Transcript Patient Engagement

Patient Engagement in
Medicaid Populations
Nancy L. Rothman, EdD, RN
Consultant/PHMC Nursing Network
Independence Foundation Professor of Urban Community Nursing
Dept. of Nursing, CHP and SW, Temple University
Bureau of TennCare
Qsource
September 11, 2013
Objectives for presentation:
At the end of the session, learners will be able to
 Describe the concept of patient engagement in health
care.
 Synthesize from the National Committee on Quality
Assurance and the Joint Commission patient-centered
medical home models the importance of patient
engagement.
 Evaluate patient engagement approaches for use with
Medicaid populations.
Patient Engagement
 Is a process of patients
 The Wagner Chronic Care
becoming invested in their own
care.
 Develops with conversation
between patients and providers
and patients setting their own
self-management or self-care
goals.
 The role of the patient is no
longer that of a passive recipient
of care.
model suggests engaged
activated patient have improved
quality measures.
 Harvard Business and Medical
Schools June, 2013 Healing
Ourselves Conference,
addressing healthcare’s
innovation, cites “making
consumerism really work” as a
key imperative to improving
health care quality and cost.
Recent Payer, State and Federal
Initiatives promote Patient Centered
Medical Homes (PCMHs), providing:
 Whole-person focus
 Long-term provider partnerships, not sporadic, hurried
visits
 Provider-led teams coordinate care, especially
prevention/chronic conditions, plus other providers’
care, community support
 Enhanced access and patient engagement
Benefits of PCMHs:
Improved health care value
 Higher quality, lower costs preventing the need for hospital
and ER admissions
 Quality Gains And Cost Savings Through Adoption Of Medical Homes,
Fields, Leshen, Patel, Health Affairs, May 2010
 Improved satisfaction – patients & clinicians
 Patient-Centered Medical Home Demonstration, Reid et al, American
Journal of Managed Care, September 2009
Update on initiatives promoting
PCMHs:
 The benefits have caused states, e.g. the PA Chronic Care
Initiative, to require participating primary care practices to
become and remain NCQA recognized PCMHs.
 However, Medicaid payers in PA who participated in the PA
Chronic Care Initiative, have left or announced that they
are leaving and providing their own pay for performance
plans.
 HRSA is providing funding to FQHCs to achieve PCMH
status under NCQA or TJC.
Two PCMH Options
National Committee for Quality
Assurance (2008, 2011)
Patient Centered Medical Home
Recognition
Three levels
Submit documentation on-line
Delivery site specific
3 years
The Joint Commission (2011)
Patient Centered Medical Home
Certification
No levels
On-site survey
Entire organization
3 years
Voluntary expansion of
ambulatory care certification
NCQA PCMH Standards 2011
Core components
Must pass elements
 Enhance Access and Continuity
 Access during office hours
 Identify and Manage Patient
 Use data for population




Populations
Plan and Manage Care
Provide Self-Care and
Community Support
Track and Coordinate Care
Measure and Improve
Performance
management
 Care management
 Support self-care process
 Track referrals and follow-up
 Implement continuous quality
improvement
The Joint Commission PCMH
Standards
 Patient-centered care
 Comprehensive care
 Coordinated care
 Superb access to care
 A system-based
approach to quality and
safety
 Patient can select their
CPC, consideration of
patient’s cultural,
linguistic and
educational preferences,
patient involvement in
treatment, support for
self-management
Nurse-Managed Health Care Home
Effectiveness Project
 Evaluating nurse-led primary
care in NCQA recognized
Patient-Centered Medical
Homes with CRNP and RN Care
Manager teams
 In two primary care clinics in
public housing
 African American women 18-60
years of age diagnosed with
diabetes, hypertension,
hyperlipidemina or at risk due to
a BMI > 30; n-116
Public Health Management
Corporation Nursing Network
PHMC Health Connection
Rising Sun Health Center
Pre-intervention
patient focus groups:
 Expressed confusion and concern about medication use, diet and self
management of diabetes.
 “I am on two medications for my blood pressure and three for my diabetes.
It is back and forth, back and forth trying to get the results they want.”
 “You have to stay stable; you have to eat breakfast on time and you have to
eat between meals.”
 Stressed difficulty adopting a diet that would allow them to lose weight
or maintain a better blood sugar level.
 “Sometimes I get nervous, like when I don’t eat…I realize my sugar is low…it
can go under 70 , that’s when I feel it.”
 Indicated family support was important to their efforts to take
medication, eat better and try to be physically active.
 “I love junk food, but my husband does not let me eat it.”
 “My granddaughter or daughter will call me and ask, Nana did you take
your medicine?”
 Identified the areas of self-care management with which they needed
assistance to improve their health outcomes.
 “It is easy for them to tell you what you need to do, but hard for you to do
it.”
 “Eating right, exercising , reducing stress…”
 “Some of the pills make you nauseous and/or sleepy.”
Intervention:
RN Care Managers Coached Patients
on their selected self-management goals
 Reducing stress
 Exercise
 Nutrition
 LDL
 Smoking Cessation
 Blood Pressure
 Statistically significant increase
in self-management goals
related to stress, exercise and
nutrition (p=>.0001)
 Statistically significant decrease
in LDL and number of cigarettes
smoked (p=>.0o01) at 12 months
 Statistically significant decrease
systolic and diastolic blood
pressure (p=>.0o01) at 18
months
Examples of Self-Management Goals
 Wish to increase exercise
for improved
cardiovascular health – I
will get off the bus two
stops earlier on my way to
and from work.
