Marcus Pierson, MD: Access

The Surprising Shared Care Plan, and what patients and families are doing with it

Sun, 21 Mar 2004 21:50:40 GMT

A few days ago a group of patients and their families talked to Ed Wagner about their experiences in Pursuing Perfection in Whatcom county. Each of these patients had a clinical care specialists and a shared care plan. What I heard changed my thinking.

They described the role of the shared care plan differently than I had expected. As I listened I came to see that for them it was a cultural artifact, an object around which improved conversations can occur. In the doctor's office, a paper copy is used to help the physician or nurse understand where the patient is in their goals and understanding. Likewise this piece of paper helps the patient learn from physician or nurse. They can write down and discuss medical concepts, diagnoses, medications, goals and plans. I heard that without this piece of paper the 15 minutes of an office visit is often confusing and less valuable. I heard over and over that this piece of paper help create a relationship between the doctor and patient that is more like a partnership than a trip to the principles office. One patient's daughter made the cute comment, "Dad is getting kind of uppity. He uses big medical words now." The point I took away is that now he understands the meaning of important medical concepts and that he, with his family and care team, can do a better job of managing his situation with diabetes.

Even more surprising was the story of a family. Before the shared care plan, "Dad, did not want to bother us with his diabetes." Little communication about his needs for special diet, exercise, and medications occurred, due to his desire not to be a burden. Since the daughters and wife have access to his shared care plan, they now print it out and talk together about what they can do to help. They have all changed their diets as they learned to change the cooking for their father. They understand more about what they can do to reduce the chances that they and their children will develop type II diabetes. This simple piece of paper has become the focus of new family conversations that help everyone. It has obviously added meaningfully to the lives of this family.

Something important is happening here. We are discovering with patients how to move beyond business medical records (which help physicians and nurses get the information they need and help insure that they get paid for what they did) toward a shared document about which learning and planning for improved self-care and partnerships can develop.

You can download a Microsoft Word version of the Shared Care Plan from https://www.patientpowered.org/PatientSite/Login.asp and you can look at the on-line electronic version which prints out for those who have assess to it. In Whatcom county, Washington, we are opening up use of the electronic version to patients and their families and caregivers.

For those of you who what to know more about the best thinking for how communities can support their citizens with chronic medical conditions, I recommend the Improving Chronic Illness Care site http://www.improvingchroniccare.org/index.html

Dawn Gauthier reports on Shared Care Plan award

Thu, 20 Nov 2003 22:01:58 GMT

PatientPowered.org wins award!

PatientPowered.org was recently recognized by receiving a silver eHealthcare Leadership Award in the category "Best Care/Disease Management Site". This award was presented by eHealthcare Strategy and Trends at their annual "Leveraging Technology and the Internet" conference ... (click here to read)

From Programs to Movements

Tue, 21 Oct 2003 20:02:03 GMT

The Bureau of Primary Health Care has successfully jump started the 100% Access 0 Disparity movement in America. Spokane, WA area is implementing a similar approch.

There is a summary of the BPHC experience that is very enlightening, if you wish to switch from projects and programs to "movements". I highly recommend reading it if you need to scale up some initiative to include more stakeholders.

A remarkable overview of the journy and the liberating concepts is chronicaled by John Scanlon in "Extrordinary Results on National Goals: Networks and Partnerships in the Bureau of Primary Healht Care's 100%/0 Campaign". The PDF file can be downloaded from THIS LINK on IBM Center for The Business of Government site. The site section is "New Ways to Manage". I agree that it is a real revolutionary way to think about how to manage large scale change.

Advanced Access--a Key to System Improvement

Sat, 20 Sep 2003 21:29:31 GMT

Several doctors at the WA State Medical Society meeting ask for more information on what Advanced Access is. So I put a web page together with some good references. Just click on "web page".

I am skeptical that rapid improvement can occur until most physicians have taken this step. It is a happy circumstance that their profit should increase about 9% and their number of visits should simultaneously decrease about 16%.

Presentation to WA State Medical Society House of Delegates

Sat, 20 Sep 2003 21:12:51 GMT

Yesterday I had the privilege of talking about our Pursuing Perfection initiative with the house of delegates for the Washington State Medical Society. Below I have included to content of my 11 slides and my notes.

PURSUING PERFECTION in Whatcom County, WA

SLIDE 1, TITLE SLIDE:

PURSUING PERFECTION

WHAT'S IN A NAME?

Perfection? ...when things seem pretty bleak. When the pace and complexity of practicing medicine is at this highest yet. When frustration or even cynicism seems ready to overwhelm many. But in a culture that takes the charge "first do no harm" seriously. A culture where each of us carries the desire and burden for faultless care with us each working moment. I suggest that by admitting to ourselves and to the public that we are all in the pursuit of perfect care may allow each of us to get some help. As the Chasm Report points out, the problem is with the system. The system that should help us do the right thing. The problem is not with the effort of doctors and nurses nor with a lack of desire or to do the right thing. The pursuit of perfect care leads directly into systems thinking.

