Ellis C Dillon

An evaluation of two interventions to enhance patient-physician communication using the observer OPTION5 measure of shared decision making

OBJECTIVE Evaluate interventions to enhance patient-physician communication and shared decision making (SDM). METHODS We used Observer OPTION5 to evaluate primary care visits within a cluster randomized controlled trial in a California delivery organization. Trial interventions included Open Communication (OpenComm), combining patient activation and physician coaching, and AskShareKnow, a patient activation tool, and were compared to a usual care arm. Scores were analyzed with descriptive statistics and generalized estimating equation analysis for 40 visits containing 200 decision topics. RESULTS The mean overall OPTION5 score was 26.5 out of 100 (s.d.=15.2). Compared to visits in the usual care arm, OpenComm visits had higher mean item scores (0-4 scale) for eliciting (mean=1.0 vs 0.8) and integrating patient preferences (mean=1.0 vs 0.8). OpenComm and AskShareKnow visits had higher scores for presenting options (mean=1.5, 1.5 vs 1.3). AskShareKnow visits had higher scores for discussing pros/cons (mean=1.5 vs 1.1). Lower patient education attainment was associated with lower scores. CONCLUSIONS OpenComm and AskShareKnow were associated with improved SDM relative to usual care. PRACTICE IMPLICATIONS Results suggest targeting patient and physician behaviors promotes SDM better than patient activation only. Improving SDM for less educated patients is crucial.

Provider Perspectives on Advance Care Planning Documentation in the Electronic Health Record: The Experience of Primary Care Providers and Specialists Using Advance Health-Care Directives and Physician Orders for Life-Sustaining Treatment:

Context: Advance care planning (ACP) is valued by patients and clinicians, yet documenting ACP in an accessible manner is problematic. Objectives: In order to understand how providers incorporate electronic health record (EHR) ACP documentation into clinical practice, we interviewed providers in primary care and specialty departments about ACP practices (n = 13) and analyzed EHR data on 358 primary care providers (PCPs) and 79 specialists at a large multispecialty group practice. Methods: Structured interviews were conducted with 13 providers with high and low rates of ACP documentation in primary care, oncology, pulmonology, and cardiology departments. The EHR problem list data on Advance Health Care Directives (AHCDs) and Physician Orders for Life-Sustaining Treatment (POLST) were used to calculate ACP documentation rates. Results: Examining seriously ill patients ≥65 years with no preexisting ACP documentation seen by providers during 2013 to 2014, 88.6% (AHCD) and 91.1% (POLST) of 79 specialists had zero ACP documentations. Of 358 PCPs, 29.1% (AHCD) and 62.3% (POLST) had zero ACP documentations. Interviewed PCPs often believed ACP documentation was beneficial and accessible, while specialists more often did not. Specialists expressed more confusion about documenting ACP, whereas PCPs reported standard clinic workflows. Problems with interoperability between outpatient and inpatient EHR systems and lack of consensus about who should document ACP were sources of variations in practices. Conclusion: Results suggest that providers desire standardized workflows for ACP discussion and documentation. New Medicare reimbursement for ACP and an increasing number of quality metrics for ACP are incentives for health-care systems to address barriers to ACP documentation.

Measuring the Impact of Patient-Engaged Research: How a Methods Workshop Identified Critical Outcomes of Research Engagement

