Why Understanding “What Matters” is Critical to Health Care PCORI Annual Meeting October 31, 2018 Amy Berman, RN, LHD, FAAN Senior Program Officer The John A. Hartford Foundation
Today: Great Innovation & Great Potential for Harm • Why “What Matters” is Critical to Health Care • The John A. Hartford Foundation & PCORI • A Story • Examples of Evidence to Impact
The John A. Hartford Foundation A private philanthropy based in New York, established by family owners of the A&P grocery chain in 1929. Dedicated to Improving the Care of Older Adults Priority Areas: Age-Friendly Health Systems Serious Family Illness Caregiving & End of Life
The Leader in Improving Care of Older Adults $580,000,000 Grants authorized since 1982 to improve health care • Building the field of aging experts • Testing & replicating innovation
Care for Older Adults Needs to Change Many factors contribute to poor outcomes Poor care coordination Duplication of services Polypharmacy Error-prone transitions Unnecessary hospitalizations Care discordant w/ patient goals
My Story Photo Credit: Amy Berman
Photo Credit: Amy Berman
How Can Care Be Pt-Centered If We Don’t Discuss Serious Illness? Photo Credit: iStock
Photo Credit: Amy Berman
What Do Older People Value? 1. Independence 2. Addressing Pain 3. Maintaining Function and dead last… 4. Length of Life Photo Credit: Julie Turkewitz Fried et al. Arch Intern Med 2011;171:1854
Palliative Care • Focuses on improving the quality of life for people facing serious illness: - Pain & symptom management - Communication & coordinated care - Appropriate from time of diagnosis - Can be provided with curative treatment Resource: Center to Advance Palliative Care https://www.capc.org
Palliative Care Shifts Care out of Hospital / Nursing Home https://www.capc.org Brumley, R.D. et al. 2007. J Am Geriatr Soc
Advance Care Planning • 75% are unable to make some or all decisions at end-of-life --- Forbes Carolyn McClanahan
How People Want to Die
How People Die
What is Palliative Care really? 16
Congratulations PCORI for your Leadership! • Authorized $48 million to address Advanced Care Planning and Community-Based Palliative Care • Approved $74 million in funding • Most successful PCORI RFP • Thank you on behalf of older adults, the s eriously ill & their families
Achieving Measurable Impact with Grantee Partners Center to Advance Palliative Care (CAPC): national organization building and sustaining care in all h ealth care settings. palliative • Over a decade of funding from JAHF • Palliative care now in 90% of large hospitals (300+ beds) 1 • Today’s focus: spreading to community / outpatient settings • Result: improved quality of life and lower costs to the system 1 America’s Care of Serious Illness, 2015 State-By-State Report Card on Access to Palliative Care in Our Nation’s Hospitals, CAPC 18
Achieving Measurable Impact with Grantee Partners Building a Collective Strategy to Accelerate Progress in End-of-Life Care : • Scaling six proven innovations A A Co Collaborative e Strategy St y for r • Developing coordinated Serious s Illness/EOL EOL strategy for dissemination • Linking strategy to public engagement efforts 19
Achieving Measurable Impact with Grantee Partners Patient Priorities Care : Patient health outcome goal and preference-directed care for older adults with multiple chronic conditions achieved through primary / specialty care alignment. • Embedded care in delivery systems that have the needed infrastructure, relationships, and incentives • Currently being prototyped in primary care ACO in CT Tinetti, Mary E. et al. Patient Priority–Directed Decision Making and Care for Older Adults with Multiple Chronic Conditions. Clin Geriatr Med, 2016, Vol 32(2):261-75 20
Achieving Measurable Impact with Grantee Partners NCQA Demonstration of Person-Driven Outcome Measures for an Age-Friendly Health System: Develop quality measures that assess how well older adults improve outcomes they identify as most important. • Demonstrating the feasibility of two approaches: • Goal Attainment Scaling • Combined Goal Attainment Scaling/PROMs • Will develop: • Tools for implementing and monitoring person-driven outcomes • Outcome measures suitable for NQF endorsement /HEDIS • Analysis of conflicts between quality measures & pt goals and options to mitigate conflicts 21
Achieving Measurable Impact with Grantee Partners Coalition for Quality in Geriatric Surgery : establishing verifiable quality improvement program with standards focused on what matters most to the individual p atient. • 59 stakeholder groups, including patient/family orgs • Vetted standards using modified RAND-UCLA Appropriateness Methodology 1 • Standards/measures: goals of care, function, cognition, longer-term outcomes • Pilot data from 40,000+ cases show geriatric-specific risk factors contribute significantly to traditional morbidity and mortality outcome models 2 1 Berian JR, et al. Hospital Standards to Promote Optimal Surgical Care of the Older Adult: A Report From the Coalition for Quality in Geriatric Surgery. Ann Surg. 2017, Mar 8 2 Berian JR, et al. Optimizing Surgical Quality Datasets to Care for Older Adults: Lessons from the American College of Surgeons NSQIP Geriatric Surgery Pilot, J Am Coll Surg. 2017 Dec;225(6):702-712.e1 22
Age-Friendly Health Systems 23
Age-Friendly Health Systems Goals of Grant 1) Define essential elements of high quality care for health systems 2) Build on Foundation’s geriatrics models and expertise 3) “4Ms” are indicators of broader shift by health systems to focus on older adults: • What Matters • Medication • Mentation (e.g. cognitive status, confusion) • Mobility 4) Reach 20% of health systems by 2020 (~ 1000 hospitals) 8
Redundant/similar 90 discrete core concepts removed Expert Meeting – features identified and 13 core features Selection of the by model experts in synthesized by IHI “vital few”…the 4Ms pre-work team 9
Core Elements: The “4Ms” • What Matters : Knowing and acting on each patient’s specific health outcome goals and care preferences • Medication : Optimize use to reduce harm/burden, focus on medications affecting mobility, mentation and what matters • Mentation : Focus on depression, dementia and delirium • Mobility : Maintain mobility/function, prevent and treat complications of immobility 10
The Evidence Behind The “4Ms” • What Matters: Asking what matters lowers inpatient utilization ( ¯ 54%), ICU stays ( ¯ 80%), increases hospice use ( 47.2%) - patient satisfaction (AHRQ 2013) • Medication: - Older adults suffering adverse drug event have higher rates of morbidity, hospital admission and costs (Field 2005) - 1500 hospitals in CMS HEN 2.0 reduced 15,611 adverse drug events saving $78m across 34 states (HRET 2017) • Mentation: - Depression in ambulatory care doubles cost of care (Unutzer 2009) - 16:1 ROI on delirium detection and treatment programs (Rubin 2013) • Mobility: - Older adults who sustain a serious fall-related injury required an additional $13,316 in hospital operating costs and increased LOS of 6.3 days (Wong 2011) - 30+% reduction in direct, indirect, and total hospital costs among patients who received care to improve mobility (Klein 2015)
The Partnership: Five Health Systems
Results To Date • More than 50,000 patients have received “Age-Friendly” health care • 5 health systems with 26 sites in 7 states transformed care in the pilot • Groundswell of interest – 400+ organizations on “Friends of Age-Friendly” calls • Over 120 sites in 73 health systems joined the Action Community
Become Part of an “Action Community” • Find out if the health care organizations you work with are involved OR • Take the lead • Go to www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems for background information • Email AFHS@IHI.org and tell them of your interest
So…Why is Understanding “What Matters” Critical to Health Care?
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