The Dr. Robert Bree Collaborative: Working together to improve health care quality, outcomes, and affordability in Washington State

Ginny Weir, MPHProgram DirectorBree Collaborative

April 15th, 2015 | Home Care Association of Washington Preconference

Background

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House Bill 1311

Health Plans

Public Purchasers

QI Organizations Hospitals

Employers

Others

Identify health care services with

high:• Variation• Utilization

Without producing better outcomes

Physicians

22 Stakeholders

Process

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Data Transparency

Provider Feedback Reports

Shared Decision Aids

Financial Incentives

Evidence-Based Guidelines

Centers of Excellence

Public Reporting

Public Comment Recommendations

to improve health care quality,

outcomes, and affordability in

Washington State

Clinical Committee

Process

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Workgroups meet for ~9 months - year

Updates at all Bree meetings

Public comment

Adoption by the Bree Collaborative

Approval by the Health Care Authority

Reports

What is the problem? Is variation unwarranted? Does it contribute to patient harm?

What does it look like in Washington State?What are solutions within the medical system?Focus areasStakeholder-specific recommendations

How do we get there?

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Topics

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Obstetrics

Cardiology

Elective Total Knee and Total Hip Replacement Bundle and Warranty

Elective Lumbar Fusion Bundle and Warranty

Low Back Pain and Spine SCOAP

Hospital Readmissions

End-of-Life Care

Addiction and Dependence Treatment

New Topics

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Coronary Artery Bypass Surgery Bundled Payment Model and Warranty

Prostate Specific Antigen Screening

Opiate Prescribing

Oncology Treatment

Implementation

Agency Medical Directors Group (AMDG) reviews and approves recommendations which are then forwarded to the Director of the Health Care Authority (HCA)HCA Director reviews and decides whether to apply to state-purchased health care programs

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Implementation

Legislation does not mandate payment or coverage decisions by private health care purchasers or carriers

Delivery systems and providers not required to implement recommendations

Bree Implementation Team (BIT):Design and implement strategies to successfully encourage stakeholders to implement the recommendations

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Presentation from topic expert

Development of change strategy

Implementation of change strategy

Implementation Team: General Strategy

Formation of sub-group, if

needed

After adoption by the Health Care Authority:

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End-of-Life Care

Inpatient Days per Medicare Decedent during the Last Six Months of Life, 2007

Slide 12Source: End of life Care. Dartmouth Atlas of Health Care. Accessed: July 2014. Available: www.dartmouthatlas.org/data/topic/topic.aspx?cat=18.

Goal for all Washingtonians:

To be informed about end-of-life options Communicate preferences in actionable

terms Receive end-of-life care aligned with goals

and values

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Focus Areas

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1. Awareness

2. Advance care planning

3. Record end-of-life care wishes and goals

4. Accessibility of forms

5. End-of-life care choices are honored

“It’s always too early until it’s too late.”

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Advance Care Planning

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Adapted from: Butler M, Ratner E, McCreedy E, Shippee N, Kane RL. Decision Aids for Advance Care Planning: An Overview of the State of the Science. Ann Intern Med. 2014 Jul 29

Advance Directives VS POLST

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Advance Directive Physician Orders for Life-Sustaining Treatment

(POLST) Durable Power of Attorney for

Health CareLiving Will/Health Care Directive Written Personal

Statement

Appropriate Population

All adults All adults All adults Those with advanced progressive chronic conditions

Timeframe Future care Future care Future care Current careWhere Completed Any setting Any setting Any setting Medical setting

Product Legal designation of a health care decision-making surrogate that is part of an advance directive in alignment with Washington State law RCW 11.94.010

Description of an individual’s health care wishes for the end of life for a time when that individual is unable to communicate those wishes that is part of an advance directive in alignment with Washington State law RCW 70.122.030

Summary of personal values and goals of care relating to end-of-life care wishes

Medical orders

Surrogate Role Surrogate cannot complete Surrogate cannot complete Surrogate responsible for presenting to health care provider

