Patient Priorities Care: - PowerPoint Presentation

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Patient Priorities Care: Moving from Disease-Based to Patient Priorities-Aligned Decision-Making

Mary Tinetti, MD, Professor of Medicine and Chief of Geriatrics, Yale School of MedicineCaroline Blaum, MD, MS, Director, Division of Geriatric Medicine and Palliative Care, NYU School of MedicineMary Tinetti: @GoalsDriveCare Caroline Blaum: @CBlaumMDPPC: @PtPriorities PatientPrioritiesCare.org

@

PtPriorities

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What is Patient Priorities Care?

Moves decision-making & conversation from:

From

: You need (

fill in treatment

) for your (

fill in disease

)

To

:

“Knowing all your conditions, your overall health, and your health outcome goals and care preferences, I suggest we try (

fill in treatment option

).

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Patient Priorities Care

Is Not:

A new care model or treatment

Not limited to any care setting, disease, or health status

Is:

Approach to helping patients & clinicians make decisions aligned with what matters most to each patient

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Patient Priorities Care

Member of health team helps patients identify their health priorities

Clinicians align their care with achieving these health priorities

Health priorities = each patient’s specific

health outcome goals

given their specific

care preferences

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What are health outcome goals?

Health & life outcomes most desired

“

SMART” goals

(e.g. Babysit grandson 3 times/week; walk 2 blocks to poker game

Distinct from behavioral goals such as stop smoking or disease goals such as A1c or BP)

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Examples of Health Outcome Goals

…babysit my grandchildren each day to help my daughter while she works

…be able to work outside in garden and push a wheel barrel – fatigue makes this difficult

…do ceramics again and walk ½ mile with my husband everyday—tiredness makes this difficult

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What are care preferences**?

Health care utilization

(e.g. # visits, hospitalizations; diagnostics)

Medication management

(e.g., complexity; adverse effects; costs)

Self-management tasks

(e.g., diet; monitor weights,

bp

, glucose)

Procedures

(time, discomfort, anxiety, complications; time to recover)

** What patients are able to do and feels helps them achieve goals

Boyd, Montori

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Examples of care preferences: Helpful and doable

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Examples of care preferences: Not help or unable

My medications are causing my muscle pain and makes it hard to walk and be active

I get hypoglycemic, I get weak and shaky. I’m taking too much of something

Ropinirole gives me hallucinations; doesn’t control my restless leg

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Patient priorities decision-making & care is important because…

Care for many older adults with multiple conditions

Of uncertain benefit (lack of evidence)

Burdensome

Unintentional harm

Frustrating for clinicians

Individuals vary in health priorities in face of tradeoffs

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To illustrate, Mr. A, an 83-year-old man with fatigue, decreased appetite, weakness

Previous M.I.DiabetesHypertensionHeart failure (EF 28%)OsteoporosisDepressionHe thinks… his medications are causing a lot of his symptomstoo much of his time involved in his health care

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Disease-based care for Mr. A

Cardiologist

: concerned about heart failure & blood pressure; ↑

β-

blocker & statin; implantable cardioverter defibrillator

Endocrinologist

: concerned about HgbA1C & fractures; start insulin, bisphosphonate

Psychiatrist

: concerned about depression; ↓ or stop

β-

blocker, add another antidepressant

Primary Care

: Concerned about BP & A1C metrics; navigate conflicting recommendations

Result for Mr. A

: ~20 visits/month + blood draws; 12 medications →fatigue, weakness,↓ appetite

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As Mr. A’s story shows……

Care for older adults with multiple conditions :

Of uncertain benefit (lack of evidence)

Not focused on what matters most

Burdensome; conflicting

Unintentional harm

Frustrating for patients & clinicians

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Care may be of uncertain benefit

Few older adult with multiple conditions and functional limitations in RCTsPersons with multiple conditions may have less benefit from treatments than RCTsWith multiple conditions: what outcome defines benefit?

