Promising: Process Improvement in Psychosocial Health

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PROMISing: Process Improvement in Psychosocial Health Carly Woodmark MS │ Dereesa Reid MBA │ Daniel Bouton MD SHC-Portland │ Department of Performance Improvement Abstract no. 20

Shriners Team And Patients PROMISing Changes Shriners Hospitals for Children is a network of 22 non-profit medical facilities across North America. Benefits of PROMIS Intervention Pre-op Post-op Since 1924, SHC-Portland has treated a wide range of pediatric orthopedic conditions, from fractures to rare diseases and syndromes. Our Integrated Practice Unit of multi-disciplinary  Minor burden of taking PROMIS is offset by quality professionals provide a comprehensive approach through specialized evaluation and treatment communication of meaningful progress between along with rehabilitative services to restore each child physically, emotionally, and socially. Below is patient/family & physician during clinic visit. a list of common conditions treated at SHC-Portland.  Medical providers can demonstrate improvements Skeletal abnormalities – Osteogenesis imperfecta (OI), osteochondritis dissecans (OCD lesions), from interventions & adjust care management if Blount disease, skeletal dysplasias, etc. needed. Outcome Performance Improvement Neuromuscular conditions – Cerebral palsy, myelomeningocele (spina bifida), Muscular dystrophy, spinal muscular atrophy After one year of data collection, rates of Minimal Clinical Important Difference (MCID) were assessed for all patient-reported domains in both surgical and non-surgical populations. Multivariate Hand/Upper extremity deformity – Congenital abnormalities, macrodactyly, syndactyly, linear regression models were produced to identify: polydactyly, TAR syndrome, etc.  statistically significant variables that are most influential in attaining MCID per domain in both Hip abnormalities – Developmental dysplasia of the hip (DDH), Legg-Calve-Perthes disease, surgical and non-surgical populations. slipped capital femoral epiphysis (SCFE), femoral acetabular impingement (FAI)  quality performance improvement opportunities with the goal of increasing MCID domain rates Lower Extremity conditions – Clubfoot, genu valgum, Osgood- Schlatter’s disease, limb-length over time by improving or establishing new processes using influential variables. inequality, macrodactyly, syndactyly, etc. Patient Population Flowchart Spinal deformity and conditions – Kyphosis, lordosis, scoliosis (congenital, neuromuscular, Surgical syndromic, idiopathic), spondylolysis, spondylolisthesis N= 110 Total MCID Total Population patient-reported Sports injuries & fractures N= 2,184 population N= 394 Non-surgical Musculoskeletal infections N= 169 Background According to the National Healthcare Expenditure Projections, the US health care system is the most Results costly in the world, accounting for 17% of the gross domestic product (GDP) with estimates growing Most Influential Variables Predicting MCID to nearly 20% by 2020. The ‘Triple Aim’ was created by the Institute of Healthcare Improvement (IHI) Surgical Population N= 110 as a blueprint to improve delivery of healthcare services, patient health outcomes, and population Domain Variable 1 Variable 2 Variable 3 Variable 4 Model p-value

health while reducing per capita costs. Pain Interference Baseline Pain Baseline Peer BMI Baseline Mobility F= 6.498 (4, 106) MCID Interference Relationships p-value< 0.001 Evidence affirms patients who are more involved in their p- value= 0.001 p- value= 0.006 p-value= 0.023 p-value= 0.033 Improved Reduced Mobility MCID Baseline Mobility F= 30.019 (1, 104) care experience better outcomes and choose less costly N= 105 Patient Costs p-value< 0.001 p-value< 0.001 yet effective interventions. Patient-reported information is Experience/ an authoritative source on outcomes beyond experience Care Upper Extremity Baseline UEF Baseline Pain F= 6.517 (2, 108) Function MCID Interference with care, but measures valued by both patient and p-value< 0.001 p-value= 0.001 p-value= 0.002 Better provider with an accurate appraisal of service quality and Baseline Peer Baseline UEF Baseline Mobility F= 11.530 Population Peer Relationships (3, 107) responsiveness to patient’s needs. Utilizing patient- Health MCID Relationships reported outcome measures (PROMs) like PROMIS is an p-value< 0.001 p-value< 0.001 p-value= 0.002 p-value< 0.001 essential step towards maximizing patient value while Most Influential Variables Predicting MCID achieving best outcomes at the lowest cost. Integrating Non-surgical Population N= 169 PROMIS into standard of care is a vital improvement to Domain Variable 1 Variable 2 Variable 3 Variable 4 Model p-value

