An ACO Case Study: Quality Improvement in Healthcare

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Quality Improvement in Healthcare:
An ACO Palliative Care Case Study

Learning Objectives
 Using technology-enabled solutions to drive
community engagement
 Driving patient, physician and community
engagement
2
1
Learn how OSF – a Pioneer ACO – is improving
healthcare quality and delivering on the Triple Aim
2
Explore innovative ways to improve care
coordination

Presenters
Dr. Robert Sawicki
Senior Vice President, Supportive Care
Linda Fehr, RN
Division Director, Supportive Care
Roopa Foulger
Executive Director, Data Delivery
2014 IHA Tim Phillip
Award for Excellence
in Palliative Care
Photo
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Poll Questions
4
a. Integrated delivery system – 19%
b. Hospital – 15%
c. Physician Group – 3%
d. Other – 62%
1 How are you involved in healthcare? 146
respondents
2 What is your role? 166 respondents
a. Management – 37%
b. Quality Improvement – 15%
c. IT – 19%
d. Consultant – 29%

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OSF and the Triple Aim
5

OSF Healthcare
6
93
Locations
667
Providers
1.5M Patients annually
185K Home Health annually
267 Hospice daily census (avr)
Visits

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OSF Mission

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OSF ACO “Triple Aim”

OSF Triple Aim & IOM Six Aims
for Improvement
9
OSFTripleAim
Institute of Medicine
(IOM) Six Aims for
Improvement
 Safety
 Effectiveness
 Efficiency
 Patient-Centered Care
 Timeliness
 Equitable

Poll Question
On a scale of 1 to 5, with 5 being the highest, how
would you rate your healthcare organization’s
progress on achieving the Triple Aim and the IOM Six
Aims for Improvement? 133 respondents
10
1 2 3 4 5
9% 21% 44% 23% 3%

Palliative (Supportive) Care
Palliative care is
specialized medical care
for people with serious
illness. It is provided by a
team of doctors, nurses
and other specialists who
work with a patient’s other
doctors to provide an extra
layer of support and is
appropriate at any age,
any stage in an illness and
can be provided together
with curative treatment.
11
Palliative
Care

The Why of Supportive Care
“It’s always too early, until it’s too late” *
What does Advance Care Planning mean to patients?
 To understand, discuss and record plans for a future scenario
when they cannot make their own medical decisions
 To feel confident that their end-of-life care preferences will be
honored
Who is Advance Care Planning appropriate for?
 All of us, ideally, but especially chronically ill patients
Why is Advance Care Planning important?
 To provide higher quality end-of-life care that honors patients'
values, goals, and preferences
12
*Source: Dr. Lachalan Forrow

Advance Care Planning
13
Durable
Power of
Attorney-
Healthcare
(DPOA-HC)

Poll Question
Does your healthcare organization have a palliative
(supportive) care program? 160 respondents
a) Yes – 36%
b) No – 14%
c) Unsure or not applicable – 50%
14

Improving the Quality of Care
2014 IOM Dying in America Report
Key Objectives
 Evaluate end-of-life care strategies
to integrate patient- and family-
centered framework
 Recommend options for aligning
care with values, preferences and
beliefs to promote high quality cost
effective care
 Offer a communication strategy to
promote public engagement
15

IOM Findings
 Financial incentives are
misaligned with patient desires
 Major reform is needed to ensure
higher quality, affordable, and
sustainable end-of-life care
 Chronic conditions and functional
limitations are key drivers of high
health care costs
 Increased health care spending
is not associated with higher-
quality care
16
An estimated 13 % of
$1.6 T in healthcare costs
is for the care of
individuals in their
last year of life*
*Source: Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life © 2014
13%

IOM Recommendations
 An early palliative care approach affords the
highest quality of life
 Improve quality and availability of medical and social
services
 Early and continuous conversations with patients
on advance care planning
 Advance care planning should be paid for by
government and private health insurers
 Improve alignment of financial incentives with patient
desires
17

NEJM Study: Benefits of
Palliative Care
Source; Temel, J.S., et al. (2010). Early palliative care for patients with metastatic non-small cell lung cancer. NEJM. 363, 733-742.
18
Median survival was
longer among patients
receiving early
palliative care
(11.6 months vs. 8.9
months, P=0.02)
Improve-
ments in
quality of
life
Fewer
depressive
symptoms

