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Welcome... 
During today’s discussion, feel free to submit questions at any time 
by using the questions box. A follow-up e-mail will be sent to all 
attendees with links to the presentation materials online. 
Today’s topic 
Patient Engagement: A Key Strategy for Population Health Management 
Tammy Richards 
Operations director, 
patient and clinical 
engagement, 
Intermountain 
Healthcare, 
Salt Lake City 
Dr. Thomas Graf 
Chief medical officer 
for population health, 
Geisinger Health System, 
Danville, Pa. 
Kristin Carman 
Vice president, director, 
Center for Patient and 
Consumer Engagement, 
American Institutes for 
Research, 
Washington
Housekeeping 
1. Viewer Window 2. Control Panel
Now speaking... 
Please use the questions box on your webinar dashboard 
to submit comments to our moderator 
Maureen McKinney 
Editorial programs manager, 
Modern Healthcare
Now speaking... 
Please use the questions box on your webinar dashboard 
to submit comments to our moderator 
Kristin Carman 
VP, director, Center for Patient and Consumer 
Engagement, American Institutes for Research
AMERICAN INSTITUTES FOR RESEARCH 
1 
Goals 
• Define patient and family engagement 
• Discuss the benefits of patient and family 
engagement 
• Explain why we created a roadmap to 
patient and family engagement 
• A Roadmap for Patient and Family 
Engagement in Healthcare Practice and 
Research: Change Strategies
AMERICAN INSTITUTES FOR RESEARCH 
2 
A working definition for patient 
and family engagement 
Patients, families, their representatives, and 
health professionals 
Working in active partnership 
At various levels across the health care system 
To improve health and health care 
Carman et al., “Patient and Family Engagement: A Framework for 
Understanding the Elements and Developing Interventions and Policies” 
Health Affairs, 32, no.2 (2013):223-231
Who: Patients, families, 
providers, systems 
Public policies and culture 
Health care organizations and systems 
Clinicians and 
health care 
providers 
Family and friends 
AMERICAN INSTITUTES FOR RESEARCH 
3 
Patients
CCoonnssuullttaattiioonn IInnvvoollvveemmeenntt 
AMERICAN INSTITUTES FOR RESEARCH 
Partnership and 
shared leadership 
4 
What: Working in active 
partnership 
• Partnership and shared leadership involves real 
culture change, which means: 
– Leadership commitment 
– Provider / patient education 
– Potential changes to workflows, policies, and 
procedures
AMERICAN INSTITUTES FOR RESEARCH 
5 
Where: At various levels
How does patient and family 
engagement differ from patient 
activation? 
• Patient activation: an “individual’s knowledge, 
skill, and confidence for managing his/her own 
health and health care” 
• How is that different from patient and family 
engagement? 
• Focuses on the individual 
• Does not look at behavior 
• Does not address the individual’s external context 
• Is one aspect of person’s ability to engage in care 
AMERICAN INSTITUTES FOR RESEARCH 
6
Who can benefit from patient 
and family engagement? 
• Patients and families 
– Improved health outcomes 
– Better experiences of care 
• Clinicians and health care providers 
– Improved satisfaction and retention 
• Health care organizations and systems 
– Competitive edge 
– Standards, reimbursement, and requirements 
AMERICAN INSTITUTES FOR RESEARCH 
7
AMERICAN INSTITUTES FOR RESEARCH 
8 
Our Goals 
• Develop a unified roadmap for practice and 
research 
• Move from what-ifs to action 
• Build on existing work and use multiple inputs 
• Convene a multidisciplinary group of key 
stakeholders
What did we ask participants to 
do? 
• Develop vision for the field – build physical roadmaps 
AMERICAN INSTITUTES FOR RESEARCH 
9 
– Milestones and destinations 
– Strategies and tactics 
– Factors that affect progress 
– Timing: today, tomorrow, future
AMERICAN INSTITUTES FOR RESEARCH 
10 
The Roadmap
AMERICAN INSTITUTES FOR RESEARCH 
11
8 Change Strategies 
AMERICAN INSTITUTES FOR RESEARCH 
12
Change Strategies: Preparing for 
Engagement 
Patient and Family Preparation 
Educate, prepare, and empower patients and families to 
engage effectively in their health and healthcare 
What can we do? Implement patient-centered tools to 
support shared decision making 
Clinician and Leadership Preparation 
Educate, prepare, and empower clinicians and 
healthcare leaders to partner effectively with patients 
and families 
What can we do? Develop standardized patient and 
family engagement competencies 
AMERICAN INSTITUTES FOR RESEARCH 
13
Care and System Redesign 
Redesign system processes, policies, and structures to provide 
opportunities for and support of partnerships between patients, 
families, and the healthcare team 
What can we do? Restructure care 
processes to support shared 
decision making. Document the 
process, including the content of 
discussion about risks, benefits, and 
patient goals, values, and 
preferences. 
