Patient Engagement

1. Patient Engagement Shared Decision Making, Group Visits, and More! Presented by: Nick Gideonse, MD gideonse@ohsu.edu Date: OAFP, April12, 2013

2. Agenda • 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?

3. Why?(Who’s in control here, anyway?)

4. Health Care = 10% We Can Do Better — Improving the Health of the American PeopleSteven A. Schroeder, M.D.N Engl J Med 2007; 357:1221-122

5. Behaviours and Risk

6. Where in the PCPCH? • There are essential “core” attributes of primary care that make it effective: • Access • Continuity • Comprehensive • Coordinated • Contextual (holistic or patient-centered)

7. And… • Chronic Care Model • Patient as Consumer • Information and Communication Technology • Will Miller 2008 • Social influences • Social media Chronic Care Model Patient as Consumer Information and Communication Technology

8. Oregon’s PCPCH • ACCESS TO CARE • Be there when I need you. • ACCOUNTABILTIY • Take responsibility for making sure I receive the best possible health care. • COMPREHENSIVE WHOLE PERSON CARE • Provide or help me get the health care and services I need. • 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.

9. 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

10. 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

11. 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 .

12. What’s old, what’s new? • Relationships • Context: family, community, faith, education, resources….. • EMR • Information continuity • availability of accurate information everywhere • Databases • Calendars • Communication • (SoCal) Social Media

13. Patient Centered Interactions & PCMH Practices • Respect patient and family values and expressed needs. • Encourage patients to expand their role in decision-making, 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.

14. 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

15. 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

16. Group Visits and Mini-groups • Intake forms • Space • Individual time with provider • Guests • A curriculum • Open discussion

17. 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

18. Patient goals; keeping track • Problem list • EHR dedicated fields • “Written Plans” • But how to develop truly patient centered goals, e.g. POEMS

19. Patient Input • Surveys • Samples • Universal Feedback (Disney) • Complaints • Conversations • PAC’s

20. 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

21. PAC’s • 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.

22. 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.

23. One place at the cutting edge: • For Patients with Chronic Pain • What You Should Know About Pain Medication • at OHSU Family Medicine at Richmond • 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. • “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. • 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

24. 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.

25. 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

26. PCOF • 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

27. Characteristics of directivecommunication Styles of communication • Explaining why the patient should make the change • Telling the person how they could change • Emphasizing how important it is to change • Persuading when meeting resistance

28. Characteristics ofguiding communication Respect for autonomy of patient and their goals and values Readiness to change must be taken into account Ambivalence is common Targets selected by the patient, not the “expert” Expert is the provider of information (patient) Be empathic, non-judgmental, respectful Styles of communication

29. Brief Interventions Brief interventions can be performed in as little 3 minutes Aimed to motivate those at-risk to change their behavior Aimed to motivate individuals with more severe risk to seek assessment/treatment Designed to provide personal feedback, enhance motivation, and promote self-efficacy to promote behavior change Brief interventions

30. Steps of the brief intervention: Steps of the brief intervention Raise the subject Provide feedback Enhance motivation Negotiate plan

31. Screening forms act as conversation starters Ask permission to raise the subject of alcohol/drug use “Thanks for filling out this form. Would you mind taking a few minutes to talk with me about your alcohol use and how it might relate to your ______?” Steps of the brief intervention Raise the subject

32. Point out the patient’s zone of misuse. Explore connection to health issues if there is one and express concern(s) Educate about NIAAA Guidelines for low-risk drinking Use Elicit-Provide-Elicit Model Steps of the brief intervention Provide feedback

33. “On a scale of 0 - 10 , how ready are you to change any aspect of your drinking (drug use)?” Steps of the brief intervention Enhance motivation • “Why did you choose that number and not a lower one?” A strategy that helps the patient identify what motivation already exists towards making change.

34. 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? Enhance motivation

35. Negotiate a plan on how to reduce use, abstain or seek referral Provide clear advice and express your concerns Negotiate and secure an agreement regarding changes the patient is willing to make, including scheduling follow-up when needed Steps of the brief intervention Negotiate plan

36. Readiness ruler Readiness Ruler: front

37. Resources ? Others? http://www.safetynetmedicalhome.org/change-concepts/patient-centered-interactions http://www.sbirtoregon.org/ http://uwfamilymedicine.org/pcof aafp.org (FPM and PCMH Toolkit) gideonse@ohsu.edu