Records
Stanford Coordinated Care
“Support the patients, manage
their care”
Alan Glaseroff MD
Co-Director, Stanford Coordinated Care
IOM Committee on Recommended Social and
Behavioral Domains and Measures for
Electronic Health
11/25/13
15%
30%
5%
10%
Social
Environmental
Medical
Behavioral
Genetic
40%
Schroeder, NEJM 357; 12
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Patient–Driven Care
• “Others have struggled to find a proper definition of
patient-centeredness. Three useful maxims that I have
encountered are these:”
– “The needs of the patient come first.”
– “Nothing about me without me.”
– “Every patient is the only patient.”
Donald M. Berwick, What 'Patient-Centered' Should Mean: Confessions Of An
Extremist Health Affairs, 28, no.4 (2009):w555-w565.
New Definition: Patients largely determine their
own outcomes within the context of their lives
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Clarifying Multimorbidity Patterns to Improve Targeting and Delivery of Clinical Services for Medicaid
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Populations
Cynthia Boyd, Bruce Leff, Carlos Weiss, Jennifer Wolff, Allison Hamblin, and Lorie Martin CHCS DECEMBER
Depression is Often Not
the Only Health Problem
Cancer
10-20%
Chronic Pain
40-60%
Depression
Geriatric
Syndromes
20-40%
Heart Disease
20-40%
2010 University of Washington – AIMS Center
Neurologic
Disorders
10-20%
Diabetes
10-20%
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Individual Self-Reported Patient
Assessments
• SF-12
• PAM
• Domains
• PHQ-9
• (Activity level)
• (Nutrition Assessment)
• (Stanford Presenteeism Scale)
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Activation is Developmental with Four
Progressively Higher Levels
10-15% of the
population*
20-25% of the
population*
35-40% of the
population*
25-30% of the
population*
* Medicaid and Medicare populations skew lower in activation
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Patient Activation and Utilization
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Patient Variation – what the patient faces
Domains
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Domains: “What to do?
Patient Activation Measure: “How to do it?”
PAM
1
2
3
4
Domains
Social
Access
Behavioral
Medical
Trajectory
Workflows based on patient variation
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The Often Hidden Driver:
Adverse Childhood Events & Trauma
ACE Score = 1 point each for positive responses to 10 questions inquiring about
exposure to:
• Physical abuse
• Emotional abuse
• Sexual abuse
• Physical neglect
• Emotional neglect
• Divorce/separation
• Domestic violence in the home
• Parent that used drugs or alcohol
• Parent that was incarcerated
• Parent that was mentally ill
From: www.acestudy.org
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How do ACE play out in later life?
• Depression:
– A person with an ACE score of 4 was 4.6 x more likely to be
suffering from depression than a person with an ACE score of 0
• Suicide:
– There was a 12.2 x increase in attempted suicide between these
two groups; at higher ACE scores, the prevalence of attempted
suicide increases 30-51 fold!
– Between 66-80% of all attempted suicides could be attributed to
ACE.
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Relationship of ACEs to Alcohol & IV Drug Abuse
3.5
% Alcoholic
Alcoholic
%
14
3
12 2.5
2
10 1.5
8
1
0.5
6
4
2
0
0
% Have Injected IV Drugs
16
% Have Injected Drugs
18
4+
2
0
1
0
2
3
4 or more
ACE Score
ACE Score
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Relationship of ACEs to
Smoking & COPD
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PTSD
“Adverse Childhood Experiences
(ACE) are common, destructive,
and have an effect that often lasts
for a lifetime. They are the most
important determinant of the health
and well-being of our nation.”
--Vincent Felitti, MD, co-chair of study
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SCC Approach
• From:
“What bothers you the most?
• To:
“Where do you want to be in a year?”
First
step
Next
step
Getting
there…
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Population Health – Risk Measures
Panel View by care team,
clinician, patient
demographics
Summary of overall risk
for patient population
View by chronic
condition
Navigate to patient
health portrait
Patient Panel list by Risk Markers
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Population Health – Health Portrait
Health Portrait – Personalized view of a
patient displaying care gaps alongside risk
measures
Patient / Provider selectable
measures to trend and
track at point of care
Obesity
Care gap measures
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Patient Advisors to SCC
• Clinic designed after input
from 34 patient interviews
• 8 people meet monthly
(led by Patient Chair, with
LCSW as “recorder” of
minutes; MDs only come
by invite)
• ACE: Cannot be “part of
the chart” – data must be
kept separately, with
patients “consenting” to
complete the survey
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Thank You!
Alan Glaseroff MD
– aglasero@stanford.edu
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