AMERICAN INSTITUTES FOR RESEARCH 
14
More information 
AIR’s Center for Patient and Consumer 
Engagement 
http://aircpce.org 
Coming September 23rd- 
Roadmap to Patient and Family Engagement 
in Health Care Practice and Research 
www.patientfamilyengagement.org/roadmap 
AMERICAN INSTITUTES FOR RESEARCH 
15
Now speaking... 
Please use the questions box on your webinar dashboard 
to submit comments to our moderator 
Tammy Richards 
Operations director, patient and clinical engagement 
Intermountain Healthcare
Patient Engagement 
Vision & Definition 
Vision: To build a patient-centered, value-oriented model for 
engaging patients. 
Definition: The effective partnership between the patient, the 
family and the healthcare team to collaboratively achieve the 
patient’s health-related goals.
HCAHPS Care Transitions Questions 
42.6% 
Intermountain Healthcare System Scores 
57.9% (PR=94) 59.8% 
51.2% 
68.0% (PR=93) 
73.0% (PR=92) 
80.0% 
70.0% 
60.0% 
50.0% 
40.0% 
30.0% 
20.0% 
10.0% 
0.0% 
During this hospital stay, staff took my 
preferences and those of my family or caregiver 
into account in deciding what my health care 
needs would be when I left. 
When I left the hospital, I had a good 
understanding of the things I was responsible for 
in managing my health. 
When I left the hospital, I clearly understood the 
purpose for taking each of my medications. 
NRC 50th percentile top box score Intermountain YTD top box score
Deloitte Report: State of Engagement 
Comparison: 2008 and 2012
Opting out of CCM (Example) 
337 pts 
169 pts 
40 pts 
Current “Opt Out” Rate = 42%
National Levels of Literacy 
Basic 
22% 
Below Basic 
14% 
Intermediate 
52% 
Proficient 
12% 
Basic 
Below Basic 
Intermediate 
Proficient
Now speaking... 
Please use the questions box on your webinar dashboard 
to submit comments to our moderator 
Dr. Thomas Graf 
Chief medical officer for population health 
Geisinger Health System
“Let us bear in mind that the most important individual after all is the 
patient. Our paramount thought must be to provide him means by which he 
can have skilled diagnostic and therapeutic service in as complete form as 
may be indicated in a given case, in the shortest possible time consistent 
with thoroughness, and at the least cost to him.” HL Foss, MD 
Heal • Teach • Discover • Serve 
Copyright Geisinger Health System 2014 
Not for reuse or distribution without permission 
Geisinger Health System Confidential and Proprietary 
11/4/1950 1
The Functional Components 
of Population Health 
Cultural 
Transformation 
Heal • Teach • Discover • Serve 
Copyright Geisinger Health System 2014 
Value Driven 
Population Care 
ProvenHealth® 
Navigator, Clinical 
Redesign 
Value Driven Post- 
Acute Care: 
TOC, SNFist 
Not for reuse or distribution without permission 
Geisinger Health System Confidential and Proprietary 
Value Driven 
Acute Care: 
Proven Care 
Acute 
Data Driven 
Care and 
Leadership 
Evolutions 
Value Driven 
Specialty Care: 
PHN Integration 
Value Driven Actuarial and Operational Informatics
Clinical Foci for Population Care 
Heal • Teach • Discover • Serve 
Copyright Geisinger Health System 2014 
Not for reuse or distribution without permission 
Geisinger Health System Confidential and Proprietary 
Automated 
prevention for all 
patients 
• Physician 
Directed, 
Team 
Delivered 
• Patient and 
Family 
Activated 
Care 
Multi-chronic 
Disease 
Chronic 
Disease 
WWeellll 
Concentrated Care 
• Technology 
enabled RN 
support 
• High Touch 
• High Tech 
Enhanced Systems of 
Care 
• Proactive Monitored 
• Office Based 
• Mobile Accelerated
Heal • Teach • Discover • Serve 
Copyright Geisinger Health System 2014 
Not for reuse or distribution without permission 
Geisinger Health System Confidential and Proprietary
What is OpenNotes? 