Purpose While strategies to evaluate the influence of engaging patient partners in research, such as the Patient-Centered Outcomes Research Institute (PCORI) WE-ENACT surveys, are beginning to emerge, a systematic set of measures for assessing the impact of patient engagement in research (PER) on study approaches and outcomes is lacking. This article describes a workshop and process used to identify and develop Critical Outcomes of Research Engagement (COREs). It proposes preliminary measures for assessing the impact of PER on the research process and outcomes of research studies. Methods A group of 24 researchers and 5 patient partners participated in a PCORI-funded workshop designed to identify key research outcomes and corresponding measures to evaluate the impact of patient-engaged research on those outcomes. Interactive group discussion and synthesis by workshop attendees led to a proposed set of core components of patient-engaged research by each stage of a research study as well as some overarching principles. Postworkshop discussions further distilled the output and considered potential gaps. Results CORE components identified were: patient-centered, meaningful, team collaboration, understandable, rigorous, adaptable/integrity, legitimate, feasible, ethical and transparent, timely, and sustainable. Existing measures skew more toward measuring the process of engagement and less toward measuring downstream outcomes of patient-partner engagement in all phases of research. Conclusions Next steps include finalizing measures, pilot testing them with the workshop participants, and building a larger community of practice to further advance this work. The new community plans to create a measurement tool and conduct a study to validate the measures.

How home hospice care facilitates patient and family engagement

ABSTRACT Little is known about how patient and family engagement manifests in home hospice care. This qualitative study included interviews and observation of home hospice care with 18 patients, 11 caregivers, and 26 hospice workers in the United States. Structural factors (e.g., home setting, ample time, personal relationships), hospice worker strategies (e.g., patient education and presenting choices), and family member support facilitated engagement. Barriers to engagement included difficult relationships and unavailable or unwilling family members. Home hospice care demonstrates potential strategies for continuous, informed, and holistic engagement. These engagement strategies may translate to other arenas of health care.

Cost Estimates for Designing and Implementing a Novel Team Care Model for Chronically Ill Patients

Little is known about the cost of implementing chronic care models. We estimate the human resource cost of implementing a novel team-based chronic care model “Champion,” at a large multispecialty group practice. We used activity-based costing to calculate costs from development through rollout and stabilization in 1 clinic with 12 000 chronic care patients. Data analyzed included Microsoft Outlook meeting metadata, supporting documents, and 2014 employee wages. Implementation took more than 29 months, involved 168 employees, and cost the organization

Community-Based Palliative Care and Advance Care Planning Documentation: Evidence from a Multispecialty Group.

2 304 787. Payers may need to consider a mixed-payment model to support the both implementation and maintenance costs of team-based chronic care.

B3-2: Re-conceptualizing Medical Decisions: How Home Hospice Care Fosters Patient and Family Engagement and Decision-making

With the growing public demand for access to critical health data across care settings, it is essential that advance care planning (ACP) information be included in the electronic health record (EHR) so that multiple clinicians can access it and understand individuals’ preferences for end‐of‐life care. Community‐based palliative care programs often incorporate ACP services. This study examined whether a community‐based palliative care program is associated with digitally extractable ACP documentation in the EHR.

Enhancing Shared Decision Making Through Carefully Designed Interventions That Target Patient And Provider Behavior

Background/Aims Despite growing acceptance that patient engagement and shared decision-making should be goals of medicine, organizational attempts to support these ideals are limited and larger institutional structures often constrain patient autonomy. Home hospice care is a subset of medical care that has consciously developed a philosophical and practical approach to encouraging patient and family engagement. This research examines how home hospice care provides a different strategy for improving patient engagement and shared decision-making. Methods This ethnographic study draws on a sample of 55 home hospice participants, including patients, family members/caregivers, staff, and volunteers, and uses in-depth interview and observation of home hospice work to examine the process of providing and receiving hospice care. Results I find that macro level hospice institutional structures and micro level daily work practices embody a holistic approach which assumes patients and family members are the critical experts in most instances of decision-making. Differences in institutional structure, such as providing care in patient homes and having an interdisciplinary team approach focused on the “whole person”, empower the patient and family members. Likewise the micro level interactions between hospice workers and patients and family members narrow the field of purely “medical” decisions and broaden the field of decisions open to patients. Hospice workers accomplish this re-conceptualization by framing many medical decisions as being more about what is best for the patient and family and less about medical expertise. Conclusions By broadening and re-conceptualizing the idea of decision-making, hospice workers enable patients and their families to have more control over their medical care and in many cases the process of dying itself. While some attributes of home hospice care are unique, many techniques could be introduced or accentuated in other models of medical care.