Paul Gruen, Implementation Consultant Bree Collaborative Implementation Survey Results for Medical Groups & Hospitals Paul Gruen, Implementation Consultant

13 Bree Collaborative Topics, 1 to 115 recommendations per topic Obstetrics Care Oncology Care Cardiology: Appropriate PCI Addiction & Dependence Treatment CABG Surgical Bundle Opioid Prescriptions Spine/Low Back Pain End Of Life Care Planning Spine SCOAP Avoidable Hospital Readmissions Lumbar Fusion Surgical Bundle Knee/Hip Replacement Prostate Cancer Screening

Implementation Survey Separate hospital and medical group surveys Surveys are voluntary, self-reported (inter-rater reliability) Bias towards larger urban & suburban systems Implementation possibly independent of Bree Recommendation Low implementation could mean “unknown” Extensive length of survey reduced response rate

Participating Hospitals &Medical Groups CHI Franciscan Health Swedish/Providence 5 hospitals 5 hospitals, 3 medical groups Confluence Health UW Hospital & medical group 4 hospitals The Everett Clinic Vancouver Clinic Evergreen Health Partners Virginia Mason Group Health Northwest Physicians Network Polyclinic

Implementation Scoring Scale 0 -No action taken 1 -Actively considering adoption 2 -Some/similar adoption 3 -Full adoption

MG #1: Addiction & Dependence Treatment (Average Score: 1.46)

MG #1: Addiction & Dependence Treatment (lowest scoring recommendations) Verbal communication takes place with the chemical dependency treatment facility to follow-up on any referrals and assess whether treatment was initiated and/or completed (0.75) The patient’s perspective is included as work is done to increase the capability of the chemical dependency system (0.75) Patients are contacted after they have been referred to chemical dependency treatment to address any barriers to accessing treatment (0.88) Patient results from alcohol and other drug misuse screens are tracked over time (1.00)

MG #8: Obstetrics (Average Score: 2.74)

Knee and Hip Replacement Surgical Bundle 11 hospitals 87 recommendations 2.32 Average Score

Knee and Hip Replacement Surgical Bundle (5 lowest scoring recommendations) Cycle 2: General health questionnaire completed: Patient Reported Outcomes Measurement Information System-10/PROMIS-10 (1.09) Cycle 2: Patient participates in Shared Decision-making with WA State- approved Decision Aid (1.36) Cycle 2: HOOS/KOOS survey completed (1.60) Cycle 4: Patient-reported functional outcomes are measured with KOOS/HOOS instrument (1.55) Cycle 4: If opioid use exceeds six weeks, a formal plan is developed for opioid management (1.55)

Hospitals: Appropriate PCI / COAP (Average Score: 3.00)

Top BARRIERS to Adoption Lack of availability & credibility of data, and burden to collect it Business case- no economic reward, and lack of contract partners interested in value-based purchasing Lack of consensus on what constitutes quality of care

Top ENABLERS to Adoption Existing organizational improvement program for minimizing errors & waste Business case- evidence of economic reward Consensus on what constitutes quality of care Individual provider-level performance feedback

Implementation- Key Lessons: 1 - 4 Systematic collection of patient self-reported goals, function & outcomes tracking are a challenge (STarT Back tool, Functional Recovery Questionnaire, Oswestry, PROMIS-10, KOOS/HOOS, Opioid pain assessment, Cancer Care treatment goals) Patient Decision Aids not yet available and shared decision making not systematic (Prostate/PSA testing, knee/hip replacement) Some recommendations may not be adopted as broadly as Bree specifies (advance care plans >18 y.o., drug & alcohol screening in ED >13 y.o.) Communication between entities not systematic (advanced directives/POLST, PMP for Opioids)

Key Lessons: 5-10 Long-term opioid use planning a challenge, also Prescription Monitoring Program (PMP) Addiction/dependency referrals, follow-up and tracking not systematic Alignment with “Choosing Wisely” an opportunity (Oncology care, Prostate/PSA screening) Decisions by “Collaborative Team” not yet systematic (Lumbar Fusion) Data issues, business case for implementation significant barriers Organization improvement program, business case, provider level performance feedback significant enablers

Next Steps (work in process) Closer examination of providers successful in implementation Work with health plans, particularly on business case WA state “Business Group on Health”? Healthier Washington/Hub, also Patient Decision Aids Choosing Wisely Bundled Payment specifications- revise/update