the commonwealth fund karen davis president, the commonwealth fund american hospital association...
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THE COMMONWEALTH
FUND
Karen DavisPresident, The Commonwealth Fund
American Hospital AssociationRoger Larson Memorial Lecture
May 2, [email protected]
A Patient-Centered Health A Patient-Centered Health SystemSystem
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THE COMMONWEALTH
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Importance of Patient- and Family-Importance of Patient- and Family-Centered CareCentered Care
• Important in and of itself – hallmark of compassion and respect
• Provides feedback to health system on how to improve care – other industries do extensive market research
• Improves loyalty, market position, and reduces malpractice
• Increases trust and adherence
• Improves coordination of care
• Improves clinical outcomes
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Black and Latino Hospital Patients ReportBlack and Latino Hospital Patients ReportMore Problems with Care ExperiencesMore Problems with Care Experiences
17
10
2721
32 32
0
10
20
30
40
Surgery Obs tetric s
White B lac k L atino
Percent of hospital patients reporting more problems*in dimensions of patient experiences
* More problems defined as highest quintile of problem scores in each dimension.
Source: Adapted from L. S. Hicks et al., “Is Hospital Service Associated with Racial and EthnicDisparities in Experiences with Hospital Care?” American Journal of Medicine, May 2005 118(5):529–35.
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Patients who Experience Worse Hospital and Worse Patients who Experience Worse Hospital and Worse Ambulatory Care Are Twice as Likely to Report Ambulatory Care Are Twice as Likely to Report
Chest Pain One Year After AMIChest Pain One Year After AMI
0 1 2 3 4
Better hospital & ambulatory care (comparison group)
Better hospital & worse Better hospital & worse ambulatory careambulatory care
Worse hospital & better ambulatory care
Worse hospital & worse Worse hospital & worse ambulatory careambulatory care
Odds RatioNote: Adjusted odds ratios and 95% confidence intervals of chest pain 12 months after myocardial infarction (MCI) according to patient experiences with hospital and ambulatory care.Source: A.M. Fremont, et al., “Patient-Centered Processes of Care and Long-Term Outcomes of Myocardial Infarction,” JGIM 16 (December 2001): 800-808.
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THE COMMONWEALTH
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Patient-Centered Hospitals Are Patient-Centered Hospitals Are Associated with Better OutcomesAssociated with Better Outcomes
Source: D.L. Bechel, W.A. Myers, and D.G. Smith, “Does Patient-centered Care Pay Off?” Joint Commission Journal on Quality Improvement 26 (July 2000): 400-9.
• Using the Picker Inpatient Survey, researchers found that patients were more likely to report lower mortality and fewer complications if they had received patient-centered care
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2020 Vision of a Patient- and Family-2020 Vision of a Patient- and Family-Centered Health SystemCentered Health System
• Superb access, quality, and safety for all
• Patient engagement in care
• Clinical information systems that support high-quality care, practice based learning, and quality improvement
• Care coordination
• Integrated and comprehensive team care
• Routine patient feedback to hospitals and physicians
• Publicly available information on patient-centered care, clinical quality, efficiency
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THE COMMONWEALTH
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Geisinger Health System’s Quality Geisinger Health System’s Quality Dashboard – System LevelDashboard – System Level
• Discharges without a reportable incident
• OSHA-recordable workman’s compensation cases
• Functional status• Inpatient mortality• Readmissions
• % of practice sites meeting their 3rd available appointment target
• % of total patient days with the patient at the wrong level of care
• Inpatient satisfaction (by payor)
• Cost per encounter
• Annualized staff discharges per staffed bed
• Average length of stay • Patient
satisfaction (by site)
Safety Effectiveness Timeliness
Equity
Patient-Centeredness
Efficiency
Source: Geisinger Quality Dashboard
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H-CAHPS – Key Measures to be ReportedH-CAHPS – Key Measures to be Reported
• Composite Measures (number of questions)
– Nurse communication (3)
– Doctor communication (3)
– Cleanliness and quiet of hospital environment (2)
– Responsiveness of hospital staff (2)
– Pain management (2)
– Communication about medicines (2)
– Discharge information (2)
• Overall Rating of Hospital (Q21)
• Willingness to Recommend Hospital (Q22)
Source: Liz Goldstein, “CAHPS Hospital Survey Implementation: Current Status and Next Steps,” Presentation to the 10th National CAHPS User Group Meeting, March 30, 2006.
