1. Records Stanford Coordinated Care “Support the patients, manage their care” Alan Glaseroff MD Co-Director, Stanford Coordinated Care IOM Committee on Recommended Social and Behavioral Domains and Measures for Electronic Health 11/25/13

2. 2 Schroeder, NEJM 357; 12 15% 5% 10% 40% 30% Social Environmental Medical Behavioral Genetic

3. 3 Patient–Driven Care “Others have struggled to find a proper definition of patient-centeredness. Three useful maxims that I have encountered are these:” – “The needs of the patient come first.” – “Nothing about me without me.” – “Every patient is the only patient.” Donald M. Berwick, What 'Patient-Centered' Should Mean: Confessions Of An Extremist Health Affairs, 28, no.4 (2009):w555-w565. New Definition: Patients largely determine their own outcomes within the context of their lives

4. 4 Clarifying Multimorbidity Patterns to Improve Targeting and Delivery of Clinical Services for Medicaid Populations Cynthia Boyd, Bruce Leff, Carlos Weiss, Jennifer Wolff, Allison Hamblin, and Lorie Martin CHCS DECEMBER 2010

5. 5 Depression is Often Not the Only Health Problem Depression Neurologic Disorders 10-20% Geriatric Syndromes 20-40% Diabetes 10-20% Heart Disease 20-40% Chronic Pain 40-60% Cancer 10-20% 2010 University of Washington – AIMS Center

6. 6 Individual Self-Reported Patient Assessments SF-12 PAM Domains PHQ-9 (Activity level) (Nutrition Assessment) (Stanford Presenteeism Scale)

7. 7 Activation is Developmental with Four Progressively Higher Levels 10-15% of the population* 20-25% of the population* 35-40% of the population* 25-30% of the population* * Medicaid and Medicare populations skew lower in activation

8. 8 Patient Activation and Utilization

9. 9 Patient Variation – what the patient faces Domains

10. 10 Domains: “What to do? Patient Activation Measure: “How to do it?” PAM Domains 1234 Social Access Behavioral Medical Trajectory Workflows based on patient variation

11. 11 The Often Hidden Driver: Adverse Childhood Events & Trauma ACE Score = 1 point each for positive responses to 10 questions inquiring about exposure to: Physical abuse Emotional abuse Sexual abuse Physical neglect Emotional neglect Divorce/separation Domestic violence in the home Parent that used drugs or alcohol Parent that was incarcerated Parent that was mentally ill From: www.acestudy.org

12. 12 How do ACE play out in later life? Depression: –A person with an ACE score of 4 was 4.6 x more likely to be suffering from depression than a person with an ACE score of 0 Suicide: –There was a 12.2 x increase in attempted suicide between these two groups; at higher ACE scores, the prevalence of attempted suicide increases 30-51 fold! –Between 66-80% of all attempted suicides could be attributed to ACE.

13. 13 Relationship of ACEs to Alcohol & IV Drug Abuse % Alcoholic 4+ 3 2 1 0 % Have Injected IV Drugs

14. 14 Relationship of ACEs to Smoking & COPD

15. 15 PTSD “Adverse Childhood Experiences (ACE) are common, destructive, and have an effect that often lasts for a lifetime. They are the most important determinant of the health and well-being of our nation.” --Vincent Felitti, MD, co-chair of study

16. 16 SCC Approach From: “What bothers you the most? To: “Where do you want to be in a year?” First step Next step Getting there…

17. 17 Population Health – Risk Measures Summary of overall risk for patient population Panel View by care team, clinician, patient demographics View by chronic condition Patient Panel list by Risk Markers Navigate to patient health portrait 17

18. 18 Population Health – Health Portrait Patient / Provider selectable measures to trend and track at point of care Care gap measures Health Portrait – Personalized view of a patient displaying care gaps alongside risk measures 18 Obesity

19. 19 Patient Advisors to SCC Clinic designed after input from 34 patient interviews 8 people meet monthly (led by Patient Chair, with LCSW as “recorder” of minutes; MDs only come by invite) ACE: Cannot be “part of the chart” – data must be kept separately, with patients “consenting” to complete the survey

20. 20 Thank You! Alan Glaseroff MD –aglasero@stanford.edu