Engaging high-need patients to produce scalable high-value health care

Project: Research project

Description

We propose a Northwestern University (NU) demonstration project to improve high-value and patient-centered health care in two programs: specialty oncology care and primary care practice focusing on chronic kidney disease (CKD). At NU, we define “high-value” care as the delivery of the best health outcomes at the lowest cost. Patient-centered care delivery is defined in collaboration with patients and families, and incorporates traditional clinical processes and outcomes as well as symptom management, patient engagement, patient activation, and cost.

Our premise is that we can involve patients in shared care planning or “coproduction” of the care plan with the clinical team, enable them to monitor their health and symptoms in collaboration with the team, and use emerging insights in clinical informatics to “nudge” their care toward optimal, appropriate, and lower cost care pathways. We anticipate that outcomes of this process will include more engaged patients, care which aligns to evidence-based pathways, better-managed symptoms, improved value of care, and safe and effective care outcomes. This proposed work will constitute a proof-of-concept which can be packaged as a toolkit for replication in other populations and provider settings.

The proposal builds on Northwestern University’s deep and broad expertise in patient-centered outcomes, learning health systems, and value-based care. This includes our Department of Medical Social Sciences’ renowned leadership in the development and clinical integration of the Patient-Reported Outcomes Measurement Information System (PROMIS), our institutional commitment to improving healthcare quality via implementation of scalable, population-based, community-engaged approaches, our Institute for Public Health and Medicine (including centers on patient-centered outcomes, health economics, and community health), and the Northwestern Memorial HealthCare Corporation (NMHC), with its resources and cultural commitment to the use of learning health systems for continuous quality improvement. With input from our partners at Dartmouth-Hitchcock Medical Center, we propose to translate decades of progress in health-related measurement and health care improvement into scalable, sustainable models of value-based care that accounts for the needs and preferences of patients and their families. We will use the robust tools and methods at our disposal to generate an innovative, high impact approach to value-based care that will serve as a model for the nation and demonstrate the substantial benefits of patient-centered learning health systems-based care.

The formal partnership of NU and NMHC, referred to hereafter as Northwestern Medicine, enables us to address real-world health care issues with academic sophistication. The centerpiece of this proposal is our Northwestern Medicine Symptom Management Shared Decision-Making (NM-SMSDM) dashboard model (Figure 1). This approach integrates emerging research indicating that better patient outcomes and reduced cost can be enhanced through patient-clinician collaboration in the context of well-designed workflows and systems.
StatusActive
Effective start/end date9/1/188/31/21

Funding

  • Peter G. Peterson Foundation (19041)

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Delivery of Health Care
Health
Patient Participation
Costs and Cost Analysis
Patient-Centered Care
Medicine
Learning
Medical Informatics
Workflow
Patient Preference
Social Sciences
Quality of Health Care
Quality Improvement
Chronic Renal Insufficiency
Information Systems
Population
Primary Health Care
Decision Making
Patient Care
Public Health