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SESSION #19The Patient’s Power in Improving Health and Care
Maureen BisognanoPresident Emerita and Senior Fellow
IHI
The Patient’s Power in Improving Health and CareHealthcare Analytics Summit 2017
September 14, 2017Salt Lake City, UT
Maureen BisognanoPresident Emerita andSenior Fellow
Our Shared Challenges3
• Across the world, we’re facing significant financial constraints, the aging of the population, and the increasing burdens of chronic disease.
• We’ll need to move to the Triple Aim of improving the experience of care, improving the health of the population, and lowering per capita costs.
• “More and faster” won’t get us there…we need new ways to think about care.
• Many answers here in this room… “all teach, all learn”.
Flipping the Classroom5
• The students’ results flipped in every grade.• In every class, failure rates dropped.• Graduation rates rose to over 90%• College attendance rates rose from 63% to 80%• Most important, the “flipped classroom” closed the gap
between the students from socio-economically challenged families and their peers
• It helped teachers identify the “silent failers” (the students most in need) and then work with them in the classroom
From
“Sage on the stage”to
“Guide on the side”
IHI Triple Aim7
What’s the matter?
What matters to you?
Barry MJ, Edgman-Levitan S. ”Shared Decision Making – The Pinnacle of Patient-Centered Care.” N Engl J Med. 366;9. pp 780-782
Move from
dis-easeto
health-ease
The Next “Blockbuster Drug”10
Patient Engagement11
• Patients in a coordinated care setting (focused on engagement) have an 88% reduced risk of dying of a cardiac-related cause when enrolled within 90 days of a heart attack compared to those not in program
• Clinical care teams reduced overall mortality by 76% and cardiac mortality by 73%
• “Imagine what the headlines would be if a new cardiac drug showed this kind of effectiveness? It would be malpractice not to use it!”
Source: Leonard Kish. HL7 Standards Blog. 8/28/12. available at: http://www.hl7standards.com/blog/2012/08/28/drug-of-the-century/
Trevor12
Video: http://www.youtube.com/watch?v=cMGgoInt1Mo
Trevor’s Definition of Health13
• “Energy to do all I need”
• “College life is hectic, the schedule is unpredictable, so being able to predict and control my health and energy…I can thrive”
What Trevor Needs from Health Care14
• No surprises• Straight answers• Advice• Easy access
– He’d love to be able to email in questions, but when I asked about texting, he said he thought he could, “cut the old people some slack.”
– He thinks they might need more time before technology is fully optimized in daily care.
Trevor’s Dream15
• A strong bond with doctor and care team• Ability to express a concern or ask a question
and get straight answers and advice• Would love to “FaceTime” visits – sees the future
as human connections and continuous communication
• All without going to the office
Poll Question #1
What percent of your young patients are like Trevor (prefer to manage their own health and care)?
a) 0%-25%b) 26%-50%c) 51%-75%d) 76%-100%
5000Hours
Source: Asch DA, et al. “Automated Hovering in Health Care – Watching Over the 5000 Hours.” New England Journal of Medicine. July 2012: 367(1).
The Cost of Diabetes18
• Complications are costly…– …in human terms– …in disability terms– …in dollar terms– …and in terms of hospital utilization
Change the Balance of PowerThe Old Way• Ryhov Hospital in Jönköping had traditional hemodialysis
and peritoneal dialysis center.• But in 2005, a patient, Christian, asked about doing it
himself.
The New WayChristian taught a 73-yr-old woman how to do it…
…and they started to teach others how to do it.
• Now, they aim to have 75% of patients to be on self-dialysis
• They currently have 60% of patients
The New Way
• From Anette (nurse leader):– Surprised at design differences between patients,
family, and staff– Managing at 1/2 – 1/3 less cost per patient– Evidence of better outcomes, lower costs, far
fewer complications and infections– “We brought in the county’s employment, helped
the patients make or update the CVs, and trained them for a new career.”
Lessons to Date
Update• Now calculated costs at 50% of costs in other hemo-
dialysis units
• Complications dramatically reduced and subsequent expensive care avoided
• Measuring success by “number of patients working”
Successful Spread - Waco, Texas26
Comparison of In-Center Self-Care Hemodialysis to Non-Self Care
27
Employment rate: 26% vs 7% in a facility within the
same building
Edward R Jones, MD, MBA, Medical Director, Self-care FMC Mt Airy Phila.