Additional Research Findings
Int J Crit Illness Inj Sci (2012): Advance Directives in the trauma ICU*
 Advance directives, when approached in the
conventional way, have limited utility
 They are not helpful in improving care quality, improving
patient/family satisfaction, or lowering costs
 A DPOA-HC does not capture the patient’s values and
preferences
 Advance care planning does
 Help better ensure patients’ desires are respected
 Reduce caregiver stress and symptoms of post-traumatic
anxiety and depression
 Help family members feel more peaceful and satisfied that
their loved one’s wishes were acted upon
19
*Source: “Advance directives in the trauma intensive care unit: Do they really matter?” Int J Crit Illn Inj Sci. 2011 Jul-Dec; 1(2): 132–137

Poll Question
On a scale of 1 to 5, with 5 being the highest, how
well do you think your healthcare organization
understands the value of advance care planning?
20
1 2 3 4 5
7% 25% 35% 24% 9%

Using Innovation to
Improve Care Coordination
21

High Risk Patients: Project
Goals
 Understand and align patients’ value system with their healthcare
goals
 Leverage the OSF supportive care program in a community-wide
initiative
 Dramatically increase the number of patients completing advance
care planning
 Drive the engagement of clinician, employees and facilitators to help
patients complete advance care planning
 Provide optimized care coordination for patients
 Quickly deploy a solution that could be used by all individuals who
were engaging with the patients to document their conversations,
advance care plan and DOPA-HC
 Provide real-time customized reporting to track targets versus goals
22

The Importance of Care
Coordination
23
Outpatient
Home
Clinic care Hospice
Skilled
nursing
facility
Inpatient
Home health
care
Care
Coordination
Community outreach
and education

Improved Quality of Life and
Care Coordination
24
Pain
Shortness of breath
Fatigue
Constipation
Nausea
Loss of appetite
Difficulty sleeping
Depression
Improve quality of life
Emotional support
Spiritual support
Doctor
Nurse
Social Worker
Chaplain
Physical therapists
Music & art therapists
Home health aides
Treatment options
Improve quality of
life
Emotional support
Spiritual support
Help navigating the
system
Smoother care
transitions
Source: Center to Advance Palliative Care © 2012
Family/
caregiver support
Pain & symptom
controlSupport for patient
Team approach:
Communication &
Coordination

Technology-Enabled Solutions to
Drive Community Engagement
Custom reporting
(supportive care team,
clinicians, executives)
EDW
Platform
Identification of
high risk patients
 Community enters data into an
easy to use, accessible
database
 Supports heterogeneous EHR
environments
 Deployable in days
Advance care planning
information is integrated
into the OSF patient EHR

Driving Engagement
 Physicians, care providers, facilitators, employees
were trained to…
 Initiate the conversation
 Identify the patients’ values
 Translate the patients’ values into medical decision making
 Document the patients’ stated preferences for care
 Co-sponsored “Considering the Conversation”
screening with 2 large hospital systems
 Developed a healthy competition with accessible,
customized reports
26

Outcomes
27

Outcomes
Outcome Targets Actuals
Number of high-risk patients
who had completed advance
care planning
1200 1243
Total number of patients who
completed advance care
planning
4,300 in 2014;
16,000 to date
Number of engaged
physicians, nurses, parish
nurse facilitators, employees…
980
One common database to
enable tracking and reporting
 Easy-to-use
 Accessible for OSF and
community-wide
patients and individuals
 Rapid deployment
 Easy-to-use interface
 Supports heterogeneous
EHR environment
 Deployed in days
Timely, customizable reporting
 Facilitator reporting,
identifying high-risk patients
 Customized reports
(supportive care, clinicians
and executives)
28

Patient Perspective
29
“I didn’t expect to need palliative care services
so soon. But this summer I underwent cancer
surgery. It was a huge relief to know my advance
care planning was already done — and that my
desires were understood by my family members.
I’ve told everyone about the palliative care
services OSF provides and how grateful I am for
their community wide service.”
- Oncology patient

What’s Next
30

Future Goals
 Expand advance care planning discussion targets to non-
high risk patients
 Continue to drive employee and employee family member
engagement in their own advance care planning
 Ensuring patients wishes are met
 Compare desired versus actual treatments
 Correlate how well the patients’ care goals were met and
the timing of the advance care planning discussion
 Analyze readmissions rates for patients with advance care
plans, versus those without advance care plans
 Evaluate the number of referrals to patients with advance
care plans who are referred to hospice
31

Concluding Reflections
32
Palliative care
improves the quality of
life for the patient
It is a team-approach to
care that addresses the
patient and family’s
physical, emotional and
spiritual needs
Palliative care is
integral to
healthcare
organizations
meeting the Triple
Aim

An ACO Case Study: Quality Improvement in Healthcare

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