The Dr. Robert Bree Collaborative: Working together to improve health care quality, outcomes, and affordability in Washington State Ginny Weir, MPH Program Director Bree Collaborative April 15th, 2015 | Home Care Association of Washington Preconference

Background QI Organizations Employers Hospitals 22 Stakeholders Identify health care services with high: Variation Utilization Without producing better outcomes House Bill 1311 22 Stakeholders Physicians Health Plans Public Purchasers Others

Process Public Comment Clinical Committee Financial Incentives Public Comment Provider Feedback Reports Recommendations to improve health care quality, outcomes, and affordability in Washington State Shared Decision Aids Evidence-Based Guidelines Clinical Committee Data Transparency Centers of Excellence Public Reporting

Process Workgroups meet for ~9 months - year Updates at all Bree meetings Public comment Adoption by the Bree Collaborative Approval by the Health Care Authority

Reports What is the problem? Is variation unwarranted? Does it contribute to patient harm? What does it look like in Washington State? What are solutions within the medical system? Focus areas Stakeholder-specific recommendations How do we get there?

Topics Low Back Pain and Spine SCOAP Obstetrics Hospital Readmissions Cardiology Elective Total Knee and Total Hip Replacement Bundle and Warranty Elective Lumbar Fusion Bundle and Warranty Low Back Pain and Spine SCOAP Hospital Readmissions End-of-Life Care Addiction and Dependence Treatment

New Topics Coronary Artery Bypass Surgery Bundled Payment Model and Warranty Prostate Specific Antigen Screening Opiate Prescribing Oncology Treatment

Implementation Agency Medical Directors Group (AMDG) reviews and approves recommendations which are then forwarded to the Director of the Health Care Authority (HCA) HCA Director reviews and decides whether to apply to state-purchased health care programs

Implementation Legislation does not mandate payment or coverage decisions by private health care purchasers or carriers Delivery systems and providers not required to implement recommendations Bree Implementation Team (BIT): Design and implement strategies to successfully encourage stakeholders to implement the recommendations

Implementation Team: General Strategy After adoption by the Health Care Authority: Presentation from topic expert Development of change strategy Implementation of change strategy Formation of sub-group, if needed

End-of-Life Care

Inpatient Days per Medicare Decedent during the Last Six Months of Life, 2007 Source: End of life Care. Dartmouth Atlas of Health Care. Accessed: July 2014. Available: www.dartmouthatlas.org/data/topic/topic.aspx?cat=18.

Goal for all Washingtonians: To be informed about end-of-life options Communicate preferences in actionable terms Receive end-of-life care aligned with goals and values

Focus Areas 1. Awareness 2. Advance care planning 3. Record end-of-life care wishes and goals 4. Accessibility of forms 5. End-of-life care choices are honored

“It’s always too early until it’s too late.”

Advance Care Planning Adapted from: Butler M, Ratner E, McCreedy E, Shippee N, Kane RL. Decision Aids for Advance Care Planning: An Overview of the State of the Science. Ann Intern Med. 2014 Jul 29

Advance Directives VS POLST   Advance Directive Physician Orders for Life-Sustaining Treatment (POLST) Durable Power of Attorney for Health Care Living Will/Health Care Directive Written Personal Statement Appropriate Population All adults Those with advanced progressive chronic conditions Timeframe Future care Current care Where Completed Any setting Medical setting Product Legal designation of a health care decision-making surrogate that is part of an advance directive in alignment with Washington State law RCW 11.94.010 Description of an individual’s health care wishes for the end of life for a time when that individual is unable to communicate those wishes that is part of an advance directive in alignment with Washington State law RCW 70.122.030 Summary of personal values and goals of care relating to end-of-life care wishes Medical orders Surrogate Role Surrogate cannot complete Surrogate responsible for presenting to health care provider The designated surrogate can consent to POLST on behalf of an incapacitated patient Responsible for Portability Currently patient or family/friends Provider/Health System Responsible for Review Patient or family/friends

Recommendations Seek to empower Washingtonians Draw from the work of many efforts across our State Work to align end-of-life care with patient’s wishes, goals, and values Do not endorse a specific advance care planning program or initiative or a specific advance directive as many are being used successfully in our state

1. Awareness Community-wide discussions Advance directive that includes: Living will/health care directive Durable power of attorney for health care Written personal statement Difference between POLST and an advance directive

Ex: Whatcom Alliance for Health Advancement Source: Whatcom Alliance for Health Advancement. End of Life Choices. Accessed: August 2014. Available: http://whatcomalliance.org/end-of-life-care/.

2. Advance Care Planning Educate health care professionals Evidence-based tools and programs Involve family members and friends Appropriate timing

Advance care planning facilitators Reimbursement Hospice Advance care planning facilitators

Ex: Honoring Choices: Pacific Northwest Source: Honoring Choices: Pacific Northwest. Copyright 2015. Available: http://www.honoringchoicespnw.org/

3. Record Wishes and Goals Accurate Easily understandable Actionable Culturally appropriate Engage low-literacy patients

A Closer Look at Advance Directives A living will/health care directive Consistent with section 030 of the Washington State Natural Death Act. Signed by the declarer in the presence of two witnesses “Artificially provided nutrition and hydration” if “diagnosed to be in a terminal condition or in a permanent unconscious condition” Stipulates specific treatment preferences (if known and applicable to the situation) A durable power of attorney for health care Names a surrogate Indicates the amount of leeway for surrogate in decision- making A written personal statement Patient’s values and goals regarding end-of-life care