The designated surrogate can consent to POLST on behalf of an incapacitated patient

Responsible for Portability

Currently patient or family/friends

Currently patient or family/friends Currently patient or family/friends

Provider/Health System

Responsible for Review

Patient or family/friends Patient or family/friends Patient or family/friends

Provider/Health System

Seek to empower WashingtoniansDraw from the work of many efforts across our StateWork to align end-of-life care with patient’s wishes, goals, and values

Do not endorse a specific advance care planning program or initiative or a specific advance directive as many are being used successfully in our state Slide 19

Recommendations

1. Awareness

Community-wide discussions Advance directive that includes:

1. Living will/health care directive2. Durable power of attorney for health care 3. Written personal statement

Difference between POLST and an advance directive

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Ex: Whatcom Alliance for Health Advancement

Slide 21Source: Whatcom Alliance for Health Advancement. End of Life Choices. Accessed: August 2014. Available: http://whatcomalliance.org/end-of-life-care/.

2. Advance Care Planning

Educate health care professionals Evidence-based tools and programsInvolve family members and friends Appropriate timing

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2. Advance Care Planning

Reimbursement Hospice Advance care planning facilitators

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Ex: Honoring Choices: Pacific Northwest

Slide 24Source: Honoring Choices: Pacific Northwest. Copyright 2015. Available: http://www.honoringchoicespnw.org/

3. Record Wishes and Goals

AccurateEasily understandable ActionableCulturally appropriateEngage low-literacy patients

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A Closer Look at Advance Directives

A living will/health care directiveConsistent with section 030 of the Washington State Natural Death Act.

Signed by the declarer in the presence of two witnesses“Artificially provided nutrition and hydration” if “diagnosed to be in a terminal condition or in a permanent unconscious condition”

Stipulates specific treatment preferences (if known and applicable to the situation)

A durable power of attorney for health careNames a surrogate Indicates the amount of leeway for surrogate in decision-making

A written personal statement Patient’s values and goals regarding end-of-life care

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Ex: prepareforyourcare.org

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Source: The Regents of the University of California. Prepare for your Care. 2013. Accessed: August 2014. Available: www.prepareforyourcare.org

4. Increase Accessibility

Advance directives and POLST registryDriver’s license

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Ex: Oregon POLST Registry

Slide 29 Source: Oregon POLST Registry. History of the Oregon POLST Registry. Accessed: August 2014. Available: www.orpolstregistry.org/oregon-polst-registry/about-opr/

5. End-of-Life Care Choices Are Honored

Quality improvement programsHospitalsNursing homesOther settings

Measure family satisfaction Legal immunity to health care providers who honor a patient's POLST

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Ex: Interventions to Reduce Acute Care Transfers (INTERACT)

Slide 31 Source: INTERACT: Interventions to Reduce Acute Care Transfers. Accessed: August 2014. Available: https://interact2.net/

RecommendationsHospitals

Education on having empathetic, realistic, and patient- and family- centered advance care planning conversations

Using lower literacy materials if appropriateDocument advance directives and/or POLST in medical record

Communicate with patient and primary care provider

Quality improvement for greater adherence to patients’ wishes

Support patients and families during times of crisis Slide 32

RecommendationsHealth Plans

Reimbursement for end-of-life care counseling and discussion regarding advance directives with patients and surrogate decision makersEncourage hospitals, nursing homes, and other applicable settings to implement a quality improvement program Inclusive and comprehensive benefits for care of patients with serious illness at the end of life allowing them to receive care consistent with their wishes and goals

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RecommendationsThe State of Washington

Reimbursement for end-of-life care counseling and discussion regarding advance directives with patients and surrogate decision makersState registry for advance directives and POLST Promote use of the registryLegal immunity for health care providers honoring POLST Slide 34

More Information

Ginny Weir, Program DirectorGWeir@qualityhealth.org (206) 204-7377www.breecollaborative.org

