Patient Engagement in Medicaid Populations Nancy L. Rothman, EdD, RN

1. Patient Engagement in Medicaid Populations Nancy L. Rothman, EdD, RN Consultant/PHMC Nursing Network Independence Foundation Professor of Urban Community Nursing Dept. of Nursing, CHP and SW, Temple University Bureau of TennCare Qsource September 11, 2013

2. Objectives for presentation: At the end of the session, learners will be able to • Describe the concept of patient engagement in health care. • Synthesize from the National Committee on Quality Assurance and the Joint Commission patient-centered medical home models the importance of patient engagement. • Evaluate patient engagement approaches for use with Medicaid populations.

3. Patient Engagement • Is a process of patients becoming invested in their own care. • Develops with conversation between patients and providers and patients setting their own self-management or self-care goals. • The role of the patient is no longer that of a passive recipient of care. • The Wagner Chronic Care model suggests engaged activated patient have improved quality measures. • Harvard Business and Medical Schools June, 2013 Healing Ourselves Conference, addressing healthcare’s innovation, cites “making consumerism really work” as a key imperative to improving health care quality and cost.

4. Recent Payer, State and Federal Initiatives promote Patient Centered Medical Homes (PCMHs), providing: • Whole-person focus • Long-term provider partnerships,not sporadic, hurried visits • Provider-led teamscoordinate care, especially prevention/chronic conditions, plus other providers’ care, community support • Enhanced accessand patient engagement

5. Benefits of PCMHs: Improved health care value • Higher quality, lower costs preventing the need for hospital and ER admissions • Quality Gains And Cost Savings Through Adoption Of Medical Homes, Fields, Leshen, Patel, Health Affairs, May 2010 • Improved satisfaction– patients & clinicians • Patient-Centered Medical Home Demonstration, Reid et al, American Journal of Managed Care, September 2009

6. Update on initiatives promoting PCMHs: • The benefits have caused states, e.g. the PA Chronic Care Initiative, to require participating primary care practices to become and remain NCQA recognized PCMHs. • However, Medicaid payers in PA who participated in the PA Chronic Care Initiative, have left or announced that they are leaving and providing their own pay for performance plans. • HRSA is providing funding to FQHCs to achieve PCMH status under NCQA or TJC.

7. Two PCMH Options National Committee for Quality Assurance (2008, 2011) The Joint Commission (2011) Patient Centered Medical Home Recognition Three levels Submit documentation on-line Delivery site specific 3 years Patient Centered Medical Home Certification No levels On-site survey Entire organization 3 years Voluntary expansion of ambulatory care certification

8. NCQA PCMH Standards 2011 Core components Must pass elements • Enhance Access and Continuity • Identify and Manage Patient Populations • Plan and Manage Care • Provide Self-Care and Community Support • Track and Coordinate Care • Measure and Improve Performance • Access during office hours • Use data for population management • Care management • Support self-care process • Track referrals and follow-up • Implement continuous quality improvement

9. The Joint Commission PCMH Standards • Patient-centered care • Comprehensive care • Coordinated care • Superb access to care • A system-based approach to quality and safety • Patient can select their CPC, consideration of patient’s cultural, linguistic and educational preferences, patient involvement in treatment, support for self-management

10. Nurse-Managed Health Care Home Effectiveness Project • Evaluating nurse-led primary care in NCQA recognized Patient-Centered Medical Homes with CRNP and RN Care Manager teams • In two primary care clinics in public housing • African American women 18-60 years of age diagnosed with diabetes, hypertension, hyperlipidemina or at risk due to a BMI > 30; n-116

11. Public Health Management Corporation Nursing Network PHMC Health Connection Rising Sun Health Center

12. Pre-intervention patient focus groups: • Expressed confusion and concern about medication use, diet and self management of diabetes. • “I am on two medications for my blood pressure and three for my diabetes. It is back and forth, back and forth trying to get the results they want.” • “You have to stay stable; you have to eat breakfast on time and you have to eat between meals.” • Stressed difficulty adopting a diet that would allow them to lose weight or maintain a better blood sugar level. • “Sometimes I get nervous, like when I don’t eat…I realize my sugar is low…it can go under 70 , that’s when I feel it.”

13. Indicated family support was important to their efforts to take medication, eat better and try to be physically active. • “I love junk food, but my husband does not let me eat it.” • “My granddaughter or daughter will call me and ask, Nana did you take your medicine?” • Identified the areas of self-care management with which they needed assistance to improve their health outcomes. • “It is easy for them to tell you what you need to do, but hard for you to do it.” • “Eating right, exercising , reducing stress…” • “Some of the pills make you nauseous and/or sleepy.”

14. Intervention:RN Care Managers Coached Patients on their selected self-management goals • Reducing stress • Exercise • Nutrition • LDL • Smoking Cessation • Blood Pressure • Statistically significant increase in self-management goals related to stress, exercise and nutrition (p=>.0001) • Statistically significant decrease in LDL and number of cigarettes smoked (p=>.0o01) at 12 months • Statistically significant decrease systolic and diastolic blood pressure (p=>.0o01) at 18 months

15. Examples of Self-Management Goals • Wish to increase exercise for improved cardiovascular health – I will get off the bus two stops earlier on my way to and from work. • Nutrition related to desire to loose weight – I will replace sugary drinks, both juice and soda, with water and unsweetened tea.