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• How?– Each hospital’s results will be compared to national
and state averages– Results will be reported for the seven composites and
two overall rating questions– The user will be able to drill down for more detailed
results– Each hospital’s results will be adjusted for mode of
data collection, patient-mix, and non-response bias– Survey response rates will also be reported– Results will be updated quarterly– Results will be integrated with clinical measures
H-CAHPS – Reporting National H-CAHPS – Reporting National Implementation ResultsImplementation Results
Source: Liz Goldstein, “CAHPS Hospital Survey Implementation: Current Status and Next Steps,” Presentation to the10th National CAHPS User Group Meeting, March 30, 2006.
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THE COMMONWEALTH
FUNDSource: AHRQ/CAHPS, CAHPS Hospital Survey Chartbook: What Patients Say about their Experiences with Hospital Care, March 2006. Prepublication Copy.
56
79
61
61
81
75
23
32
21
21
24
25
17
14
19
6
12
8
15
14
26
6
7
71
70
58
0% 20% 40% 60% 80% 100%
Rating of hospital (9-10, best; 7-8, medium; 0-6, worst )
Discharge information (yes/no)
Pain management
Cleanliness and quiet of hospital environment
Responsiveness of hospital staff
Communication about medications
Communication with doctors
Communication with nurses
Alw ays U sually N ever
What Patients Say About their Experiences with What Patients Say About their Experiences with Hospital CareHospital Care
Willingness to recommend (Definitely yes, probably
yes, definitely/probably no)
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THE COMMONWEALTH
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National Variation in Problem Scores by National Variation in Problem Scores by Hospital TypeHospital Type
AcademicHealthCenter
Teaching Hospital
Non-Teaching Hospital
0.0 10.0 20.0 30.0
13.2 22.9
10.2 22.1
8.6 16.7
Range Median
Source: Paul D. Cleary and Susan Edgman-Levitan
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Center for Shared Decision-MakingCenter for Shared Decision-Making Dartmouth-Hitchcock Medical Center Dartmouth-Hitchcock Medical Center
• Provides tools to assist with health care decisions (e.g., videotapes, booklets, websites)
• Provides follow-up counseling with skilled staff
• Seeks to be a prototype for health care systems nationwide
Kate Clay, BA, MSN, Program Director
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Advanced Practice Nurse Transitional Care Model Advanced Practice Nurse Transitional Care Model Improves Patient Outcomes and Decreases Improves Patient Outcomes and Decreases
Health Care Costs Health Care Costs
• Innovative model of care coordination delivered by advanced practice nurses (APNs)
– Focuses on older adults making difficult transition from hospital to home and at risk for poor outcomes
• Team from University of Pennsylvania, Aetna Corporation, and Penn Home Care and Hospice promoting widespread adoption
• Examining effectiveness of APN Model with a high-risk Medicare managed care population in the mid-Atlantic region who are referred for telephonic case management
• Enrollment:
– 48 Aetna members enrolled in a large scale evaluation of the APN Model as of March 31, 2006
Source: Mary Naylor, Project Update to The Commonwealth Fund, April 2006.
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Transitional Care ReducesTransitional Care ReducesRehospitalization for Heart Failure PatientsRehospitalization for Heart Failure Patients
61
48
0
20
40
60
80
100
162
104
0
50
100
150
200
$12,481
$7,636
$0
$4,000
$8,000
$12,000
$16,000
Percentage of patients who were rehospitalized or died
Number ofhospital readmissions
Average cost of care
Source: Medical records and patient interviews (N=239) (Naylor et al. 2004), S. Leathermanand D. McCarthy, Quality of Health Care for Medicare Beneficiaries: A Chartbook, 2005,The Commonwealth Fund. www.cmwf.org/usr_doc/MedicareChartbk.pdf.