SLIDE 2, OUR JOURNEY

1990 vision
Persistence
Access for uninsured, level 2 trauma system, seamless care?, Whatcom Integrated Delivery System, Community Health Record, Whatcom Health Information Network, Whatcom Community Health Improvement Consortium, diabetes collaborative, registry system
IOM: To Err is Human & Quality Chasm
Pursuing Perfection, Robert Wood Johnson Foundation & Institute for Healthcare Improvement, +16 others

Like many of your communities, cooperation has a long history in the community. Community wide efforts developed access for under-insured OB patients and others including dental patients. The community developed a common sense, yet bold vision to have seamless care and the best outcomes in the state within 10 years (It will happen but it will take 20 years. Who knew?) A series of large-scale initiatives have occurred in Whatcom County. The most audacious effort may be the current P2 initiative to transform healthcare in our community and in the nation.

SLIDE 3, PARTNERS & FRIENDS LOCAL AND REGIONAL
This P2 initiative has caught the imagination of lots of folks.

3000 patients with diabetes & congestive heart failure
Family Care Network
SeaMar Clinic
NorthCascade Cardiology
SJH Center for Senior Health
St. Joseph Hospital/PeaceHealth
Group Health Cooperative
Regence Blue Shield,
Community Health Plans of Washington
Olympic/Sterling/Aon

SLIDE 4, PARTNERS & FRIENDS NATIONAL & INTERNATIONAL

NATIONALLY
Cambridge Health Alliance,
Cincinnati Children?s Medical Center,
Tallahassee Memorial Hospital,
Hackensack University Medical Center,
HealthPartners,
McLeod Medical Center, and
Whatcom County coalition
INTERNATIONALLY
8 communities in Great Britain,
1 in the Netherlands,
1 in Sweden

SLIDE 5, LEARNING

Advanced Access
Patient input into design
We did not have to wait
Collaboration among all sectors
Leadership by physicians for collaboration

So, in this P2 initiative what have we learned to date: a year and a half into it? Doing Advanced Access, in primary care and specialty care, seems to me to be the only thing that can free up people and time to take on the work of redesigning the acute care system into one that provides chronic care. HealthPartners and Jonkoeping County, Sweden point to this conclusion. We have been working with Catherine Tantau, RN. Others have worked with Mark Murray, MD. Patients are of surprising help in redesigning care systems. Their insights are generally lead to simpler and cheaper solutions that we imagine on our own. We could have been doing this 5 years ago. Without working together little will occur. The innovations almost all require cooperation of others beyond your organization. Fortunately the benefits are that diffuse too. Physicians can lead their organizations into cooperation. It will not happen otherwise.

SLIDE 6, 80/20 SYSTEMS THINKING

Baby boomer demographic bulge
Chronic care in acute care system
Winners and losers (modeled)
Collaborators (relationships between parts on behalf of all stakeholders)

There are a lot of things we all consider doing. but which are the most important? The biggest problem and opportunity is heading our way--the aging baby boomers. Chronic care accounts for almost 80% of the healthcare costs and it is going to get higher. If we can effect this dynamic it will have more impact that almost any other change. (Possibly at the same or lower cost for a given population.) We have reviewed the literature on chronic care, we have worked with our patients and our physicians. We have designed a system for patient-centered, community-wide chronic care management. We have modeled the outcomes. We know who the winners and losers are likely to be. Nothing big will happen if the winners don?? help the losers. Medicare, pharmaceutical companies, employers, and taxpayers will need to rethink their roles if the benefits are to be gained and sustained.

SLIDE 7, SOLUTION SPACES

Care management and managers
Navigators and insider advocates for patients
Activated informed patients
Group visits
Shared care plan (electronic and paper versions)
Advanced access
Results based advocacy

Our approach combines community-based care managers (nurses). Improved access to information for patients with DM and CHF and for the members of their care team. There are group visits, web access to tailored information and to a personal medical record called the shared care plan. I now call our previous medical records business medical records, not patient medical records. The shared care plan may be a step toward a real patient medical record. None of the changes are manageable in physician offices or with physician staff until excess capacity for seeing patients and for improvement work is created. Advanced access has this great side effect. Modeling the effects of the changes and getting those affected to participate in the solution is essential. Otherwise it is not sustainable. Medicare (thus Congress), pharmaceutical companies, local businesses and government, and patients as purchasers and voters.

SLIDE 8, INTERESTED PARTIES

Robert Wood Johnson Foundation
Institute for Healthcare Improvement
Medicare (CMS)
Healthcare insurance companies
Our community as well as other communities and healthcare organizations
Other foundations

The work and learning going on in Whatcom County has captured the interest of numerous organizations and communities. Many of whom we are working with. There are now 17 communities or healthcare provider organizations. We are hoping to spread this to Ketchikan, AK. beginning this year. We hope to spread to more of the patients and providers in Whatcom County.

SLIDE 9, COOPERATION

Necessity or preference?
System? ...or only parts?
How? or YES!
Leaders?

