Why Understanding What Matters is Critical to Health Care PCORI - - PowerPoint PPT Presentation

Why Understanding “What Matters” is Critical to Health Care

PCORI Annual Meeting October 31, 2018 Amy Berman, RN, LHD, FAAN Senior Program Officer The John A. Hartford Foundation

Today: Great Innovation & Great Potential for Harm

• Why “What Matters” is Critical to Health Care
• The John A. Hartford Foundation & PCORI
• A Story
• Examples of Evidence to Impact

The John A. Hartford Foundation

A private philanthropy based in New York, established by family owners of the A&P grocery chain in 1929. Dedicated to Improving the Care of Older Adults Priority Areas:

Age-Friendly Health Systems

Serious Illness & End

• f

Life Family Caregiving

The Leader in Improving Care of Older Adults

$580,000,000

Grants authorized since 1982 to improve health care

• Building

the field

• f aging

experts

• Testing & replicating innovation

Care for Older Adults Needs to Change

Poor care coordination

Many factors contribute to poor

• utcomes

Duplication

• f

services Polypharmacy Error-prone transitions Unnecessary hospitalizations Care discordant w/ patient goals

My Story

Photo Credit: Amy Berman

Photo Credit: Amy Berman

How Can Care Be Pt-Centered If We Don’t Discuss Serious Illness?

Photo Credit: iStock

Photo Credit: Amy Berman

What Do Older People Value?

• 1. Independence
• 2. Addressing Pain
• 3. Maintaining Function

and dead last…

• 4. Length of Life

Photo Credit: Julie Turkewitz

Fried et al. Arch Intern Med 2011;171:1854

Palliative Care

• Focuses on improving the quality of life for

people facing serious illness:

• Pain

& symptom management

• Communication

& coordinated care

• Appropriate

from time

• f

diagnosis

• Can

be provided with curative treatment

Resource: Center to Advance Palliative Care https://www.capc.org

Palliative Care Shifts Care out of Hospital / Nursing Home

https://www.capc.org Brumley, R.D. et al. 2007. J Am Geriatr Soc

Advance Care Planning

• 75% are unable to make some or all decisions at end-of-life
• -- Forbes

Carolyn McClanahan

How People Want to Die

How People Die

What is Palliative Care really?

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Congratulations PCORI for your Leadership!

• Authorized $48 million to address Advanced Care Planning and

Community-Based Palliative Care

• Approved $74 million in funding
• Most successful PCORI RFP
• Thank you on behalf of older adults,

the s eriously ill & their families

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Achieving Measurable Impact with Grantee Partners

Center to Advance Palliative Care (CAPC): national

• rganization

building and sustaining palliative care in all h ealth care settings.

• Over a decade of funding from JAHF
• Palliative care now in 90% of large hospitals (300+ beds)1
• Today’s focus: spreading to community / outpatient settings
• Result: improved quality of life and lower costs to the system

1 America’s Care of Serious Illness, 2015 State-By-State Report Card on Access to Palliative Care in Our

Nation’s Hospitals, CAPC

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Achieving Measurable Impact with Grantee Partners

Building a Collective Strategy to Accelerate Progress in End-of-Life Care:

• Scaling six proven

innovations

• Developing coordinated

strategy for dissemination

• Linking strategy to public

engagement efforts

A A Co Collaborative e St Strategy y for r Serious s Illness/EOL EOL

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Achieving Measurable Impact with Grantee Partners

Patient Priorities Care: Patient health outcome goal and preference-directed care for older adults with multiple chronic conditions achieved through primary / specialty care alignment.

• Embedded care in delivery systems that have the needed

infrastructure, relationships, and incentives

• Currently being prototyped in primary care ACO in CT

Tinetti, Mary E. et al. Patient Priority–Directed Decision Making and Care for Older Adults with Multiple Chronic

• Conditions. Clin Geriatr Med, 2016, Vol 32(2):261-75

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Achieving Measurable Impact with Grantee Partners

NCQA Demonstration of Person-Driven Outcome Measures for an Age-Friendly Health System: Develop quality measures that assess how well older adults improve outcomes they identify as most important.

