1. Shared Decision Making From Concept to Reality Richard Wexler, MD Chief Clinical Integration Officer rwexler@healthwise.org

2. Big Picture - Changing Roles and Relationships

3. Creating An Engaging Patient Experience

4. Outline Level setting – shared decision making and patient decision aids Implementing – an overview Implementing – a couple of scenarios Discussion and next steps

5. Shared Decision Making “the process of interacting with patients who wish to be involved in arriving at an informed, values-based choice among two or more medically reasonable alternatives”¹ Informed There is a choice The options The benefits and harms of the options Values-Based What’s important to the patient The Clinician Information The Patient ¹A.M. O'Connor et al, “Modifying Unwarranted Variations In Health Care: Shared Decision Making Using Patient Decision Aids” Health Affairs, 7 October, 2004

6. The Six Steps of Shared Decision Making 1.Invite patient to participate 2.Present options 3.Provide information on benefits and risks 4.Assist patient in evaluating options based on their goals and concerns 5.Facilitate deliberation and decision making 6.Assist with implementation

7. A Word on Taxonomy Effective Care Strong evidence base supports care Benefit-to-harm ratio high All with need should receive Preference-Sensitive Care Evidence supports more than one approach Treatment/testing options involve significant trade offs Personal values, preferences, and life circumstances should drive decisions SDM Sweet Spot MI Sweet Spot

8. Patient Decision Aids Tools to facilitate SDM Come in all shapes and sizes

9. Minimum Standards to Qualify as a DA Describes the condition or problem Explicitly states the decision that needs to be considered Describes the options available for the decision Describes the positive features of each option Describes the negative features of each option Describes what it is like to experience the consequences of the options Joseph-Williams N, Newcombe R, Politi M, Durand MA, Sivell S, Stacey D, O'Connor A, Volk RJ, Edwards A, Bennett C, Pignone M, Thomson R, Elwyn G: Toward Minimum Standards for Certifying Patient Decision Aids: A Modified Delphi Consensus Process. Med Decis Making 2013, in press.

10. These are not decision aids Educational materials not geared to a specific decision Materials that advise people to choose one option over another Materials designed to promote compliance with a recommended option Passive informed consent materials

11. Patient Decision Aid Inventory Some DAs are in the public domain Others are available for a fee Check for last update or review IPDAS = International Patient Decision Aid Standards https://decisionaid.ohri.ca/AZinvent.php

12. Health Dialog and Informed Medical Decisions Foundation

13. Healthwise

14. National Cancer Institute

15. AHRQ

16. Implementing SDM Where the Rubber Meets the Road

17. Implementation Options 17

18. Primary Care Implementation Works well when The test or treatment is generally managed in primary care –Screening tests – e.g. screening for PCA and CRC –Chronic conditions – e.g. diabetes, depression, HF The care team shares the responsibility The diagnosis is known and surgical consultation is being considered Financial incentives are aligned

19. Specialty Care Implementation Works well when Wait times are long Non-operating clinicians perform triage The reason for specialty consultation is clearly defined at the time of referral Financial incentives are aligned

20. Implementation – Frequent Barriers Common provider misconceptions –I’m already doing SDM –Patients want me to decide or won’t understand –It takes too much time Multiple competing priorities Lack of IT infrastructure and easily available DAs Lack of training Lack of reimbursement Not knowing the reason for a visit Not knowing the numbers

21. Implementing SDM Engage Motivation = Importance + Confidence Importance – Present SDM as a quality of care initiative Importance – Make SDM is an organizational priority Importance – Encourage patients and care givers Importance – Lead often with a physician champion Confidence – Provide training and tools

22. Implementing SDM Target and Identify Patients Target patients that can be identified Target patients in a decision window Target decisions where DAs are available Leverage technology and integrate with work flows Don’t rely solely on physician memory

23. Implementing SDM Distribute DAs to Patients Pre-visit distribution decompresses” the visit and allows for personalized discussions In-visit distribution and review can be done with short form “DAs” Post-visit distribution requires a “close the loop” strategy Population-based distribution can be a patient engagement strategy

24. Implementing SDM Encourage DA Viewing Patients need a WIFM Enthusiastic endorsement helps Clinical context matters

25. Implementing SDM Support Patients During SDM Conversations This is the game changer Capturing the “patient response” can focus the conversation Use others on the clinical team Decision aids help but aren’t required Start by inviting the patient into the conversation Present all the options and do your best with the pros and cons Be curious about what’s important to your patients

26. Patient Response in EHR D\D Patient leaning Decision Conflict Scale Readiness to Decide

27. Implementing SDM Where the Rubber Meets the Road Questions? Comments! Concerns! Stories!

28. Clinical Scenario One 50 year old male scheduled for preventive care visit.

29. Clinical Scenario Two 50 year old female scheduled for f/u visit with hip OA on NSAIDS

30. Thank You!