SHC-Portland’s Integrated Practice Unit (IPU) model Pain Interference Baseline Pain Baseline Peer F= 7.568 (2, 167) MCID Interference Relationships which dovetails seamlessly in upholding the Triple Aim p-value= 0.001 p-value< 0.001 p-value< 0.001 initiative. Mobility MCID Baseline Mobility BMI Baseline Pain Baseline Peer F= 7.006 (4, 161) N= 165 Interference Relationships p-value< 0.001 p-value< 0.001 p-value= 0.001 p-value= 0.005 p-value= 0.017

Upper Extremity Baseline Pain Baseline Mobility F= 4.797 (2, 167) How to efficiently integrate PROMIS data collection in clinical practice, and implement Function MCID Interference p-value= 0.009 quality processes readily when a patient’s score(s) are severe? p-value= 0.003 p-value= 0.006

Peer Relationships Baseline Peer Baseline Pain BMI F= 8.500 (3, 166) MCID Relationships Interference p-value< 0.001 Pediatric Patient-reported & Parent Proxy (PP) Item p-value< 0.001 p-value< 0.001 p-value= 0.004 Bank v2.0 Domains Psychosocial Health Process Improvement Pain Interference (PI) – SHC Custom Short Form 8a  Psychosocial screening questions at surgical waitlist Mobility Short Form 8a improvement & utilize validated tools to risk stratify patients Upper Extremity Function (UEF) Short Form 8a when positive screenings do occur.

Peer Relationships (PR) Short Form 8a/7a (PP)  Referral to a mental health professional for further evaluation (moderate-severe risk), and patient’s mental health status signed off before surgery (inpatient PROMISing Actions spine/halo). Computer information technology is not only essential in the application of item response theory  TEDI team- RNs trained in trauma informed principles to (IRT) in computer adaptive testing, but real-time: better care for patients with known childhood trauma.

 upload of PROMIS scores & display trends in the patient’s Electronic Medical Record (EMR). Future Multi-site Evaluate baseline PROMIS  severe score(s) follow up with patient/family during clinic visit. 12 Shriners Hospitals characteristics for specific pediatric SHC- Portland implemented PROMIS conditions such as  availability of different language versions such as English and Spanish to capture more patients over time.

SHC-Portland implemented PROMIS via computer tablets in December 2017 in the outpatient clinic Combine, Compare & Contrast Cerebral Palsy after intake assessments as part of standard care. PROMIS scores are integrated into the EMR in Adolescent idiopathic scoliosis  Other disease-specific PROMs: real-time which facilitates their use for patient-centered care management and provides data for  Scoliosis Research Society- 22 (SRS-22r) performance improvement.  Pediatric Outcomes Data Collection Instrument (PODCI)  Cerebral Palsy- Profiles of Health and Surgical Surgical PROMIS Flowchart in Outpatient Clinic Function (CP-PRO)  MD(s) address Radiographic outcomes  Gait lab analyses severe pain Non-surgical Non-surgical  interference Complications/Unplanned return to during clinic surgery PROMIS scores Patient/Proxy visit. receives tablet upload to EMR and after intake viewed. Severe  Track PROMIS data long-term to determine scores (PI & PR) are assessments in RN/CMA page Social worker(s) optimal treatment strategies by studying effects alerted to MD(s) and exam room. social worker(s) enters clinic of different treatment options. social workers. regarding room after MD(s) severe peer finishes for  Improve efficiency & efficacy in healthcare relationships further delivery by implementing changes in treatment score. evaluation. pathways.