 Nutrition related to desire
to loose weight – I will
replace sugary drinks, both
juice and soda, with water
and unsweetened tea.
Outcome Measures
 Body Mass Index
 Hemoglobin A1C
 Clinically significant
reductions in BMI (40%)
and A1C (25%), but not
statistically significant
SF 12 Outcome Measures
 Medical Outcomes Short Form measures perceptions
of the patient’s own health to include: general health,
physical functioning, bodily pain, vitality, social
functioning, role limitation physical, role limitation
emotional, physical health and mental health.
 Subjects had statistically significant positive changes
in bodily pain, role limitation emotional and mental
health.
Post-intervention
patient focus groups:
 Expressed better understanding of medication use, diet and self
management of diabetes, hypertensions and lipid levels because RN
Care Manager took time with them and helped patients to set monthly
goals.
 “Because I didn’t have a clue what was going on with being a diabetic and
you really took time out to help me.”
 “You helped me out with my smoking. I am down to half a pack per day.”
 Meeting one on one with RN Care Managers provided very personal
individualized assistance in taking small steps to improve their health
over time.
 “My cholesterol is really good. Like I was shocked when my heart doctor
told me it was perfect because it was sky high.”
 “Yeah, me with the junk food and I stopped. I drink water and I eat alot of
vegetables and fruit.”
 Both parents and children supported patients efforts to take
medication, reduce their stress, eat better, decrease or stop smoking
and to be more physically active.
 “All of my family stopped smoking.”
 My mother started buying more healthy stuff for the house.”
 RN Care Managers and clinic staff are encouraging and caring, when
you have insurance and when you do not.
 “I love this clinic and program, because a few months ago my insurance ran
out. No one would provide my medicine but here the nurse practitioner
went to the back and gave me some. ”
 “The RN Care Manager is very dedicated and sincere. I feel it is more than
just a program to her.”
Challenges
 African American Women in the study were: Residents of
public housing or homeless
 Uninsured or had Medicaid insurance
 Auditing the records of the low income women in this
study provides a continuing context for understanding the
complexity of their lives, primarily related to exposure to
infectious diseases (STDS and TB), violence, physical
abuse, emotional abuse, substance abuse, loss of
employment and homelessness.
Success and Future Direction
 In spite of the complexity of their lives, the women
responded positively to selecting their own selfmanagement goals and being supported with
individualized coaching from RN Care Managers.
 Public Health Management Corporation, owner of these
two nurse-led NCQA recognized PCMHs, is committed to
continue to provide support for patients to meet their
selected self-management goals.
Acknowledgements
Project was conducted in collaboration with:
the National Nursing Centers Consortium; and
the American Nurses Association and Pfizer, Inc.
who also in part provided financial support for
the study.
Shared Decision Making:
Better Decisions Together
2009
•Ann Torregrossa,
(Director of PA Governor’s
Office of Health Care Reform)
•Nancy Rothman
•Seek support from the
Informed Medical Decisions Foundation and
Health Dialogue for:
•Supply of decision aids
•Support for project from Foundation Staff
•Richard Wexler, MD
2010
•Local planning and implementation of project at
5 nurse practitioner practices
( all were participating in the Governor’s
Chronic Care Initiative)
Decision aids viewed in centers
Or sent home ( to mail back)
Referral sheet faxed from centers
•Patient name and contact information
•Name of decision aid(s)
•Permission to contact patient
•Pre-viewing surveys
Director of Patient Support Strategies
• Kate Clay, MA, BSN, RN
•Post-viewing surveys
Office of Professional Education and Outreach
The Dartmouth Institute of Health Policy and Follow-up with a nurse practitioner
Clinical Practice
•In person
•By phone
•Answer questions
•Clarify values related to decision
•Help support a decision related plan
2011, 2012, 2013
Decision aids viewed in centers
Or sent home ( to mail back)
Referral sheet faxed from
centers
•Patient name and contact
information
•Name of decision aid(s)
•Permission to contact patient
•Pre-viewing surveys
•Post-viewing surveys
Coaching by on-site
RN Care Managers
•In person
•By phone
•Answer questions
•Clarify values related to
decision
•Help support a decision related
plan
•Posters were placed in the waiting
rooms as well as other locations in all
of the participating clinics.
•Corresponding brochures with a
short description of each decision aid
were provided to be handed out either
in the waiting room or by providers
in the exam rooms.
•Decision aids have been added.
Descriptive Statistics
Gender
Education
Race
Age
59% Male
77% HS Grad or <
82% Black
59% 18-49
(non-Hispanic)
41% Female
23% > than HS Grad
17% Hispanic
(any race)
1% White
(non-Hispanic)
33% 50-59
6% 60-69
2%
70+
Diabetes Only
Pre-Viewing Health Info
at Temple vs Other Demo Sites
 Temple (n=35)
 Other Demo Sites (n=292)
Diabetes Only
Post-Viewing Total Taking or Planning to Talk About
Medications at Temple vs Other Demo Sites
Cholesterol
Meds
Blood
Pressure
Meds
View availability of decision aids as an
enhancement to patient engagement
 Recently added decision aids to job descriptions of RN
Care Managers and Medical Receptionists.
 Performance evaluations include goals for increasing
distribution of decision aids.
 Had a visit in Fall 2012 from MedPAC staff who
interviewed patients and staff and reported positively
on our use of decision aids to the Commissioners.
Time for others to share examples of
patient engagement
Contact information
 Nancy L. Rothman
 215-707-5436
 [email protected]