Maple Valley MultiCare Clinic

1. Maple Valley MultiCare Clinic Level III NCQA Certified Patient Centered Medical Home

2. MultiCare Health System • MultiCare is a not-for-profit health care organization with more than 9,300 employees and a comprehensive network of services throughout Pierce, South King, Thurston and Kitsap counties. • The Maple Valley Clinic is located at Four Corners in Maple Valley. We provide a full range of family practice services with a dedicated health care team that includes two physicians, a physician's assistant, two LPNs, two MAs, two receptionists, and one patient care coordinator (PCC).

3. General Process-How Shared Decision Making fits with a Patient Centered Medical Home • The Maple Valley clinic was chosen for Shared Decision Making implementation because of their involvement with the Medical Home Collaborative. • Initially the clinic decided to start with five conditions that closely correlate to the highest diagnosed patient population: • Acute Low Back Pain • Chronic Low Back Pain • Chronic Pain • Diabetes • Depression • In May 2010 the providers decided to add two additional conditions: • PSA Testing and Colon Cancer Screening

4. Inter office Promotion-Creating Awareness • All team members were excited about the implementation of Shared Decision Making. Various ideas and reflections were discussed during numerous office visits. • Everyone was encouraged to check out Decision Aid materials to help familiarize themselves with the information that would be made available to patients. • In office DA viewing opportunities were provided with a TV/VHS or computer software. • Decision Aid summaries were also made available for providers who expressed they appreciated this format of information sharing.

5. Implementation ProcessStage 1 and 2 • Stage One-The providers were initially responsible for identifying patients they believed would be beneficial candidates for SDM during an office visit. They introduced the topic and referred the patient to the PCC who further discussed the program and provided materials for check-out. • Stage Two-The patient care coordinator provided reminders for the providers and nurses including placing cue cards on the computer monitor in each exam room indicating the available DA topics. The PCC also experimented with a trial period of reviewing and identifying potential candidates by flagging the daily schedule ahead of time for the providers.

6. Implementation Process Stage 3 and 4 • Stage Three-Patient initiated interest. Promotional materials such as flyers, were created and displayed in the reception area and in the exam rooms with a sample pamphlet encouraging patients to self identify and inquire for additional information. • Stage Four-Patient Care Coordinator created reports identifying patients diagnosed with diabetes, depression, and chronic pain, analyzed data through chart review and presented a list of possible candidates to the providers. Providers then approved the patient list and DAs were distributed through mail with an informational letter and self addressed stamped envelope for return of the survey.

7. Outcomes • Our distribution rate throughout the past year and a half did not meet our goals for numerous possible reasons: • Provider and Staff Engagement • Other check lists make it difficult to remember that DAs are available • Even though each patient was provided at least two reminders via telephone and letter with a self addressed stamped envelope, our return rate was not as impressive as desired. • We checked out a total of 73 decision aids and have had 20 completed surveys returned to our clinic, a return rate of 27%. • The patients who did actively participate with SDM expressed that they enjoyed the information and believe it should be made available to all patients, especially those who are newly diagnosed with chronic conditions.

8. Lessons Learned • Provider and staff engagement is integral for the success of implementation. • Completing mandatory in-office viewing sessions would be beneficial. • Having a mandatory process “check-in” for each provider and condition would ensure participation and encourage friendly competition. • An automated process for the Electronic Medical Record would help facilitate ease of use for the providers and help generate a mode of reminders at regular intervals. For example, creating an orderable code like a CPT that would generate detailed instructions and information for the patient to take with them after their visit, similar to a discharge summary would be very helpful.

9. Patient Feedback and Quotes “Believable” “Education materials for the average person” “Uplifting and encouraging” • All of the patients who responded to the SDM survey or had direct conversations with the PCC and providers have expressed that they appreciate the fact that decision aids were made available to them and they believe this should be a tool that is accessible for all patients. • Some patients have made a few suggestions for what they would like to see in version 2.0 of “Living with Diabetes”, such as including tools similar to tracking measures for a blood sugar log, blood pressure log, food journal, exercise plan and meal plan. • Overall, the implementation process has been successful in that our patients appreciate the additional education and support that Shared Decision Making provides.

10. Thank you! Any Questions?