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THE COMMONWEALTH FUND A Patient-Centered Health System Karen Davis President, The Commonwealth Fund American Hospital Association Roger Larson Memorial Lecture May 2, 2006 [email protected] www.cmwf.org 2 Importance of Patient- and FamilyCentered 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 THE COMMONWEALTH FUND 3 Black and Latino Hospital Patients Report More Problems with Care Experiences Percent of hospital patients reporting more problems* in dimensions of patient experiences White Black 40 27 30 20 Latino 32 32 21 17 10 10 0 Surgery Obstetrics * More problems defined as highest quintile of problem scores in each dimension. THE COMMONWEALTH FUND Source: Adapted from L. S. Hicks et al., “Is Hospital Service Associated with Racial and Ethnic Disparities in Experiences with Hospital Care?” American Journal of Medicine, May 2005 118(5):529–35. 4 Patients who Experience Worse Hospital and Worse Ambulatory Care Are Twice as Likely to Report Chest Pain One Year After AMI Worse hospital & worse ambulatory care Worse hospital & better ambulatory care Better hospital & worse ambulatory care Better hospital & ambulatory care (comparison group) 0 1 2 Odds Ratio 3 Note: 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. 4 THE COMMONWEALTH FUND 5 Patient-Centered Hospitals Are Associated with Better Outcomes • 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 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. THE COMMONWEALTH FUND 6 2020 Vision of a Patient- and FamilyCentered Health System • Superb access, quality, and safety for all • Patient engagement in care • Clinical information systems that support highquality 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 patientcentered care, clinical quality, efficiency THE COMMONWEALTH FUND 7 Geisinger Health System’s Quality Dashboard – System Level Safety Effectiveness • Discharges without • Functional status a reportable incident • Inpatient mortality • OSHA-recordable • Readmissions workman’s compensation cases Efficiency Equity • Inpatient satisfaction (by payor) Source: Geisinger Quality Dashboard • Cost per encounter • Annualized staff discharges per staffed bed • Average length of stay Timeliness • % of practice sites meeting their 3rd available appointment target • % of total patient days with the patient at the wrong level of care PatientCenteredness • Patient satisfaction (by site) THE COMMONWEALTH FUND 8 H-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. THE COMMONWEALTH FUND 9 H-CAHPS – Reporting National Implementation Results • 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 Source: Liz Goldstein, “CAHPS Hospital Survey Implementation: Current Status and Next Steps,” Presentation to the10th National CAHPS User Group Meeting, March 30, 2006. THE COMMONWEALTH FUND What Patients Say About their Experiences with Hospital Care Always Usually Never 75 Communication with nurses 19 81 Communication with doctors 58 Communication about medications 7 14 6 17 26 Responsiveness of hospital staff 61 25 14 Cleanliness and quiet of hospital environment 61 24 15 70 Pain management Rating of hospital (9-10, best; 7-8, medium; 0-6, worst ) 32 71 yes, definitely/probably no) 20% 40% 8 21 56 Willingness to recommend (Definitely yes, probably 0% 21 79 Discharge information (yes/no) 10 12 23 60% Source: AHRQ/CAHPS, CAHPS Hospital Survey Chartbook: What Patients Say about their Experiences with Hospital Care, March 2006. Prepublication Copy. 80% 6 100% THE COMMONWEALTH FUND National Variation in Problem Scores by Hospital Type Academic Health Center 13.2 Teaching Hospital 22.9 10.2 NonTeaching Hospital 22.1 8.6 0.0 11 16.7 10.0 Range 20.0 30.0 Median THE COMMONWEALTH FUND Source: Paul D. Cleary and Susan Edgman-Levitan Center for Shared Decision-Making Dartmouth-Hitchcock Medical Center 12 • 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 THE COMMONWEALTH FUND Advanced Practice Nurse Transitional Care Model Improves Patient Outcomes and Decreases Health Care Costs • 13 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. THE COMMONWEALTH FUND Transitional Care Reduces Rehospitalization for Heart Failure Patients 14 Resource use among congestive heart failure patients ages 65+ treated at six Philadelphia hospitals during 1997–2001 who were randomly assigned to receive a three-month transitional care intervention or usual care Usual care group 100 200 $16,000 162 80 $12,481 150 61 60 Intervention group 48 $12,000 104 100 $8,000 50 $4,000 0 $0 40 20 0 Percentage of patients who were rehospitalized or died Number of hospital readmissions $7,636 Average cost of care Source: Medical records and patient interviews (N=239) (Naylor et al. 2004), S. Leatherman and D. McCarthy, Quality of Health Care for Medicare Beneficiaries: A Chartbook, 2005, The Commonwealth Fund. www.cmwf.org/usr_doc/MedicareChartbk.pdf. THE COMMONWEALTH FUND 15 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. THE COMMONWEALTH FUND 16 CTM-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. THE COMMONWEALTH FUND Care Transition Measure Scores, Emergency Department Use and Hospital Readmissions Emergency Department Use Hospital Readmissions 69 69 68 68 p=0.01 67 66 65 65 64 64 63 63 62 62 61 61 60 60 Yes p=0.04 67 66 No 17 No 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. Yes THE COMMONWEALTH FUND 18 Veterans 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 THE COMMONWEALTH FUND 19 Heart Failure Patients Given Written Instructions or Educational Materials When Discharged, 2004 Percent of heart failure patients discharged home with written instructions or educational material* 100 87 80 60 64 50 60 49 33 40 20 26 9 0 National Average Top 10 %tile Hospitals Bottom 10 %tile Hospitals Top 10% States Top 25% State Median Bottom 25% Bottom 10% States States *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 THE COMMONWEALTH FUND 20 Managing Chronic Conditions at Cincinnati Children’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 THE COMMONWEALTH FUND 21 Policies 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 THE COMMONWEALTH FUND 22 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 THE COMMONWEALTH FUND