By Susan Nowicki, APR
As part of its strategic planning process, the AAOS Board of Directors (Board) held two half-day workshops to develop the parameters for a new initiative focused on patient-centered care and to advance the work on the “AAOS in 2010” initiative. AAOS First Vice President Stuart L. Weinstein, MD, chaired both sessions.
Patient-centered care represents a new paradigm in health care. Most definitions of patient-centered care agree that it establishes a partnership among health care providers, patients and their families to ensure that decisions about medical treatments respect patients’ wants, needs, preferences and values. This session focused on defining patient-centered care and its application to orthopaedics, providing the Board with some baseline knowledge of patient-centered activities and establishing a conceptual approach for the AAOS to become a leader in orthopaedic patient-centered care approaches.
In his overview of the topic, Dr. Weinstein noted that the voice of the patient is often missing from national debates about health care. Discussions focus on cost and access issues, while patients worry about the safety and effectiveness of the health care system.
Dr. Weinstein noted that patients are demanding a change in the way health care is delivered. A growing body of research over the past three decades has focused on making the health care system more “patient-centered.” This approach views the health care delivery system from the perspective of patients, their family and friends.
(Left to right) Robert W. Bucholz, MD, AAOS president; Karen Sendelback, executive
A set of principles offered by the National Health Council, a forum of business, industry,nonprofit, professional association and health agencies, includes these elements of patient centered care:
1. Patients and their families manage their health care in partnership with a coordinated health care team that recognizes, respects and acts upon their identified goals, needs, values, preferences, cultural wishes and/or other factors.
2. Patients and their families receive evidence-based, cost-effective, quality health care that maximizes health, alleviates discomfort and is safe and free from avoidable errors.
3. Patients and their families can obtain and understand health information and services, and make appropriate health decisions.
AAOS initiatives such as the Communications Skills Mentoring Program, “Sign Your Site,” Your Orthopaedic Connection, development of practice guidelines, and publication of the Dartmouth Atlas and Improving Musculoskeletal Care in America provide a base for a patient-centered culture in orthopaedics. However, more could be done.
Three panelists—from government, business and patient groups—then shared a definition of patient-centered care and discussed its importance to their constituencies.
Shamiram R. Feinglass, MD, MPH, medical officer, Medicare Coverage and Analysis Group, Centers for Medicare & Medicaid Services (CMS) spoke about CMS efforts to support patient-centered care, including a demonstration project on patient decision making. She noted that the evidence shows that the quality of medical care improves when patients are given clear, unbiased information about their options. In many cases, shared decision-making leads to lower costs and higher patient satisfaction.
To CMS, patient-centered care includes three key elements:
• Evidence-based framework—key to patient-centered care
• Safety—innovative care that is not safe is not effective
• Transparency—information available online and in readily-accessible publications so that decision-making is “transparent” for all to see
Dr. Feinglass outlined the CMS demonstration project designed to encourage shared decision-making in the hospital setting. Modeled on the Center for Shared Decision-Making at Dartmouth-Hitchcock Medical Center, the project includes financial support by CMS to reduce the budgetary impact of fewer surgeries and other intensive medical procedures.
CMS is also concerned about racial and geographic disparities in standards of care.
Gregory N. Larkin, MD, director, Corporate Health Services, Eli Lilly and Company, provided the business perspective on patient-centered care. He stated that many employers are advocating innovative, competitive health care delivery programs to improve quality and reduce costs.
Dr. Larkin pointed out that there is substantial variation in quality and cost performance both across the United States and within communities. Studies show under use of effective care (for diabetes and asthma, for example) and overuse of preference-sensitive treatment (regional medical culture).
Performance is hidden from both health care purchasers and providers, he said. Further, provider self-interest is not aligned with the interests of employees or employers, and providers have little incentive to invest in technology and programs that enhance quality and accountability. Although the primary focus is on provider prices, variations in total cost and quality may mean that lower costs do not lead to better outcomes.
