nih.gov/docs/HHSNational_Pain_Strategy.pdf

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GuidelinesFocus Areas

Patient Engagement and SupportAssessmentDevelop a Treatment Plan Treatment PathwaysMaintain and MonitorReduce DosageTransition to medication-assisted therapy

Health Systems

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GuidelinesPatient EngagementDiscuss goals of care and preferencesSet expectationsAssess knowledge about pain and medication(s), educate on knowledge gapsAssess concernsRespectInvolve othersConsistencySource: Wyse JJ, Ganzini L, Dobscha SK, Krebs EE, Morasco BJ. Setting Expectations, Following Orders, Safety, and Standardization: Clinicians' Strategies to Guide Difficult Conversations About Opioid Prescribing. J Gen Intern Med. 2019 Jul;34(7):1200-1206.Kennedy LC, Binswanger IA, Mueller SR, Levy C, Matlock DD, Calcaterra SL, Koester S, Frank JW. "Those Conversations in My Experience Don't Go Well": A Qualitative Study of Primary Care Provider Experiences Tapering Long-term Opioid Medications. Pain Med. 2018 Nov 1;19(11):2201-2211.Sullivan MD, Turner JA, DiLodovico C, D'Appollonio A, Stephens K, Chan YF. Prescription Opioid Taper Support for Outpatients With Chronic Pain: A Randomized Controlled Trial. J Pain. 2017 Mar;18(3):308-318.

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Next Meeting:

Wednesday, November 20th, 201912:30 – 4:30

Puget Sound Regional Council5th Floor Board Room1011 Western Avenue, Seattle WA

Presentation-19-0918.pdfBree Collaborative MeetingAgendaJuly 24th Meeting MinutesImplementation: �2020 and 2021��Ginny Weir, MPH�Director, Bree CollaborativeImplementation Funding �ESHB 1109Welcome Amy!Save the Date�March 25th, 2020Presentation for Public Comment: �Shared Decision Making��Ginny Weir, MPH�Director, Bree CollaborativeWorkgroup MembersToday’s GoalFocus AreasDefining Shared Decision MakingAppropriateness Workgroup Goal Drivers of Shared Decision Making ImplementationSelected Health Care ServicesImplementation FrameworkHealth Care Delivery Organizations and SystemsHealth Care Delivery Organizations and SystemsHealth Plans and/or Professional Liability CarriersDocumentation, Coding, ReimbursementNext StepsPresentation for Public Comment: �Palliative Care��John Robinson, MD, SM�Chief Medical Officer, First Choice HealthWorkgroup MembersToday’s GoalFocus AreasDefinitionsThe power of metaphorPrimary V Specialty Palliative CareInterdisciplinary TeamInitial Assessment and Ongoing �Assessment and Management Benefit Structure Benefit Structure Stakeholder GroupsNext Steps

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9.Franklin-Opioid-Prescribing-19-0918.pdf�Workgroup Update: �Opioid Prescribing: Supporting Patients on Chronic Opioid Therapy ��Gary Franklin, MD, MPH�Medical Director, Washington State Department of Labor and IndustriesWorkgroup MembersRecap: Patient-Centered Approach to Chronic Opioid Management�Vancouver, WA Conference August 9thGuidelines�BackgroundSlide Number 5Guidelines�Focus AreasGuidelines�Patient Engagement

10.End-19-0918.pdf�Next Meeting:��Wednesday, November 20th, 2019�12:30 – 4:30 ��Puget Sound Regional Council�5th Floor Board Room�1011 Western Avenue, Seattle WA