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Care is not always aligned with what matters most …

Patients vary in their health outcome goals when faced with tradeoffs

Maintain function even if don’t life as long: 42%

Relief of symptoms like pain, dyspnea, fatigue: 32%

Stay alive even if less functional: 27%

Fried TR

Patients vary in their care preferences / treatment burden tolerance (willing & able to do to achieve outcomes)

Montori, Boyd

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Care may be burdensome

“ Caring for my chronic conditions is more burdensome than the conditions” (Montori; Boyd)

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Care may be unintentionally harmful

1 in 3 older adults receives a guideline-recommended drug to help one condition that may worsen another one (Tinetti, 2014)

Older adults with multiple conditions face many tradeoffs and are at risk of adverse medication effects

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Care can be frustrating for clinicians

Conflicting recommendations from colleagues who focus on a different disease

Patients don’t do what we want

Clinician thinks patient not adherent

Patient thinks “I cant do this” or “this won’t help me do what’s important”

Conflicts & frustration arise because different priorities (unspoken)

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How can we work together to make Mr. A’s care…

Less burdensome & frustrating, and better focused on what matters most to him and his family?

Less expensive and fragmented for health systems and society?

Less frustrating for the clinicians who care for people like Mr. A?

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Answer: Patient Priorities Care

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A bridge between:

Disease-based decision-making & care

Decision-making & care based on what matters most to patients

and

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For whom is patient priorities care most helpful?

Appropriate for everyone

Multiple conditions and multiple clinicians

Getting conflicting recommendations

Feeling burdened by care

Uncertain benefit of guideline-based care

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The number of people in each of the above 3 groups may vary depending on the population and the specific comorbidities or advanced disease. The model is intended to demonstrate that there is a substantial group of older adults (uncertain) for whom guideline-driven care or advanced disease care is of uncertain benefit or not appropriate.

Blaum

, et al JAGS 2018.

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Planning patient priorities care (

Carealign): 2014-2015

Advisory groups of patients, caregivers, primary & specialty clinicians, health systems, payers, systems design, policy makers (~150)

Ferris R et al. J Aging Health, 2017

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Planning Patient Priorities Care: Aims

Identify modifiable contributors to fragmented, burdensome care

Build feasible, sustainable approach to care of older adults with multiple conditions that

addresses the modifiable contributors

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Can Patient Priorities Care be implemented in practice?

2015-2018

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Patient Priorities Care: Pilot

Process: Activate & train patients & cliniciansAddress workflow, practice change, decision-makingLocations: 10 primary care providers & 5 cardiologists in central CT. Evaluation: Patient, clinician, health system outcomes: PPC vs. usual care

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Progress building Patient Priorities Care:

Feasible process for helping patients identify their SMART health outcome goals and care preferences

Workflow for incorporating patient priorities care into clinical practice

Identified challenges faced in aligning care with patient’s goals & preferences

Main challenge:

Translating goals & preferences into care decisions

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Develop & Implement (Translating prototype into practice):

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What patients need to know & do

Know:

Their health priorities:

Health outcomes most important in face of tradeoffs

What willing and able to do (healthcare preferences)

Do

:

Active partner in decisions with their clinicians

Do what say they willing and able to do

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Specific Ask (One thing)

Specific ask (One Thing):

If we could change one thing about my health or healthcare, it would be:

My arthritis pain in my hands

so that I can:

cook and cut up things easier, it is hard

I want to be less tired so that I can: walk more with my husband and have more energy in the mornings

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Develop priorities identification process

Method:

user-centered design framework, ideate



prototype



test



redesign

Development team

: Baylor (Naik, Dindo), PPC team, patients, caregivers, & clinicians to develop & refine

Products

Value-based, collaborative goal (& preferences) setting process

Training for facilitators

Patient engagement process

EHR template with health priorities

Naik AD, J Am

Ger

Soc. 2018

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Patient priorities identified

Member of care team

help patients:

Clarify Values

Set SMART Goals

Identify healthcare preferences

Engage actively in their healthcare

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Transmit Priorities Template to…

EHR

Patient’s healthcare team

34

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What clinicians need to know & do

Know

: Patients’ outcome goals & healthcare preferences

Do:

Engage patient, caregiver, & other clinicians in decision making aligned with priorities

Stop, start, or continue care aligned with patients' goals & preferences, health trajectory

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How do clinicians align care with patient priorities?: Methods

Participant observation

Coaching huddles; emergent learning

PPC team, training experts (ACP, Baylor), clinicians

Identify key challenges & strategies

Tinetti ME et al. submitted

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A year with Mr. A through Patient Priorities Care

Before patient priorities care

~ 20 visits /month12 medications →tired, weakCheck glucose daily, monthly blood testsSpecialists want more tests & procedures (ICD)Can’t do what wants

With patient priorities care

9 visits/month

8 medications, less tired, weak

Check glucose weekly

Only tests & procedures consistent with his priorities (no ICD)

Walks 2 blocks to babysit 3

y.o

. grandson twice a week

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How to align decisions & care with priorities?

