1. Collaborative Implementation of Shared Decision Making State Legislation Megan Morris, MS CCC-SLP 1,2 ; Leah Hole-Curry, JD 3 ; Douglas Conrad, PhD, MBA, MHA 2 ; Anne Renz, MPH 2 1 Dept. of Rehabilitation Medicine, University of Washington, Seattle, WA; 2 Dept. of Health Services, University of Washington, Seattle, WA; 3 Washington State Health Care Authority, Olympia, WA Resources Center for Shared Decision Making (Dartmouth-Hitchcock Medical Center): www.dhmc.org/shared_decision_making.cfm Ottawa Patient Decision Aids (OHRI): http://decisionaid.ohri.ca/decaids.html Washington State (2007) E2S S.B. 5930: Blue Ribbon Commission on Health Care Costs and Access: http://apps.leg.wa.gov/documents/billdocs/2007- 08/Pdf/Bills/Session%20Law%202007/5930-S2.SL.pdf What is Shared Decision Making? Shared decision making (SDM) is a way to make clinical care decisions for specific medical conditions. There are some conditions for which scientific evidence suggests that several treatment options provide similar outcomes, but with different side effects, risks, or courses of disease. The point of SDM is that in these instances, the patients should play an important role in deciding which treatment to undertake, based on their values and preferences. Treatment decisions should be shared between patient and provider. Abstract Shared Decision Making (SDM) is a collaborative model of patient-provider communication in which a health care provider and patient jointly consider treatment options and the patient’s values and preferences. SDM involves multiple steps to ensure that patients understand the risks and benefits of all treatment options. Decision aids (DAs) are used to inform patients about treatment options. Multiple benefits of SDM and DAs have been demonstrated, including improved patient outcomes and increased patient and provider satisfaction. In 2007, recognizing these benefits, the Washington State Legislature passed a bill mandating that the Health Care Authority implement an SDM demonstration project at one or more multi-specialty practice sites. Because the legislation did not include appropriated funds, the Health Care Authority sought collaborators for the demonstration. Researchers from the University of Washington obtained funding from a foundation to facilitate an SDM demonstration. Three practice sites in the Puget Sound area are currently participating in the project. National health care reform bill HR 3590 includes a section on SDM that calls for creating Shared Decision Making Resource Centers and awarding grant funding to providers for developing, implementing, and assessing SDM and DAs. As one of the few states with an active SDM demonstration project, Washington State offers important lessons in collaboration and implementation. Background on SDM Demonstration Project The WA State legislature passed a bill that mandated, but did not fund, the state HCA to implement decision aid demonstration projects. In response, HCA convened a Collaborative Stakeholder Group. The group’s members include representatives from the University of Washington, the Puget Sound Health Alliance, Group Health Cooperative, and several multispecialty group practices. Representatives from UW secured funding to fund the demonstration project Decision Aids Decision aids are a way to provide patients with information about treatment options, the risks and benefits associated with each one, and the likely outcomes and side effects in an easy-to-understand fashion. Decision aids have been developed for a number of preference-sensitive conditions, chronic conditions, and screening options. Preliminary data about decision aids suggest that they can be used successfully to increase patient-provider communication and promote shared decision making. Benefits of Shared Decision Making Patients are more invested in their medical care and understand the treatment better, which leads to better adherence to a medical treatment Increased understanding of a treatment leads to better self-management and health outcomes Increased patient satisfaction Decreased medical costs Decreased malpractice claims Acknowledgements and References This study is funded in part by the Foundation for Informed Medical Decision Making (Boston, MA). Partial support is also provided by the National Institutes of Health, National Institute of Child Health and Human Development, National Center for Medical Rehabilitation Research (T32HD007424). 1.Edwards, M., Davies, M., & Edwards, A. (2009). What are the external influences on information exchange and shared decision- making in healthcare consultations: A meta-synthesis of the literature. Patient Education & Counseling, 75(1), 37-52. 2.Elwyn, G., Edwards, A., Kinnersley, P., & Grol, R. (2000). Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices. Br J Gen Pract, 50(460), 892-899. 3.Gravel, K., Legare, F., & Graham, I. D. (2006). Barriers and facilitators to implementing shared decision-making in clinical practice: a systematic review of health professionals' perceptions. Implement Sci, 1, 16. 4.Makoul, G., & Clayman, M. L. (2006). An integrative model of shared decision making in medical encounters. Patient Educ Couns, 60(3), 301-312. 5.Mauksch, L. B., Dugdale, D. C., Dodson, S., & Epstein, R. (2008). Relationship, communication, and efficiency in the medical encounter: creating a clinical model from a literature review. Arch Intern Med, 168(13), 1387-1395. 6.Towle, A., & Godolphin, W. (1999). Framework for teaching and learning informed shared decision making... including commentary by Greenhalgh T and Gambrill J. BMJ: British Medical Journal, 319(7212), 766-771. 7.Whitney, S. N., Holmes-Rovner, M., Brody, H., Schneider, C., McCullough, L. B., Volk, R. J., et al. (2008). Beyond shared decision making: an expanded typology of medical decisions. Med Decis Making, 28(5), 699-705. Shared Decision Making Steps PatientPhysician Relationship building Personally define what is required and preferred in a physician-patient relationship Establish the patient’s preferences for the amount and format for presented information Find a physician and establish, develop, and adapt a partnership Establish the patient’s preferences for each person’s role in decision-making and who might be involved in the process Articulate health problems, feelings, beliefs, values and expectations Gather information while attempting to understand the patient’s perspective in regards to their ideas, concerns, and expectations Share medical information and evidence relevant to patient’s medical case and personal values and expectations Recognize that a decision can or must be made in the situation Decision-making Process Evaluate the presented information and potential options by: - Listing the pros, cons, and other characteristics - Identifying and comparing the possible options Evaluate the presented information and potential options by: - Listing the pros, cons, and other characteristics - Identifying and comparing the possible options - Keep in mind patient’s previously established preferences Negotiate decisions and resolve any conflicts Frequently check understanding of facts and perspectives and then provide further clarification if needed Decision finalizing and implementation Agree on decision and an action plan and create arrangements for follow-up Authorize the final choice Implement the agreed upon choice Complete follow up Demonstration sites and conditions of interest SiteLocationConditions of Interest The Everett ClinicEverett- Hip Osteoarthritis - Knee Osteoarthritis MultiCare Medical GroupTacoma- Low Back Pain - Chronic Pain - Depression - Diabetes - PSA Testing - Colon Cancer Screening Virginia Mason Medical CenterSeattle- Ductal Carcinoma In Situ - Early Stage Breast Cancer Summary and Current Status of the Project Start-up: Early steps in the project included obtaining IRB approval, identifying executive champions and project managers at each site, choosing conditions of interest, and creating workflow process maps. Dissemination: Activities include: 1)Developing a website that features information about SDM, project partners and sponsors, SDM legislation, related resources, and a toolbox containing templates for many aspects of SDM implementation, 2)Being interviewed for an article about SDM (Harris Meyer, “Power to the Patient,” Hospitals & Health Networks, February 2010), 3)Hosting a conference for site partners, interested parties, and Foundation representatives in March 2010 4)Presenting posters at the Washington State Public Health Association’s Joint Conference on Health and at the Society for Medical Decision Making’s annual conference. Monthly Meetings: We hold monthly meetings, sometimes featuring expert guest speakers, to discuss the demonstration project and SDM generally. Attendees include representatives from the demonstration sites, the Washington State Health Care Authority, Group Health, and the Puget Sound Health Alliance. Decision Aid Distribution: The demonstration sites have distributed a total of 48 decision aids (DAs) and received back 19 surveys. The distribution of decision aids is as follows: 23 preference-sensitive DAs (early breast cancer, DCIS, hip and knee osteoarthritis) 24 chronic condition DAs (chronic low back pain, chronic pain management, depression, and diabetes) 1 screening DA (colon cancer screening) Lessons Learned: We learned the importance of having both executive champions and project managers, working through competing priorities, and the value of being part of a network.