Patient Engagement
Shared Decision Making, Group Visits, and More!
Presented by: Nick Gideonse, MD
Date: OAFP, April12, 2013
gideonse@ohsu.edu
Agenda
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Why?
Where in the PCPCH?
What’s old, what’s new?
Group Visits and Mini-groups
Patient goals; keeping track
Motivational interviewing and the like
Resources
Others?
Why?
(Who’s in control here, anyway?)
Health Care = 10%
We Can Do Better — Improving the Health of the American People
Steven A. Schroeder, M.D.
N Engl J Med 2007; 357:1221-122
Behaviours and Risk
Where in the PCPCH?
1. There are essential “core” attributes of
primary care that make it effective:
① Access
② Continuity
③ Comprehensive
④ Coordinated
⑤ Contextual (holistic or patient-centered)
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Will Miller 2008
• Social influences
• Social media
Patient as Consumer
Information and Communication
Technology
• Chronic Care Model
• Patient as Consumer
• Information and Communication
Technology
Chronic Care Model
And…
Oregon’s PCPCH
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• ACCOUNTABILTIY
Take responsibility for making sure I receive the best possible health care.
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• COMPREHENSIVE WHOLE PERSON CARE
Provide or help me get the health care and services I need.
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ACCESS TO CARE
Be there when I need you.
• CONTINUITY
Be my partner over time in caring for my health.
• COORDINATION AND INTEGRATION
Help me navigate the health care system to get the care I need in a safe and timely way.
• PERSON AND FAMILY CENTERED CARE
Recognize that I am the most important member of my care team - and that I am ultimately
responsible for my overall health and wellness.
PCPCH Standards
Core Attribute #6: Person-and Family Centered Care
“Recognize
that we are the most important part of the care team and that we are
ultimately
responsible for our overall health and wellness.”
6A) Language / Cultural Interpretation 6.A.0
6B) Education & Self- Management Support 6.B.1
6C) Experience of Care
6.C.1 (D) Annual
6.C.2 (D) Regular, and CAHPS
6.C.3 (D) To Benchmarks
PCPCH Standards
6.A Language/Cultural Interpretation Standard
Measure:
6.A.0 PCPCH documents the offer and/or use of either providers who speak a patient
and family’s language or time of service in person or telephonic trained interpreters to
communicate with patients and families in their language of choice.
(Must Pass)
6.B Education & Self-Management Support Standard
Measure:
6.B.1 PCPCH documents patient and family education, health promotion and
prevention, and self-management support efforts, including available community resources. (Tier 1 -5
points)
This is not a must pass standard
PCPCH Standards
6.C Experience of Care Standard
Measures:
6.C.1
PCPCH surveys a sample of its patients and families at least annually on their
experience of care. The patient survey must at least include questions on
access to care, provider communication, coordination of care, and practice staff
helpfulness.
The recommended patient experience of care survey is one of the CAHPS survey tools.
(Tier 1 –5 points)
6.C.2 PCPCH surveys a sample of its population using one of the CAHPS survey tools.
(Tier 2 - 10 points)
6.C.3 PCPCH surveys a sample of its population using one of the CAHPS survey tools
and meets benchmarks on a majority of the survey domains.
(Tier 3 –15 points)
This is not a must-pass standard
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What’s old, what’s new?
• Relationships
• Context: family, community, faith, education,
resources…..
• EMR
• Information continuity
– availability of accurate information everywhere
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Databases
Calendars
Communication
(SoCal) Social Media
Patient Centered Interactions & PCMH Practices
• Respect patient and family values and expressed needs.
• Encourage patients to expand their role in decisionmaking, health-related behaviors, and self-management.
• Communicate with patients in a culturally appropriate
manner, in a language and at a level that the patient
understands.
• Provide self-management support at every visit through
goal setting and action planning.
• Obtain feedback from patients/families about their
healthcare experience and use this information for
quality improvement.
What is Self-Management Support?
• The goal of self management support is to aid
and inspire patients to become informed about
their conditions and take an active role in their
treatment.
• It can be viewed in two ways: as a portfolio of
techniques and tools; and as a fundamental
transformation of the patient-caregiver
relationship into a collaborative partnership.
• Adapted from Bodenheimer, CHCF, 2005
Group Visits and Mini-groups
• www.aafp.org/fpm/2006/0100/p37.html
• And many others……
• Challenges: billing, TAT, cohorting, MA
time, space, cohort fatigue
Group Visits and Mini-groups
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Intake forms
Space
Individual time with provider
Guests
A curriculum
Open discussion
Group Visits and Mini-groups
• Shared medical Appointments
– Diagnosis based?
– New diagnoses?
– Urgent Care/open hours
• Education sessions
• Mini-groups
• REWARDS: scheduling flexibility, peer
support, focus groups, Provider efficiencies
Patient goals; keeping track
• Problem list
• EHR dedicated fields
• “Written Plans”
• But how to develop truly patient centered
goals, e.g. POEMS
Patient Input
• Surveys
• Samples
• Universal Feedback
(Disney)
• Complaints
• Conversations
• PAC’s
You have to ask
The “big ASK”: routinely asking patients about their
experience of care to guide teams in the
improvement and redesign aspects of achieving
patient-centered medical home
Methods to capture our patients’ experiences
• Regularly host focus groups
• Have patient representatives on the improvement team
• Informally ask patients about their ideas
• Routinely conduct patient surveys and review the results
immediately
PAC’s
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Patient Advisory Council Meeting
March 18, 2013
6:00-7:30 p.m.
