A Patient-Centered Health System

1. A Patient-Centered Health System Karen Davis President, The Commonwealth Fund American Hospital Association Roger Larson Memorial Lecture May 2, 2006 kd@cmwf.org www.cmwf.org

2. Importance of Patient- and Family-Centered 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

3. Black and Latino Hospital Patients ReportMore Problems with Care Experiences Percent of hospital patients reporting more problems* in dimensions of patient experiences * More problems defined as highest quintile of problem scores in each dimension. Source: Adapted from L. S. Hicks et al., “Is Hospital Service Associated with Racial and EthnicDisparities 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) Odds Ratio 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.

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.

6. 2020 Vision of a Patient- and Family-Centered Health System • Superb access, quality, and safety for all • Patient engagement in care • Clinical information systems that support high-quality 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 patient-centered care, clinical quality, efficiency

7. Geisinger Health System’s Quality Dashboard – System Level Safety Effectiveness Timeliness Discharges without a reportable incident OSHA-recordable workman’s compensation cases Functional status Inpatient mortality Readmissions % of practice sites meeting their 3rd available appointment target % of total patient days with the patient at the wrong level of care Efficiency Cost per encounter Annualized staff discharges per staffed bed Average length of stay Equity Inpatient satisfaction (by payor) Patient-Centeredness • Patient satisfaction (by site) Source: Geisinger Quality Dashboard

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.

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.

10. What Patients Say About their Experiences with Hospital Care Willingness to recommend (Definitely yes, probably yes, definitely/probably no) Source: AHRQ/CAHPS, CAHPS Hospital Survey Chartbook: What Patients Say about their Experiences with Hospital Care, March 2006. Prepublication Copy.

11. National Variation in Problem Scores by Hospital Type Academic Health Center 13.2 22.9 Teaching Hospital 10.2 22.1 Non- Teaching Hospital 8.6 16.7 0.0 10.0 20.0 30.0 Range Median Source: Paul D. Cleary and Susan Edgman-Levitan

12. Center for Shared Decision-Making Dartmouth-Hitchcock Medical Center 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

13. Advanced Practice Nurse Transitional Care Model Improves Patient Outcomes and Decreases Health Care Costs • 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.

14. Transitional Care ReducesRehospitalization for Heart Failure Patients Resource use among congestive heart failure patients ages 65+ treated atsix Philadelphia hospitals during 1997–2001 who were randomly assignedto receive a three-month transitional care intervention or usual care Usual care group Intervention group Percentage of patients who were rehospitalized or died Number ofhospital readmissions Average cost of care Source: Medical records and patient interviews (N=239) (Naylor et al. 2004), S. Leathermanand D. McCarthy, Quality of Health Care for Medicare Beneficiaries: A Chartbook, 2005,The Commonwealth Fund. www.cmwf.org/usr_doc/MedicareChartbk.pdf.

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.

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.

17.  Care Transition Measure Scores, Emergency Department Use and Hospital Readmissions Emergency Department Use Hospital Readmissions p=0.01 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.

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

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* *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

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

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

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