Usual care group Intervention group
Resource use among congestive heart failure patients ages 65+ treated atsix Philadelphia hospitals during 1997–2001 who were randomly assignedto receive a three-month transitional care intervention or usual care
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Care Transitions Measure (CTM)Care Transitions Measure (CTM)
• Developed by Dr. Eric Coleman at University of Colorado Health Sciences Center
• Current project aimed at showing how a patient centered measure can drive quality
• Under review at National Quality Forum
• High demand – 450 requests for permission
• At least 10 QI projects are using the measure
E.A. Coleman, “Windows of Opportunity for Improving Transitional Care,” Presentation to The Commonwealth Fund Commission on a High Performance Health System, March 30, 2006.
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THE COMMONWEALTH
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CTM-3 ItemsCTM-3 Items
• When I left the hospital, I had a good understanding of the things I was responsible for in managing my health
• When I left the hospital, I clearly understood the purpose for taking each of my medications
• The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital
E.A. Coleman, “Windows of Opportunity for Improving Transitional Care,” Presentation to The Commonwealth Fund Commission on a High Performance Health System, March 30, 2006.
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Care Transition Measure Scores, Emergency Care Transition Measure Scores, Emergency Department Use and Hospital ReadmissionsDepartment Use and Hospital Readmissions
60
61
62
63
64
65
66
67
68
69
No Yes
p=0.01
E.A. Coleman, “Windows of Opportunity for Improving Transitional Care,” Presentation to The Commonwealth Fund Commission on a High Performance Health System, March 30, 2006.
60
61
62
63
64
65
66
67
68
69
No Yes
p=0.04
Emergency Department Use Hospital Readmissions
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Veterans Health AdministrationVeterans Health Administration
Source: Charles Humble, Jim Schaefer, and Barbara Fleming, “Measuring the Patient’s Experience of VA Health Care,” Forum, November 2004. Accessed through www.academyhealth.org
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THE COMMONWEALTH
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Heart Failure Patients Given Written Instructions or Heart Failure Patients Given Written Instructions or Educational Materials When Discharged, 2004Educational Materials When Discharged, 2004
50
87
9
64 6049
3326
0
20
40
60
80
100
NationalAverage
Top 10 %tileHospitals
Bottom 10%tile
Hospitals
Top 10%States
Top 25%State
Median Bottom 25%States
Bottom 10%States
Percent of heart failure patients discharged home with written instructions or educational material*
*Heart failure patients discharged home with written instructions or educational material given to patient or care giver at discharge or during the hospital stay addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen.
SOURCE: Hospital Compare, CMS, http://www.hospitalcompare.hhs.gov
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Managing Chronic Conditions at Cincinnati Managing Chronic Conditions at Cincinnati Children’s HospitalChildren’s Hospital
• Patients and families become part of the team
• Visioning perfect care• Family perspective• Health care team
• Increasing the urgency for change
• Transparency• Family Preference Card
• Includes information on families’ and patients’ preferences for documenting on chart and participating in rounds
Source: Maria T. Britto, “Improving Care for Children with Chronic Conditions at Cincinnati Children’s Hospital: Cystic Fibrosis and Beyond,” Presentation at Pennyhill Park Meeting, July 15, 2005
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Policies to Promote Patient-Centered CarePolicies to Promote Patient-Centered Care
• Public reporting• Pay for performance
– Clinical quality– Patient-centered care– Efficiency across acute care episodes– Premier experience
• Coverage of shared decision making and translation services
• Coordination of care standards and payment reform
• Information technology
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Thank You!Thank You!• Stephen C. Schoenbaum, M.D., Executive Vice President and
Executive Director, Commonwealth Fund Commission on a High Performance Health System
• Anne-Marie J. Audet, Vice President, Commonwealth Fund, Quality and Efficiency Program
• Melinda K. Abrams, Senior Program Officer, Commonwealth Fund, Child Development and Preventive Care Program and Patient-Centered Primary Care Initiative
• Alyssa L. Holmgren, Research Associate, Commonwealth Fund
Visit the Fund at: www.cmwf.org