patient engagement, activation & the aco: an early...

Patient Engagement, Activation & The ACO:

An Early AssessmentStephen Shortell, PhD, MBA, MPH

Principal InvestigatorNational Surveys of Physician Organizations

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Outline

• Definitions – What Are We Talking About?

• Some Early Findings

• Insights from Recent Site Visits

• Some “Better Practices”

• Moving Forward – Policy Implications and Early Developments

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PurposeTo produce baseline data on ACO involvement in patient/family activation and engagement.

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Why ACOs?

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ACOs are accountable for a defined population and have financial

incentives to keep people well


Definitions

Patient Activation • Defined from the patient’s perspective as...– Understanding one’s own role in the care process– Having the knowledge, skills, and confidence to take on

that role

Patient Engagement • A broader concept, including...– Patient activation– The interventions designed to increase it– The patient behavior that results from it

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Patient Activation and Engagement Dimensions

• Preventing disease and promoting health

• Involvement in care planning and treatment- shared decision making

• Involvement in advanced serious illness and end-of-life care

• Involvement in overall design and operation of the health care delivery organization itself

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"Health Policy Brief: Patient Engagement," Health Affairs, February 14, 2013.http://www.healthaffairs.org/healthpolicybriefs/

A Multidimensional Framework for Patient and Family Engagement in Health and Health Care

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Health Policy Brief: Patient Engagement," He alth Affairs, February 14, 201 3. http:// www.healthaffairs .org/healthpolicybriefs/

Predicted Per Capita Costs of Patients by Patient Activation Level

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2010 Patient Activation Level

Predicted Per Capita Billed Costs ($)

Ratio of Predicted Costs Relative to Level 4 PAM

Level 1 (lowest) 966** 1.21**

Level 2 840 1.05

Level 3 783 0.97

Level 4 (highest) 799 1.00

Source: Judith H. Hibbard, Jessica Greene, and Valerie Overton, “Patients with Lower ActivationAssociated with Higher Costs; Delivery Systems Should Know Their Patients ‘Scores.’” Health Affairs32, no. 2 (2013): 216-22. Authors' analysis of Fairview Health Services billing and electronic health record data, January-June 2011. In patient and pharmacy costs were not included. PAM is Patient Activation Measure. **p < 0.05


Data Sources

• National Web-based survey of ACOs (N = 101 respondents)

• Phone interviews with 11 ACOs – key informants, both Medicare and commercial contracts.

• Site Visits– Group Health Cooperative of Puget Sound– UCLA Medical Center and Health System

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Response Rate

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Number of Completions

Received to Date

Response Rate

Number of ACO’s Sent

Survey

282 101 36%


Summary Statistics for Selected PA&E Variables

Respondent Comments on Training:

• “Physicians’ offices must be trained on the roles of the Community Health Workers, as they are unfamiliar with this practice”

• “Patient engagement training and assessment of the engagement training has started with the care coordinators here.”

Question N Mean (SD)

% of PCPs that have received training in PA&E 101 48.5 (30.6)

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Respondent Comments on Developing a Treatment Plan:

• “We currently have health care coaches in almost all of our primary care practices”

• “Case managers work with high risk patients to set goals and monitor compliance or other issues.”

Question N Mean (SD)% of PCPs that work with patients/families to develop a treatment plan that sets goals for their care 101 61.6 (29.0)

% of PCPs that follow-up with patients/families to assess and monitor the treatment plan 101 57.3 (28.5)

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% of ACO’s high-risk chronic illness patients that receive health coaching 101 45.4 (27.5)

% of ACO’s high-risk chronic illness patients that participate in peer support groups or group visits 101 18.5 (17.8)

% of ACO’s high-risk chronic illness patients that participate in a care-transition program 101 60.7 (31.2)

% of PCPs that offer patients/families evidence-based decision aids 101 45.5 (30.8)

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Overall Means and Standard Deviations for Selected PA&E Variables


ACO uses telehealth 101 53.5%*

If YES, % of ACO’s patients that use telehealth 53 20.4 (26.4)

ACO formally assesses literacy levels 100 30.0%*

If YES, % of PCPs that use health literacy information in working with patients/families 23 53.4 (34.9)

ACO has calculated the return on investment (ROI) for PA&E 96 26.0%*

If YES, best estimate of the ROI 8 2:1 to 5:1

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Respondent Comments on Patient Activation and Engagement Examples

“Conducted Patient Journey market research to learn more about the journey of chronically ill patients”

“Purchased Patient Activation Management software to use when interviewing patients and educating care coordinators”

“Proactively reaching out to patients through calls, e-communications, and other communication”

“Home visits as part of Transition of Care and increased Home Health referrals”