He also observed that employees are not engaged as consumers because they lack quality information and financial incentives to become value purchasers when choosing providers. Employees may also lack timely, relevant information to participate in treatment choices and care planning. Further, the lack of quality reports does not indicate provider value to consumers.
Finally, Dr. Larkin said that employers are not buying “smart.” Few plans offer employees meaningful choices or quality information to support their choice of provider. Worst of all, such plans subsidize inefficient care. He asked, “What other business expense would be purchased this way?”
Karen Sendelback, executive director of the American Kidney Fund (AKF), spoke about improving health through patient-focused care. Established in 1971, the AKF provides direct assistance and education to needy kidney patients. Ms. Sendelback noted that, from a patient’s viewpoint, there are important reasons for making the shift to patient-centered care: improve the quality of care, increase patient satisfaction, lower costs and reduce preventable medical errors.
She agreed that there is too much focus on the cost of care. Patients want to:
• Feel “known” by their providers
• Feel like they are valued participants
• Be communicated with frequently and appropriately
• Have coordinated health care
Ms. Sendelback agreed that the health literacy of patients needs improvement. Patients often have unrealistic expectations about what medical treatments can accomplish. Information overload makes it difficult to discern what is accurate. And, she pointed out, too many patient education materials have been developed to reduce liability, not to inform patients. There is also an unrealistic perception that health care should be 100 percent safe.
The Board debated several strategic questions including both the role and focus of the AAOS in patient-centered care. The Board agreed that AAOS should be involved in patient-centered care activities; initiating a patient-centered care culture in orthopaedics supports and enhances many of the AAOS current initiatives, including evidence-base guidelines, patient education and patient safety.
A Board project team will establish a framework for the AAOS to develop and build a patient-centered care initiative. Charges include:
1. Inventory, define and identify the status of existing AAOS programs, products and services that support patient-centered care.
2. Outline an overall plan for developing a patient-centered culture in orthopaedics that includes, but is not limited to:
a. A working definition of ortho-
paedic patient-centered care
b. Goals and scope of an AAOS patient-centered care initiative
3. Present the plan outline to the Board in February for approval or modification.
4. Based on the Board’s action, develop a detailed plan for that will guide AAOS patient-centered care activities.
AAOS in 2010
The second Board workshop focused on the “AAOS in 2010.” The AAOS began reviewing its organizational goals and direction early in 2004, building upon the previous strategic effort, “AAOS in 2005.” The two-year process will help define the shape, services and direction for the AAOS at the end of the Bone and Joint Decade.
A project team of AAOS members and staff began by re-examining the validity and basis of the assumptions that guided development of “AAOS in 2005.” The next step was to analyze both the internal and external forces affecting AAOS as it moves forward into the future.
The project team, along with the AAOS Board, Committee and Council chairs and staff, completed a SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis of each aspect of the AAOS. They also completed an environmental scan of the various issues that may affect the organization, including medial liability, Medicare reimbursement and diversity.
The results of these two analyses were used to develop a Member Needs Assessment survey, which was mailed in fall 2004 to a random sample of 3,000 AAOS members. Members were asked to rank the importance and their level of satisfaction with program areas such as education, advocacy, research, practice management and professionalism.
The survey received a 21 percent response rate. As part of the workshop, the AAOS research department presented a detailed analysis of the survey results to the Board.
The Board then revisited key “AAOS in 2010” planning assumptions that were developed earlier in the project to test their validity. Several changes were recommended and the Board was then challenged to develop models and approaches for adding new programs, where appropriate, and eliminating those that were no longer pertinent.
Finally, several follow-up actions and recommendations were made to the “AAOS in 2010” project team. The team will meet to review the updated assumptions, as well as the results of the Member Needs Assessment. It will then refine the criteria for evaluating AAOS programs and activities and develop recommendations for organizational change where needed. A plan for moving forward will be presented to the Board in February.