Somehow we think this is optional, on an organizational level. We do cooperate as individuals. Our organizations must understand the experience of the patients and design and connect our processes so that they work as a system. Peter Block has written a book called The Answer to How? Is Yes! It is a kind of Nike "Just do it!" attitude. On can delay starting assuming the worst and endlessly asking how, rather than experimenting and working our way forward together, with the patients. A new kind of leader is needed--courageous in collaboration, not in war.

SLIDE 10, MORE?

You may find the details and the tools at these websites. Do feel free to contact me. I put some of what I think on my web log, as do many of the people working in this endeavor.

SLIDE 11, PARTNERS?

Already down this road?
Learn together?
Tipping points?

The Institute for Halthcare Improvement is attempting to spread the learning from Pursuing Perfection communities.
We have time for those who want to transform healthcare locally, in their communities.

Thank you for your time and attention.

Light at the End of the Tunnel for Ideal Office Practice

Sun, 19 Jan 2003 13:32:45 GMT

Here are three new documents on Idealized Design of Clinical Office Practice. Each is well worth the time to read, study, and then implement the ideas and suggestions contained in them.

Microsystems in Healthcare: The Essential Building Blocks of High Performing Systems (Exec. Summary for Health Care Leaders. (PDF file format)

Clinical Microsystems Action Guide (PDF file format)

Putting the Pieces Together--a complete primary care system redesign (PowerPoint file format)

Be patient all three are large files and will take some time to down load. The first two documents are from Dartmouth, the thrid is from Alaska Native Medical Center, an internationally recognized leader in implementation of these innovations. Happy reading. What you learn will prove to be critically important to your business and your persoanl satisfaction with medicine.

Clinical Microsystems resources on line--for clinical workplace improvement

Thu, 02 Jan 2003 17:32:15 GMT

Bill Mahoney sends us a very useful web link: http://clinicalmicrosystem.org/

These folks give us much useful information on clinical work place improvements. Robert Wood Johnson Foundation supports their efforts. There is a strong team involved in the work and tools make available from this site. OD specialists and Process Engineers/Facilitators will find it useful as will folks in clinical work units.

Systems approach to a community's ACCESS to healthcare, a proposal by Gary Hirsch

Sat, 06 Jul 2002 17:37:51 GMT

I'm writing to summarize the approach that I suggested in our phone conversation.

The project we discussed will help to develop an initial, shared understanding of the problems concerning access to health care in Whatcom County. Merely listing the problems and their components is not enough. In examining these problems, we will use elements of the System Dynamics approach to understand the interrelationship of:

· the availability of physicians and other care providers,

· payment patterns and rates,

· the nature and volume of care delivered,

· consequences of that care for the health of the population,

· impact of health status on future demand for care,

· efforts to solve the problems such as physician recruiting, provision of alternative sources of care, demand reduction strategies, and changes in the nature of care that is delivered, and

· effects of all of the above on residents, providers, payors, and employers and responses of each of these groups to the problems.

A System Dynamics approach should be especially helpful because the situation in Whatcom County is not likely to remain static. These interrelationships have the potential for making problems worse over time and for thwarting attempts at solving the problems. For example, delays in receiving care because of limited physician availability may lead to patients having more serious health problems that increase the demand for care, create additional costs that stress individuals, employers, and payors, make existing health care resources even less adequate, and potentially drive overworked providers out of the community. Attempts to solve these problems such as recruiting more physicians may not succeed unless they are coordinated with changes in payment mechanisms and rates and the manner and efficiency with which care is delivered.

Jack Homer and I will work with a group of health care providers and other stakeholders to identify the nature of the problem and its key indicators. We will use System Dynamics diagramming techniques with the group to map causal factors that:

· Create and maintain the problems

· Produce consequences for community health status and costs to residents and employers

· Can help to provide remedies for the problems, and

· Potentially work against those remedies succeeding.

With the group and in analyses afterwards, we will use these maps to:

· Enumerate potential impacts of the problems on various stakeholders

· Identify data required for more extensive analysis and richer set of policy questions to be explored

· Identify potential remedies for the problems including some that might not have been apparent without taking this systemic view, and

· Examine how these remedies might interact and combinations likely to be most effective.

We would meet with the group one additional time to discuss and expand on these analyses and help think through next steps for the community. At this point, we will also be in a better position to determine the value of going further with the System Dynamics approach which could include the development of a simulation model to project the impact of various sets of remedies. The effort we are now proposing would be limited to mapping the causal factors and analyzing the implications of these maps as described above. The results will be preliminary in nature and provide a good context for further analysis and action.

We will limit the costs by "piggybacking" travel on work we are already doing in Bellingham on chronic illness. We will also be alert for potential overlaps between this project and the chronic illness effort in order to avoid any duplication. We estimate that the cost of the project I have outlined above would be in the range of $10,000-15,000 for consulting fees plus any extra travel costs such as extra meals and hotel nights and possibly a share of our air fare.

Please let me know if you have any questions or would like to discuss any aspects of the proposal further.

Sincerely yours, Gary Hirsch [gbhirsch@attbi.com]

There is an access learning group at IHI.

Wed, 26 Jun 2002 03:11:43 GMT

no body included