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Perceived Impact of Patient Activation and Engagement on Performance Outcomes (1-9 scale)

Question N Mean (SD)Extent to which ACO's leadership believes that having activated and engaged patients will lead to improved quality of care

101 7.8 (1.9)

Extent to which ACO's leadership believes that having activated and engaged patients will lead to improved health outcomes

101 7.8 (1.6)

Extent to which ACO's leadership believes that patient activation and engagement will result in the retention of patients within the ACO system

101 7.4 (1.7)

Extent to which ACO's leadership believes that patient activation and engagement will lead to reduced costs of care

101 7.4 (1.7)

Extent to which ACO's leadership believes that patient activation and engagement is critical to ACO's success 101 7.4 (1.7)

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There were no statistically significant differences by ACO size, ownership, or region of the country, but early responders more likely to do PAE.

Respondent Comments on Results Achieved to Date

“Too early to tell”

“20,000 patients signed up thus far on the patient portal after one year”

“We find a high correlation between Health Risk Assessment completion and lower admission/readmission rates”

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Respondent Comments on “Anything Else”

“It’s been a tough sell here. I’m a real believer in having more robust strategies but the medical communities seems to have a futility about the notion of engaging patients”

“Your capital partner needs to be VERY involved and able to make decisions at the local level”

“It’s a struggle but worth the effort in the end”

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Comments from Interviewees and Site Visit Respondents

“We have the same struggles that I am sure everybody else does. And that is, are we really building patient-centric care or is it just a continuation of provider centric?”

“Our clinicians have…..so much on their plates that it’s really hard for them to think about the full package that’s available for their patients. ….there’s competing priorities.”

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Comments from Interviewees and Site Visit Respondents (cont’d)

“We gave them [patients] an initial care pathway as we saw it, and had them fill in what we missed. Every single interview raised using catheters as a point of anxiety for the patient; and the urologist didn't realize that that was a point of anxiety.”

“It is hard to do his kind of work because it’s got to be professionally led …but it’s through the engagement of people in the trenches that you get the acceptance and the spread, but it takes time. It takes a lot of effort to do that.”

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Comments from Interviewees and Site Visit Respondents (cont’d)

“So when we first started putting care coordinators in the offices, we got pushback from the doctors that you’re taking away some of the things I used to do. But after they got familiar with it and realized that these aren’t things that you really need a medical degree for and it actually means that the minutes I’m in the room with the patient I can talk to the patient about their health (they were OK with it).”

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Limitations

• Likely over-estimate the amount of PAE occurring to respondents more likely to be doing more than non-respondents

• Cannot generalize

• Interviewed knowledgeable leaders. Frontline clinicians and staff may have different views.

• Findings reflect associations: no causal inferences

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Insights from Recent Site Visits to Two Large ACOs – PCORI Funded Study in Progress

• Patient engagement is heavily dependent on – Physician engagement– Meaningful information exchange– Effective healthcare teams

• The challenge of physician delegating tasks to team members

• The challenge of the “hard core” patients – 10-15%

• Integrating behavioral health into primary care

• Application of LEAN production management techniques

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Some “Better” Practices

• Respecting choices – Gundersen Clinic, La Crosse, Wisconsin– Sends notices to all patients 55+ to discuss their wishes

with their primary care provider

• Improving communication – “Teach back”– Providers ask patients to explain back to them what the

patients have learned, their understanding of their condition, available option, and their intention to act on the information

• “Choice Architecture”– Decisions structured so as to “nudge” patients toward a

particular choice– Express scripts – use lower priced drugs first before

“stepping up” to other options26


Public Policy Implications

• Shared Decision Making (SDM) Resource Centers

• Patient-Centered Outcomes Research Institute (PCORI)

• Washington State Legislation (2007)

• Encouraging SDM as part of the informed consent process

• Massachusetts certification of ACOs must include SDM

• NCQA Patient-Centered Medical Home certification requires patient assessment of SDM

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Motivational Interviewing (MI): Evidence-Based Method for Improving Activation

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Emerging Developments

• Movement away from fee-for-service to global budgets –Alternative Payment Models (APM) and Merit Incentive Payments (MIP)

• Increased patient cost sharing – High deductibles and co-insurance

• Accountability/transparency and advances in measurement

• Movement towards Accountable Communities for Health –expanded opportunities for citizen participation and engagement

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Additional Resources

• Health Affairs Special Issue on Patient Engagement –February 2013

• Shortell SM, Sehgal NJ, Bibi S, et al. “An Early Assessment of Accountable Care Organization’s Efforts to Engage patients and Their Families.” Medical Care Research and Review, October 2015; 72(5):580-604.

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Moving from“what is the matter with you?”

to “what matters to you?”

In Conclusion

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patient engagement, activation & the aco: an early...

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