Ex: prepareforyourcare.org Source: The Regents of the University of California. Prepare for your Care. 2013. Accessed: August 2014. Available: www.prepareforyourcare.org

4. Increase Accessibility Advance directives and POLST registry Driver’s license

Ex: Oregon POLST Registry Source: Oregon POLST Registry. History of the Oregon POLST Registry. Accessed: August 2014. Available: www.orpolstregistry.org/oregon-polst-registry/about-opr/

5. End-of-Life Care Choices Are Honored Quality improvement programs Hospitals Nursing homes Other settings Measure family satisfaction Legal immunity to health care providers who honor a patient's POLST

Ex: Interventions to Reduce Acute Care Transfers (INTERACT) Source: INTERACT: Interventions to Reduce Acute Care Transfers. Accessed: August 2014. Available: https://interact2.net/

Recommendations Hospitals Education on having empathetic, realistic, and patient- and family- centered advance care planning conversations Using lower literacy materials if appropriate Document advance directives and/or POLST in medical record Communicate with patient and primary care provider Quality improvement for greater adherence to patients’ wishes Support patients and families during times of crisis

Recommendations Health Plans Reimbursement for end-of-life care counseling and discussion regarding advance directives with patients and surrogate decision makers Encourage hospitals, nursing homes, and other applicable settings to implement a quality improvement program Inclusive and comprehensive benefits for care of patients with serious illness at the end of life allowing them to receive care consistent with their wishes and goals

Recommendations The State of Washington Reimbursement for end-of-life care counseling and discussion regarding advance directives with patients and surrogate decision makers State registry for advance directives and POLST Promote use of the registry Legal immunity for health care providers honoring POLST

More Information Ginny Weir, Program Director GWeir@qualityhealth.org (206) 204-7377 www.breecollaborative.org Recommendations available here: www.breecollaborative.org/about/reports

Comments/Questions

Appendix

Topics Low Back Pain and Spine SCOAP Obstetrics Hospital Readmissions Cardiology Elective Total Knee and Total Hip Replacement Bundle and Warranty Elective Lumbar Fusion Bundle and Warranty Low Back Pain and Spine SCOAP Hospital Readmissions End-of-Life Care Addiction and Dependence Treatment

Obstetrics Elective Deliveries Elective Inductions of Labor Eliminate all elective deliveries before the 39th week of pregnancy (for which there is no appropriate documentation of medical necessity) Elective Inductions of Labor Decrease elective inductions of labor between 39 and up to 41 weeks Primary C-sections Decrease unsupported variation among Washington hospitals in the C-section rate for women who have never had a C-section

Cardiology Clinical Outcomes Assessment Program (COAP), a neutral, third-party quality improvement program of the Foundation for Health Care Quality All hospitals in Washington State who perform open-heart surgery and PCIs participate in COAP Ask to publicly disclose hospitals’ insufficient information reports and the appropriateness of PCI procedures Realistic and aggressive timeline

Bundles and Warranties Health care currently pays physicians and other providers for the number of services provided rather than the quality of care Goal to tie payment to an entire episode of care including potential complications resulting from poor care

Total Knee and Total Hip Replacement High volume of procedures Variation in way procedures are done Readmission Rates by hospital on website: http://www.breecollaborative.org/topic-areas/apm/ Source: Readmission Rates for TKR/THR Procedures in Washington State: Summary of Findings from 2011 CHARS Data Bree Collaborative – Accountable Payment Model Subgroup October 2013. Available: http://www.breecollaborative.org/wp-content/uploads/bree_summary_CHARS_Analysis.pdf

Warranty A contract between provider and purchaser/payer whereby… Provider will correct failure of their product… At no additional cost to purchaser

Warranty Cont. 7 days 30 days 90 days Acute myocardial infarction Pneumonia Sepsis 30 days Death Surgical site bleeding Wound infection Pulmonary embolism 90 days Mechanical complications related to surgical procedure Periprosthetic joint infection

Bundle: Four Components Document disability despite conservative therapy Ensure fitness for surgery Provide all elements of high quality surgery Facilitate rapid return to function And transparent quality metrics

Quality Standards Appropriateness Evidence-based surgery Rapid and durable return to function Patient care experience Patient safety and affordability

Low Back Pain Appropriate evaluation and management of patients with newly diagnosed and persistent acute low back pain and/or nonspecific low back pain not associated with major trauma in primary care Early identification and management of patients diagnosed with low back pain that is not associated with major trauma but have psychosocial factors (e.g., anxiety) that place them at a high risk for developing chronic low back pain and disability Awareness of low back pain management among individual patients and the general public

Spine SCOAP All hospitals participate in the Spine Surgical Care and Outcomes Assessment Program (SCOAP) to improve surgical outcomes for chronic low back pain patients SCOAP is a provider-led program of the Foundation for Health Care Quality that collects data on select surgical procedures for quality improvement Results unblinded

Hospital Readmissions Build community-collaboratives Adopt the Washington State Hospital Association's Care Transitions Toolkit For patients with diagnoses of acute myocardial infarction, heart failure, community acquired pneumonia, chronic obstructive pulmonary disease, or stroke measure and report whether: Patient discharge information was provided to the primary care provider or aftercare provider within three days of discharge A follow-up phone call to the patient or caregiver occurred within three business days

Addiction and Dependence Treatment Reduce stigma associated with alcohol and other drug screening, intervention, and treatment Increase appropriate alcohol and other drug use screening Increase capacity to provide brief intervention and/or brief treatment for alcohol and other drug misuse Decrease barriers for facilitating referrals to appropriate treatment facilities Address the opioid addiction epidemic