Records Stanford Coordinated Care “Support the patients, manage their care”

1. RecordsStanford Coordinated Care“Support the patients, manage their care” Alan Glaseroff MD Co-Director, Stanford Coordinated Care IOMCommittee onRecommended Social and Behavioral Domains and Measures for Electronic Health 11/25/13

2. Causes of Premature Mortality 15% Social 30% 5% Environmental 10% Medical Behavioral Genetic 40% Schroeder, NEJM 357; 12

3. 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

4. Clarifying Multimorbidity Patterns to Improve Targeting and Delivery of Clinical Services for Medicaid Populations Cynthia Boyd, Bruce Leff, Carlos Weiss, Jennifer Wolff, Allison Hamblin, and Lorie Martin CHCS DECEMBER 2010

5. Depression is Often Notthe Only Health Problem Cancer10-20% Chronic Pain40-60% Neurologic Disorders10-20% Depression Geriatric Syndromes20-40% Heart Disease20-40% Diabetes10-20% 2010 University of Washington – AIMS Center

6. Individual Self-Reported Patient Assessments • SF-12 • PAM • Domains • PHQ-9 • (Activity level) • (Nutrition Assessment) • (Stanford Presenteeism Scale)

7. 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

8. Patient Activation and Utilization

9. Patient Variation – what the patient faces Domains

10. Domains: “What to do?Patient Activation Measure: “How to do it?” Workflows based on patient variation

11. The Often HiddenDriver: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

12. 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.

13. % Have Injected IV Drugs Relationship of ACEs to Alcohol & IV Drug Abuse 4+ 3 % Alcoholic 2 1 0

14. Relationship of ACEs to Smoking & COPD

15. 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

16. SCC Approach • From: “What bothers you the most? • To: “Where do you want to be in a year?”

17. 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 17

18. 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 18

19. 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

20. Thank You! Alan Glaseroff MD • aglasero@stanford.edu