In OpenNotes, doctors use a secure Internet portal 
to invite patients to review notes following an office 
visit. 
The heart of OpenNotes is to: 
• Involve patients far more actively in all aspects 
Heal • Teach • Discover • Serve 
Copyright Geisinger Health System 2014 
Not for reuse or distribution without permission 
Geisinger Health System Confidential and Proprietary 
of care 
• Improve communication between the doctor and 
patient 
• Encourage patients to share information with 
others, including those who care for them 
• Help prevent mistakes 
5 
5
Heal • Teach • Discover • Serve 
Copyright Geisinger Health System 2014 
Not for reuse or distribution without permission 
Geisinger Health System Confidential and Proprietary
CHANGE 
“Every few hundred years, throughout Western 
history, a sharp transformation has occurred. 
In a matter of decades, society altogether 
rearranges itself: its world view, its basic values, 
its social and political structures, its arts, its key 
institutions. Fifty years later, a new world exists, 
and the people born into that world cannot even 
imagine the world in which their grandparents 
lived and into which their own parents were born. 
Our age is such a period of transformation.” 
Heal • Teach • Discover • Serve 
Copyright Geisinger Health System 2014 
Not for reuse or distribution without permission 
Geisinger Health System Confidential and Proprietary 
7 
Peter Drucker, “Managing in a Time of Great Change”
Patient Engagement: A Key Strategy for Population Health Management 
Today’s panelists... 
Tammy Richards 
Operations director, 
patient and clinical 
engagement, 
Intermountain Healthcare, 
Salt Lake City 
TODAY’S MODERATOR 
Maureen McKinney 
Editorial programs 
manager, 
Modern Healthcare 
Kristin Carman 
Vice president, director, 
Center for Patient and 
Consumer Engagement, 
American Institutes 
for Research, 
Washington 
Dr. Thomas Graf 
Chief medical officer 
for population health, 
Geisinger Health System, 
Danville, Pa. 
During today’s discussion, feel free to submit questions at any time by using the questions box.
Thank you... 
... for attending today’s editorial webinar on patient engagement and population health management. 
We also thank our panelists, Kristin Carman, vice president, director, Center for Patient and Consumer 
Engagement, American Institutes for Research,Washington; Dr. Thomas Graf, chief medical officer for 
population health, Geisinger Health System, Danville, Pa.; and Tammy Richards, operations director, 
patient and clinical engagement, Intermountain Healthcare, Salt Lake City. 
Expect a follow-up e-mail within two weeks. For more information, 
send an e-mail to webinars@modernhealthcare.com 
Register now for Modern Healthcare’s next virtual conference, “Building Tomorrow’s Delivery Model,” set for 
Wednesday, Oct. 15. For more information, please visit modernhealthcare.com/building

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Webinar: Patient Engagement

  • 1. Welcome... During today’s discussion, feel free to submit questions at any time by using the questions box. A follow-up e-mail will be sent to all attendees with links to the presentation materials online. Today’s topic Patient Engagement: A Key Strategy for Population Health Management Tammy Richards Operations director, patient and clinical engagement, Intermountain Healthcare, Salt Lake City Dr. Thomas Graf Chief medical officer for population health, Geisinger Health System, Danville, Pa. Kristin Carman Vice president, director, Center for Patient and Consumer Engagement, American Institutes for Research, Washington
  • 2. Housekeeping 1. Viewer Window 2. Control Panel
  • 3. Now speaking... Please use the questions box on your webinar dashboard to submit comments to our moderator Maureen McKinney Editorial programs manager, Modern Healthcare
  • 4. Now speaking... Please use the questions box on your webinar dashboard to submit comments to our moderator Kristin Carman VP, director, Center for Patient and Consumer Engagement, American Institutes for Research
  • 5. AMERICAN INSTITUTES FOR RESEARCH 1 Goals • Define patient and family engagement • Discuss the benefits of patient and family engagement • Explain why we created a roadmap to patient and family engagement • A Roadmap for Patient and Family Engagement in Healthcare Practice and Research: Change Strategies
  • 6. AMERICAN INSTITUTES FOR RESEARCH 2 A working definition for patient and family engagement Patients, families, their representatives, and health professionals Working in active partnership At various levels across the health care system To improve health and health care Carman et al., “Patient and Family Engagement: A Framework for Understanding the Elements and Developing Interventions and Policies” Health Affairs, 32, no.2 (2013):223-231