• Demonstrating the feasibility of two approaches:
• Goal Attainment Scaling
• Combined Goal Attainment Scaling/PROMs
• Will develop:
• Tools for implementing and monitoring person-driven outcomes
• Outcome measures suitable for NQF endorsement /HEDIS
• Analysis of conflicts between quality measures & pt goals and options to mitigate conflicts

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Achieving Measurable Impact with Grantee Partners

Coalition for Quality in Geriatric Surgery: establishing verifiable quality improvement program with standards focused

• n what

matters most to the individual p atient.

• 59 stakeholder groups, including patient/family orgs
• Vetted standards using modified RAND-UCLA Appropriateness Methodology1
• Standards/measures: goals of care, function, cognition, longer-term outcomes
• Pilot data from 40,000+ cases show geriatric-specific risk factors contribute

significantly to traditional morbidity and mortality outcome models2

1 Berian JR, et al. Hospital Standards to Promote Optimal Surgical Care of the Older Adult: A Report From the Coalition

for Quality in Geriatric Surgery. Ann Surg. 2017, Mar 8

2 Berian JR, et al. Optimizing Surgical Quality Datasets to Care for Older Adults: Lessons from the American College of

Surgeons NSQIP Geriatric Surgery Pilot, J Am Coll Surg. 2017 Dec;225(6):702-712.e1

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Age-Friendly Health Systems

Age-Friendly Health Systems

Goals of Grant

1) Define essential elements of high quality care for health systems 2) Build on Foundation’s geriatrics models and expertise 3) “4Ms” are indicators of broader shift by health systems to focus on older adults:

• What Matters
• Medication
• Mentation (e.g. cognitive status, confusion)
• Mobility

4) Reach 20% of health systems by 2020 (~ 1000 hospitals)

8

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90 discrete core features identified by model experts in pre-work Redundant/similar concepts removed and 13 core features synthesized by IHI team Expert Meeting – Selection of the “vital few”…the 4Ms

Core Elements: The “4Ms”

• What Matters: Knowing and acting on each patient’s specific health
• utcome goals and care preferences
• Medication: Optimize use to reduce harm/burden, focus on medications

affecting mobility, mentation and what matters

• Mentation: Focus on depression, dementia and delirium
• Mobility: Maintain mobility/function, prevent and treat

complications of immobility

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The Evidence Behind The “4Ms”

• What Matters:
• Asking what matters lowers inpatient utilization (¯ 54%), ICU stays (¯ 80%), increases hospice use (­ 47.2%)

patient satisfaction (AHRQ 2013)

• Medication:
• Older adults suffering adverse drug event have higher rates of morbidity, hospital admission and costs (Field 2005)
• 1500 hospitals in CMS HEN 2.0 reduced 15,611 adverse drug events saving $78m across 34 states (HRET 2017)
• Mentation:
• Depression in ambulatory care doubles cost of care (Unutzer 2009)
• 16:1 ROI on delirium detection and treatment programs (Rubin 2013)
• Mobility:
• Older adults who sustain a serious fall-related injury required an additional $13,316 in hospital operating costs and

increased LOS of 6.3 days (Wong 2011)

• 30+% reduction in direct, indirect, and total hospital costs among patients who received care to improve mobility

(Klein 2015)

The Partnership: Five Health Systems

Results To Date

• More than 50,000 patients have received “Age-Friendly” health care
• 5 health systems with 26 sites in 7 states transformed care in the pilot
• Groundswell of interest – 400+ organizations on “Friends of Age-Friendly” calls
• Over 120 sites in 73 health systems joined the Action Community

Become Part of an “Action Community”

• Find out if the health care organizations you work with are involved

OR

• Take the lead
• Go to www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems for

background information

• Email AFHS@IHI.org and tell them of your interest

So…Why is Understanding “What Matters” Critical to Health Care?

So We C an Live THE the Best Life