Recommendations available here: www.breecollaborative.org/about/reports

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Comments/Questions

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Appendix

Topics

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Obstetrics

Cardiology

Elective Total Knee and Total Hip Replacement Bundle and Warranty

Elective Lumbar Fusion Bundle and Warranty

Low Back Pain and Spine SCOAP

Hospital Readmissions

End-of-Life Care

Addiction and Dependence Treatment

Obstetrics

Elective DeliveriesEliminate all elective deliveries before the 39th week of pregnancy (for which there is no appropriate documentation of medical necessity)

Elective Inductions of LaborDecrease elective inductions of labor between 39 and up to 41 weeks

Primary C-sectionsDecrease unsupported variation among Washington hospitals in the C-section rate for women who have never had a C-section

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Cardiology

Clinical Outcomes Assessment Program (COAP), a neutral, third-party quality improvement program of the Foundation for Health Care Quality

All hospitals in Washington State who perform open-heart surgery and PCIs participate in COAP

Ask to publicly disclose hospitals’ insufficient information reports and the appropriateness of PCI procedures

Realistic and aggressive timeline

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Bundles and Warranties

Health care currently pays physicians and other providers for the number of services provided rather than the quality of careGoal to tie payment to an entire episode of care including potential complications resulting from poor care

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Total Knee and Total Hip Replacement

High volume of proceduresVariation in way procedures are done

Readmission Rates by hospital on website: http://www.breecollaborative.org/topic-areas/apm/

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Source: Readmission Rates for TKR/THR Procedures in Washington State:Summary of Findings from 2011 CHARS DataBree Collaborative – Accountable Payment Model SubgroupOctober 2013. Available: http://www.breecollaborative.org/wp-content/uploads/bree_summary_CHARS_Analysis.pdf

Warranty

A contract between provider and purchaser/payer whereby…Provider will correct failure of their product…At no additional cost to purchaser

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Warranty Cont.

7 days Acute myocardial infarction Pneumonia Sepsis

30 days Death Surgical site bleeding Wound infection Pulmonary embolism

90 days Mechanical complications related to surgical procedure Periprosthetic joint infection

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Bundle: Four Components

1. Document disability despite conservative therapy

2. Ensure fitness for surgery3. Provide all elements of high quality surgery4. Facilitate rapid return to function And transparent quality metrics

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Quality Standards

AppropriatenessEvidence-based surgeryRapid and durable return to functionPatient care experiencePatient safety and affordability

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Low Back Pain

Appropriate evaluation and management of patients with newly diagnosed and persistent acute low back pain and/or nonspecific low back pain not associated with major trauma in primary care

Early identification and management of patients diagnosed with low back pain that is not associated with major trauma but have psychosocial factors (e.g., anxiety) that place them at a high risk for developing chronic low back pain and disability

Awareness of low back pain management among individual patients and the general public

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Spine SCOAP

All hospitals participate in the Spine Surgical Care and Outcomes Assessment Program (SCOAP) to improve surgical outcomes for chronic low back pain patients

SCOAP is a provider-led program of the Foundation for Health Care Quality that collects data on select surgical procedures for quality improvement

Results unblinded

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Hospital Readmissions

Build community-collaborativesAdopt the Washington State Hospital Association's Care Transitions Toolkit

For patients with diagnoses of acute myocardial infarction, heart failure, community acquired pneumonia, chronic obstructive pulmonary disease, or stroke measure and report whether:

Patient discharge information was provided to the primary care provider or aftercare provider within three days of discharge

A follow-up phone call to the patient or caregiver occurred within three business days

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Addiction and Dependence Treatment

Reduce stigma associated with alcohol and other drug screening, intervention, and treatment

Increase appropriate alcohol and other drug use screening

Increase capacity to provide brief intervention and/or brief treatment for alcohol and other drug misuse

Decrease barriers for facilitating referrals to appropriate treatment facilities

Address the opioid addiction epidemic Slide 50