Key Challenges…

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Challenges aligning

decision-making with patients’ priorities

Uncertainty, complexity, & multiplicity

Where to start?

No obvious best option

Patient focus on symptoms; to many; cause(s) uncertain & not totally remediable

Differing perspectives on what matters most

Patient-Clinician:

Current discomfort or treatment burden (e.g. antihypertensives) vs. future event (e.g. stroke)

Clinician-Clinician

Differ in what treatments to start, stop or continue

Switch to patients’ priorities as focus of decision-making

Revert to diseased-based decisions

Need to follow guidelines

Therapeutic inertia

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Other Challenges

Disconnect between goal (outcome desired) and preferences (what able/willing to do)

Unrealistic or unachievable goals

Care preferences vague and not actionable

Acute decision not addressed in patient’s priorities

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How to align decisions & care with priorities?

Strategies that emerged…

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Strategies for patient priorities -aligned decision-making

Begin with what matters most:

Start with one actionable

thing that matters most to the patient

Sample script

“

If we could accomplish or change one thing in your health or healthcare, what would it be? What would you want to be doing more of if we could accomplish this?”

Trial and Error:

Conduct serial trials

of starting, stopping, or continuing therapies (N of 1 trials)

Measure benefit by patient’s health priorities

Sample script

“We can’t be sure what will work best for each person, but …we will work together to try different things if that’s ok. We’ll see what helps you (fill in patient’s desired goals)”

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Strategies for patient priorities-aligned decision-making

Function over symptoms

Focus on function and activities

- health outcome goals - rather than symptoms

Sample script

“If you were in less pain (less dizzy, not so tired, weren’t so depressed), what would you be doing more of?”

Priorities-based communication

Use patient’s health outcome goals and care preferences

(rather than diseases) to select and discuss care

Sample script:

“

There are different things that we could do. But knowing your conditions, your overall health, and your health outcome goals and care preferences (what matters most to you), I suggest we try (fill in)”.

Use patient’s health outcome goals and care preferences

(rather than diseases) to select and discuss care

Sample consult/referral:

“Mr. B’s main concern is…his goals are… and he finds…too burdensome. Given her priorities, please recommend appropriate (tests, medications, procedure”)

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Strategies for patient priorities-aligned decision-making: Arrive at a shared decision

Reconcile different perspectives/priorities

Agree on information to inform the decision

patient’s priorities; burden of treatment; life situation, context; family concerns; coexisting conditions; health trajectory

Reconcile different perspectives/ priorities between patient & clinician

Present tradeoffs (unbiased)

Be realistic about absolute benefits (2-3% absolute)

Patients focus on today appropriate

If patient understands alternatives, then accept decision

Reconcile different perspectives/ priorities between clinicians

Collaborative negotiations

Accept that there is no one best answer

Agree on information guiding decision

Brainstorm compromise alternatives

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Feedback from pilot participants

What do patients think?

“… I don't always know the wisest thing to focus on. Helps to discuss things to make up your mind. It also gives you options about what you can do to make your life and health better.”

What do clinicians think?

“…because I know what matters to her more than my goal to preserve her kidney function, I didn’t just increase her Lisinopril or something else I may have done...”

“ This helps my relationship but I still get measured on BP, BMI, A1C…”

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A few lessons learned so far

Prioritize: Focus on 1 thing that the patient really wants to work on (Specific Ask)

Focus on function not symptoms (“

If you were not in so much pain what would you do more of

?)

Link treatments to patient goal, “(patient goal)…

is important to you, I know you don’t like

…

but are you willing to try it to see if it helps you

…”

Reality test unrealistic goals,

“Can you meet this goal in a way that may be more doable for you?”

Focus communication on goals & preferences, not just diseases and bad future events

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Is PPC feasible and acceptable?

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Products to support Patient Priorities Care

Online curriculum to prepare health systems, clinicians, patients (with ACP) – in developmentTraining & point-of-care materials for patients & priorities facilitatorsDecisional and communication tools (tips & scripts) for cliniciansAGS/ACP/ACC multiple chronic conditions (how to) action steps – in developmentFuture: self-directed health priorities elicitation*All current products available at PatientPrioiritiesCare.org

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PatientPrioritiesCare.org: check back soon & often