human centered design & pace · 2019-12-18 · insight - design - innovation evolve. better....
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
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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
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“Foster kids get a mom.” How can we offer a ‘care mom’?
Its about… Building relationships
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“We matchmake a care provider with a participant.”
Its about… Finding the right match
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“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
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Its about… small, non hierarchal teams
“Team-based model flattens the hierarchy.
Even drivers provide feedback on resident changes.”
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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
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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
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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
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“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?
