1. 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

2. 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

3. 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

4. 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

5. 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?

6. 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

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

8. 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

9. 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

10. 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

11. End-of-Life Care

12. 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 Available:

13. 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

15. 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

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

17. 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 Jul 29

18. 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
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
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

19. 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

20. 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

21. Ex: Whatcom Alliance for Health Advancement
Source: Whatcom Alliance for Health Advancement. End of Life Choices. Accessed: August Available:

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

23. Advance care planning facilitators
Reimbursement
Hospice
Advance care planning facilitators

24. Ex: Honoring Choices: Pacific Northwest
Source: Honoring Choices: Pacific Northwest. Copyright Available:

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

26. 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

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

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

29. Ex: Oregon POLST Registry
Source: Oregon POLST Registry. History of the Oregon POLST Registry. Accessed: August Available:

30. 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

31. Ex: Interventions to Reduce Acute Care Transfers (INTERACT)
Source: INTERACT: Interventions to Reduce Acute Care Transfers. Accessed: August Available:

32. 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

33. 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

34. 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

35. More Information Ginny Weir, Program Director GWeir@qualityhealth.org
(206)
Recommendations available here:

36. Comments/Questions

37. Appendix

38. 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

39. 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

40. 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

41. 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

42. Total Knee and Total Hip Replacement
High volume of procedures
Variation in way procedures are done
Readmission Rates by hospital on website:
Source: Readmission Rates for TKR/THR Procedures in Washington State:
Summary of Findings from 2011 CHARS Data
Bree Collaborative – Accountable Payment Model Subgroup
October Available:

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

44. 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

45. 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

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

47. 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

48. 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

49. 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

50. 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