  • 7. Who: Patients, families, providers, systems Public policies and culture Health care organizations and systems Clinicians and health care providers Family and friends AMERICAN INSTITUTES FOR RESEARCH 3 Patients
  • 8. CCoonnssuullttaattiioonn IInnvvoollvveemmeenntt AMERICAN INSTITUTES FOR RESEARCH Partnership and shared leadership 4 What: Working in active partnership • Partnership and shared leadership involves real culture change, which means: – Leadership commitment – Provider / patient education – Potential changes to workflows, policies, and procedures
  • 9. AMERICAN INSTITUTES FOR RESEARCH 5 Where: At various levels
  • 10. How does patient and family engagement differ from patient activation? • Patient activation: an “individual’s knowledge, skill, and confidence for managing his/her own health and health care” • How is that different from patient and family engagement? • Focuses on the individual • Does not look at behavior • Does not address the individual’s external context • Is one aspect of person’s ability to engage in care AMERICAN INSTITUTES FOR RESEARCH 6
  • 11. Who can benefit from patient and family engagement? • Patients and families – Improved health outcomes – Better experiences of care • Clinicians and health care providers – Improved satisfaction and retention • Health care organizations and systems – Competitive edge – Standards, reimbursement, and requirements AMERICAN INSTITUTES FOR RESEARCH 7
  • 12. AMERICAN INSTITUTES FOR RESEARCH 8 Our Goals • Develop a unified roadmap for practice and research • Move from what-ifs to action • Build on existing work and use multiple inputs • Convene a multidisciplinary group of key stakeholders
  • 13. What did we ask participants to do? • Develop vision for the field – build physical roadmaps AMERICAN INSTITUTES FOR RESEARCH 9 – Milestones and destinations – Strategies and tactics – Factors that affect progress – Timing: today, tomorrow, future
  • 14. AMERICAN INSTITUTES FOR RESEARCH 10 The Roadmap
  • 15. AMERICAN INSTITUTES FOR RESEARCH 11
  • 16. 8 Change Strategies AMERICAN INSTITUTES FOR RESEARCH 12
  • 17. Change Strategies: Preparing for Engagement Patient and Family Preparation Educate, prepare, and empower patients and families to engage effectively in their health and healthcare What can we do? Implement patient-centered tools to support shared decision making Clinician and Leadership Preparation Educate, prepare, and empower clinicians and healthcare leaders to partner effectively with patients and families What can we do? Develop standardized patient and family engagement competencies AMERICAN INSTITUTES FOR RESEARCH 13
  • 18. Care and System Redesign Redesign system processes, policies, and structures to provide opportunities for and support of partnerships between patients, families, and the healthcare team What can we do? Restructure care processes to support shared decision making. Document the process, including the content of discussion about risks, benefits, and patient goals, values, and preferences. AMERICAN INSTITUTES FOR RESEARCH 14
  • 19. More information AIR’s Center for Patient and Consumer Engagement http://aircpce.org Coming September 23rd- Roadmap to Patient and Family Engagement in Health Care Practice and Research www.patientfamilyengagement.org/roadmap AMERICAN INSTITUTES FOR RESEARCH 15
  • 20. Now speaking... Please use the questions box on your webinar dashboard to submit comments to our moderator Tammy Richards Operations director, patient and clinical engagement Intermountain Healthcare
  • 21. Patient Engagement Vision & Definition Vision: To build a patient-centered, value-oriented model for engaging patients. Definition: The effective partnership between the patient, the family and the healthcare team to collaboratively achieve the patient’s health-related goals.
  • 22. HCAHPS Care Transitions Questions 42.6% Intermountain Healthcare System Scores 57.9% (PR=94) 59.8% 51.2% 68.0% (PR=93) 73.0% (PR=92) 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. When I left the hospital, I clearly understood the purpose for taking each of my medications. NRC 50th percentile top box score Intermountain YTD top box score
  • 23. Deloitte Report: State of Engagement Comparison: 2008 and 2012
  • 24. Opting out of CCM (Example) 337 pts 169 pts 40 pts Current “Opt Out” Rate = 42%
  • 25. National Levels of Literacy Basic 22% Below Basic 14% Intermediate 52% Proficient 12% Basic Below Basic Intermediate Proficient
  • 26.