AGENDA
6:00-6:30
Open Forum & Dinner – all
Front Desk
Focus Group last month
6:30-6:50
OHSU Walk In Clinic at Cascadia Behavioral Health – Ern Teuber
6:50-7:15
Alternative Payment Method – Ern Teuber & Erin Kirk
7:15-7:30
Future agenda items – all
Self-Care Plans
Social Media
Other?
Please contact Jill O’Neal at 503-418-3989 or onealj@ohsu.edu if you are unable to attend or have questions.
Feedback, shared and used
Subject: Weekly Medical Practice Scorecard & Comments Report March 29th 2013
Hi Richmondites,
Attached are the Patient Satisfaction Survey results for the entire organization. In the 2nd attachment you can see how our scores compare with other
practices throughout OHSU.
Please note that our goal is to hit the 50th percentile at this point and we are currently in the 9th percentile for the month (number of patients that have
responded for this quarter: 25) and at the 11th percentile for the quarter we are in (Q3).
Q1 2012 6th percentile
Q2 2012 11th percentile
Below are our comments from attachment 1 that are just our clinics comments for this past week. Please take note of those things that are of value to patients
and those things that upset our patients or are disappointing. All faculty clinicians are now being surveyed (sorry residents and staff – hopefully you will
be soon)
Theme for this week:
Positive: great care and wonderful staff
Negative: wait time and chronic pain
Let me know if you have any questions in your review.
Thanks
Megan
Comments:
I was seen immediately by the nurse for vitals, but waited 1/2 hour for the doctor. After the appointment, I needed blood work. There was only one person in
front of me, but we waited 20 minutes because there was no one in the blood lab.This was one of the most difficult doctor's visits I've ever had, as I
learned I was having a miscarriage for a badly wanted pregnancy. The doctor was incredibly compassionate, took as much time as was needed to
answer all my questions, called after the visit to see how I was doing. I can't imagine having a better experience for such a crappy
problem.Nurse/assistants at this clinic are most excellent.
One place at the cutting edge:
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For Patients with Chronic Pain
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What You Should Know About Pain Medication
at OHSU Family Medicine at Richmond
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We care about your pain and we want to evaluate and treat it
appropriately, with your help. This means:
The safety of our patients and the community is important to us.
We have many ways to help with painful conditions. Much of our
help will NOT involve prescription medications.
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“Opiate” pain medicines (sometimes called “narcotics”) like
Vicodin, Oxycodone, Morphine, Tramadol, and Methadone can
cause much harm.
Use of these opiate pain medications is especially dangerous
when combined with other sedatives such as Alcohol, Promethazine,
and Benzodiazepines (e.g. Xanax, Klonopin).
Other community clinics in the area follow the same basic
policies.
Our clinicians, not management personnel, have the final
decision-making authority and responsibility on all prescriptions
they write.
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Generally, they will not write a prescription for opiate pain
medication:
At your first visit,
Without records from your prior clinician’s office,
If pain medication was stopped by another primary care clinician,
If you are taking Xanax, Valium, Ativan, Klonopin, or are seen at a
Methadone clinic,
If your clinician thinks the potential harms outweigh the potential
benefits, especially improvement in function,
If you have a history of “diversion” (passing your opiates on to
another person),
If you are at high risk for misusing medications (by use of a standard
tool),
If you have unstable mental health,
If you have active substance use or abuse,
Use of medical marijuana
If you are prescribed opiates for chronic pain:
We will require ongoing behavioral health services,
Non-medication therapies must be used (e.g. physical therapy,
exercise, yoga, chiropractor, acupuncture, relaxation techniques),
Long-acting pain medications will be preferred,
Random drug tests, and pill counts will be required,
The state prescription report will be checked,
Maximum total daily doses will not be more than 120mg of
Morphine, 80 mg of Oxycodone, or 60 mg of Methadone
Motivational interviewing and the like
Motivational interviewing is a semi-directive, client-centered counseling style for eliciting behavior
change by helping clients to explore and resolve ambivalence. Compared with non-directive
counseling, it's more focused and goal-directed. Motivational Interviewing is a method that works
on facilitating and engaging intrinsic motivation within the client in order to change behavior.[1]
The examination and resolution of ambivalence is a central purpose, and the counselor is
intentionally directive in pursuing this goal
Four General Principles
• Express empathy.
• Develop discrepancy
• Roll with resistance.
• Support self-efficacy.
Patient Centered Observation Form (L Mauksch)
• A method for Team-let (e.g. provider, MA)
and peer feedback on visit-based
communication
• Observing and developing the “observer
within”
• Larry Mauksch,M.Ed
lmauksch@gmail.com
PCOF
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Establishing rapport:
Maintain the relationship
Plan the use of time
Think out loud (transparent thinking)
Gathering information.
Watch for cues
Explore patient or family perspectives (Kleinmann and Eisenberg)
Using the HER
Physical findings
Sharing information
Co-creating plans
Closure
http://uwfamilymedicine.org/pcof
Styles of communication
Styles of communication
Brief interventions
Steps of the brief intervention
Steps of the brief intervention
Steps of the brief intervention
Steps of the brief intervention
Steps of the brief intervention
Explore pros and cons:
• What are some
things you like about
your drinking?
• What are some
things you don’t like
about your drinking?
Steps of the brief intervention
Readiness ruler
Resources ?
Others?
http://www.safetynetmedicalhome.org/changeconcepts/patient-centered-interactions
http://www.sbirtoregon.org/
http://uwfamilymedicine.org/pcof
aafp.org (FPM and PCMH Toolkit)
gideonse@ohsu.edu