16. Outcome Measures • Body Mass Index • Hemoglobin A1C • Clinically significant reductions in BMI (40%) and A1C (25%), but not statistically significant

17. SF 12 Outcome Measures • Medical Outcomes Short Form measures perceptions of the patient’s own health to include: general health, physical functioning, bodily pain, vitality, social functioning, role limitation physical, role limitation emotional, physical health and mental health. • Subjects had statistically significant positive changes in bodily pain, role limitation emotional and mental health.

18. Post-intervention patient focus groups: • Expressed better understanding of medication use, diet and self management of diabetes, hypertensions and lipid levels because RN Care Manager took time with them and helped patients to set monthly goals. • “Because I didn’t have a clue what was going on with being a diabetic and you really took time out to help me.” • “You helped me out with my smoking. I am down to half a pack per day.” • Meeting one on one with RN Care Managers provided very personal individualized assistance in taking small steps to improve their health over time. • “My cholesterol is really good. Like I was shocked when my heart doctor told me it was perfect because it was sky high.” • “Yeah, me with the junk food and I stopped. I drink water and I eat alot of vegetables and fruit.”

19. Both parents and children supported patients efforts to take medication, reduce their stress, eat better, decrease or stop smoking and to be more physically active. • “All of my family stopped smoking.” • My mother started buying more healthy stuff for the house.” • RN Care Managers and clinic staff are encouraging and caring, when you have insurance and when you do not. • “I love this clinic and program, because a few months ago my insurance ran out. No one would provide my medicine but here the nurse practitioner went to the back and gave me some. ” • “The RN Care Manager is very dedicated and sincere. I feel it is more than just a program to her.”

20. Challenges • African American Women in the study were: Residents of public housing or homeless • Uninsured or had Medicaid insurance • Auditing the records of the low income women in this study provides a continuing context for understanding the complexity of their lives, primarily related to exposure to infectious diseases (STDS and TB), violence, physical abuse, emotional abuse, substance abuse, loss of employment and homelessness.

21. Success and Future Direction • In spite of the complexity of their lives, the women responded positively to selecting their own self-management goals and being supported with individualized coaching from RN Care Managers. • Public Health Management Corporation, owner of these two nurse-led NCQA recognized PCMHs, is committed to continue to provide support for patients to meet their selected self-management goals.

22. Acknowledgements Project was conducted in collaboration with: the National Nursing Centers Consortium; and the American Nurses Association and Pfizer, Inc. who also in part provided financial support for the study.

23. Shared Decision Making:Better Decisions Together • 2009 • Ann Torregrossa, • (Director of PA Governor’s • Office of Health Care Reform) • Nancy Rothman • Seek support from the • Informed Medical Decisions Foundation and Health Dialogue for: • Supply of decision aids • Support for project from Foundation Staff • Richard Wexler, MD • Director of Patient Support Strategies • Kate Clay, MA, BSN, RNOffice of Professional Education and OutreachThe Dartmouth Institute of Health Policy and Clinical Practice • 2010 • Local planning and implementation of project at • 5 nurse practitioner practices • ( all were participating in the Governor’s • Chronic Care Initiative) • Decision aids viewed in centers • Or sent home ( to mail back) • Referral sheet faxed from centers • Patient name and contact information • Name of decision aid(s) • Permission to contact patient • Pre-viewing surveys • Post-viewing surveys • Follow-up with a nurse practitioner • In person • By phone • Answer questions • Clarify values related to decision • Help support a decision related plan 2011, 2012, 2013 • Decision aids viewed in centers • Or sent home ( to mail back) • Referral sheet faxed from centers • Patient name and contact information • Name of decision aid(s) • Permission to contact patient • Pre-viewing surveys • Post-viewing surveys • Coaching by on-site • RN Care Managers • In person • By phone • Answer questions • Clarify values related to decision • Help support a decision related plan

24. Posters were placed in the waiting • rooms as well as other locations in all • of the participating clinics. • Corresponding brochures with a • short description of each decision aid • were provided to be handed out either • in the waiting room or by providers • in the exam rooms. • Decision aids have been added.

25. Descriptive Statistics

26. Diabetes OnlyPre-Viewing Health Infoat Temple vs Other Demo Sites  Temple (n=35)  Other Demo Sites (n=292)

27. Diabetes OnlyPost-Viewing Total Taking or Planning to Talk About Medications at Temple vs Other Demo Sites Cholesterol Meds Blood Pressure Meds

28. View availability of decision aids as an enhancement to patient engagement • Recently added decision aids to job descriptions of RN Care Managers and Medical Receptionists. • Performance evaluations include goals for increasing distribution of decision aids. • Had a visit in Fall 2012 from MedPAC staff who interviewed patients and staff and reported positively on our use of decision aids to the Commissioners.

29. Time for others to share examples of patient engagement

30. Contact information • Nancy L. Rothman • 215-707-5436 • rothman@temple.edu