  • 27. Now speaking... Please use the questions box on your webinar dashboard to submit comments to our moderator Dr. Thomas Graf Chief medical officer for population health Geisinger Health System
  • 28. “Let us bear in mind that the most important individual after all is the patient. Our paramount thought must be to provide him means by which he can have skilled diagnostic and therapeutic service in as complete form as may be indicated in a given case, in the shortest possible time consistent with thoroughness, and at the least cost to him.” HL Foss, MD Heal • Teach • Discover • Serve Copyright Geisinger Health System 2014 Not for reuse or distribution without permission Geisinger Health System Confidential and Proprietary 11/4/1950 1
  • 29. The Functional Components of Population Health Cultural Transformation Heal • Teach • Discover • Serve Copyright Geisinger Health System 2014 Value Driven Population Care ProvenHealth® Navigator, Clinical Redesign Value Driven Post- Acute Care: TOC, SNFist Not for reuse or distribution without permission Geisinger Health System Confidential and Proprietary Value Driven Acute Care: Proven Care Acute Data Driven Care and Leadership Evolutions Value Driven Specialty Care: PHN Integration Value Driven Actuarial and Operational Informatics
  • 30. Clinical Foci for Population Care Heal • Teach • Discover • Serve Copyright Geisinger Health System 2014 Not for reuse or distribution without permission Geisinger Health System Confidential and Proprietary Automated prevention for all patients • Physician Directed, Team Delivered • Patient and Family Activated Care Multi-chronic Disease Chronic Disease WWeellll Concentrated Care • Technology enabled RN support • High Touch • High Tech Enhanced Systems of Care • Proactive Monitored • Office Based • Mobile Accelerated
  • 31. Heal • Teach • Discover • Serve Copyright Geisinger Health System 2014 Not for reuse or distribution without permission Geisinger Health System Confidential and Proprietary
  • 32. What is OpenNotes? In OpenNotes, doctors use a secure Internet portal to invite patients to review notes following an office visit. The heart of OpenNotes is to: • Involve patients far more actively in all aspects Heal • Teach • Discover • Serve Copyright Geisinger Health System 2014 Not for reuse or distribution without permission Geisinger Health System Confidential and Proprietary of care • Improve communication between the doctor and patient • Encourage patients to share information with others, including those who care for them • Help prevent mistakes 5 5
  • 33. Heal • Teach • Discover • Serve Copyright Geisinger Health System 2014 Not for reuse or distribution without permission Geisinger Health System Confidential and Proprietary
  • 34. CHANGE “Every few hundred years, throughout Western history, a sharp transformation has occurred. In a matter of decades, society altogether rearranges itself: its world view, its basic values, its social and political structures, its arts, its key institutions. Fifty years later, a new world exists, and the people born into that world cannot even imagine the world in which their grandparents lived and into which their own parents were born. Our age is such a period of transformation.” Heal • Teach • Discover • Serve Copyright Geisinger Health System 2014 Not for reuse or distribution without permission Geisinger Health System Confidential and Proprietary 7 Peter Drucker, “Managing in a Time of Great Change”
  • 35. Patient Engagement: A Key Strategy for Population Health Management Today’s panelists... Tammy Richards Operations director, patient and clinical engagement, Intermountain Healthcare, Salt Lake City TODAY’S MODERATOR Maureen McKinney Editorial programs manager, Modern Healthcare Kristin Carman Vice president, director, Center for Patient and Consumer Engagement, American Institutes for Research, Washington Dr. Thomas Graf Chief medical officer for population health, Geisinger Health System, Danville, Pa. During today’s discussion, feel free to submit questions at any time by using the questions box.
  • 36. Thank you... ... for attending today’s editorial webinar on patient engagement and population health management. We also thank our panelists, Kristin Carman, vice president, director, Center for Patient and Consumer Engagement, American Institutes for Research,Washington; Dr. Thomas Graf, chief medical officer for population health, Geisinger Health System, Danville, Pa.; and Tammy Richards, operations director, patient and clinical engagement, Intermountain Healthcare, Salt Lake City. Expect a follow-up e-mail within two weeks. For more information, send an e-mail to webinars@modernhealthcare.com Register now for Modern Healthcare’s next virtual conference, “Building Tomorrow’s Delivery Model,” set for Wednesday, Oct. 15. For more information, please visit modernhealthcare.com/building