My Dialysis, My Choice• The patient starts by selecting a
few values that matter most to them when choosing a treatment plan
• Then detailed information is provided to help the patient rate treatment options according to how well they match each chosen value
29
mydialysischoice.org
My Dialysis, My Choice• Based on the patient’s rankings on each value, the
results are compiled to help them decide which dialysis treatment option is best for their lives and health
30
mydialysischoice.org
All Aspects of Care31
• If we can flip care to coordinate all aspects of care – physical, social, functional, emotional, and safety – we can prevent hospitalizations, improve the quality of life for millions, and save millions.
Centering Pregnancy32
Boston Medical Center
Norah34
• Young woman from Boston – 24 weeks pregnant with her first child.
• Her husband is still back in Nigeria and she’s hoping he’ll be here for the birth.
Centering Model35
• Norah, like all the young women who participate in the group visit, takes her own vital signs, weighs herself, and enters all the info into her record.
• She shares the record with the physician and midwife – it’s flipped! – and then moves to the back of the room to be examined before the group portion of the visit begins.
• While the exams are conducted, there is a lot of chatter, a lot of questions asked and advice given, and a lot of relationship-building.
What Matters to Norah36
“I’m very afraid of labor. I’m terrible with pain. I’m scared. I don’t think I’ll be able to do it.” The midwife said, “those of you who have had babies before, what advice do you have for Norah?”
– Relaxed– Ice cubes– Confidence
Centering Results37
• Reduced the risk of preterm birth by 33%1
• Reduces Racial Disparities for Preterm Births– Hispanic women in Centering demonstrated lower preterm
birth rates than those in traditional care models (5% vs. 13%)2
– Reduced the odds of preterm births by 41% in African American women3
• Nearly twice the number of Centering Healthcare participants breastfed (46%) than those in a comparison study (28%)4
1Ickovics, et al. Obstetrics and Gynecology, 20072Tandon, et al. J. Midwifery & Women’s Health, 20123Ickovics, et al. 20074J of Midwifery & Women’s Health, 2004
What If We Flipped the Patient Discharge Process?
38
Link
Reablement- Oslo Kommune• Interprofessional team who are the first to meet with new
patients in need of home-based care– occupational therapists– physiotherapists– nurses – social workers
• Work towards independence and mastery of everyday life, transitioning patients to either: - discharge without need of further healthcare, or- home-based care with the best possible function
39
Thomas Lystad
Reablement- Oslo Kommune• Assess the needs of the patient:
– Interests– Resources– Limitations– Current function– Goal– Plan
• Assessment of the care and adaptation of the plan is ongoing• Goal: transfer or discharge the patient when we have achieved best
possible function and a stable need for healthcare
40
Thomas Lystad
JarleHistory:
– 70 year old man with COPD, type 2 diabetes, and two previous heart attacks
– Suffered a major stroke, and spent a month in the hospital
– Left side paralysis, poor cognitive and physical function
41
Thomas Lystad
Began prescribed reablement program, which was continuously reassessed; made good progress and entered health rehabCame back to reablement after challenges; they helped him find a new, more accessible apartmentNow largely independent, and needs a wheelchair only for long distances
Flipping Health Care43
• Flip the balance of care – from the hospital to the community
• Flip the balance of delivery – from individual providers to care teams• Flip the balance of power – from the provider to
the patient and family• Flip the balance of costs – from treatment to prevention and co-
production• Flip the balance of emphasis from volume to value; and from health
care to health
The Importance of Curiosity44
• IQ – Intelligence Quotient–processing complex data sets and having the mental capacity to problem solve at speed
• EQ – Emotional Quotient–the ability to perceive, control and explain emotions; risk-taking, creating resilience and empathy
• CQ – Curiosity Quotient–inquisitive, open to new experiences, finding novelty exciting
Chamorro-Premuzic T. “Curiosity Is as Important as Intelligence.” Harvard Business Review. Aug 27, 2014.
Innovation-Spread-Exnovation45
Innovation• Where are care models and processes broken?• Where do we need new thinking?
– Innovation labs, design processes– Harvesting
Spread• Where do we see variation in performance?• How can we reliably spread to ensure that we can provide the best care to every patient, where they are?
– Transparent data– Curiosity – Spread Model
Exnovation• How do we stop what doesn’t work anymore?• How will we eliminate wasteful practices and processes? It takes courage!
Poll Question #2
Do you have a CEO- “Chief Exnovation Officer”?
a) Yesb) No
46
Thank you!Maureen Bisognano
President Emerita and Senior FellowInstitute for Healthcare Improvement20 University Road, 7th FloorCambridge, [email protected]
