States and the federal government are focusing on person-centered planning as an opportunity to better support high quality care, in particular for people with complex care needs. The COVID-19 pandemic has highlighted the importance of incorporating person and family-centered goals and preferences for care in those with complex and serious conditions; and specifically, the role of patient engagement and shared decision-making. Shared decision-making engages patients to identify individual preferences; evaluate treatment risks, benefits, and other information about treatment options; and work with providers to decide on a plan of treatment.
By involving the care recipient and family throughout the care process as partners and delivering care in line with an individual’s goals, shared decision-making approaches can reduce delivery of unwanted or unnecessary care and resulting costs. While historically person-centered planning has not been linked to value-based purchasing models, recent initiatives from the Centers for Medicare and Medicaid Services (CMS) around quality measurement are incorporating patient-centered measures into the Meaningful Measures initiative. Measures that strengthen person and family-centered care include patient experience, patient functional outcomes, personalized care that is aligned with patient’s goals, and end-of life-care according to preferences. To assist state governments and other partners, recent CMS guidance outlines strategies to engage patients and families through shared decision-making and appreciation of individual values by standardizing best practices and measuring outcomes. While CMS action will spur increased focus on person centered care, states have experience in implementing different models for such care across payers.
Spotlight: Washington State’s Promotion of Person and Family-Centered Care in Health Systems
In 2016, Washington State codified person-centered planning and shared decision-making by certifying Patient Decision Aids (PDAs). PDAs are tools, including written documents, interactive websites, videos, and visual aids, that help providers talk with patients as they make choices about their care and help align these choices with their values and goals.
Under authorizing legislation, Washington’s Health Care Authority (HCA) — which administers Medicaid and health insurance for public and school employees in the state — has the authority to certify PDAs. HCA has certified PDAs for end-of-life care, cardiac care, cancer screening, total joint replacement, spine care, maternity and labor/delivery. The legislation also extends legal protections to providers who utilize certified PDAs and defines “shared decision-making” and “patient decision aid” in its regulation around consent, alleviating risk for providers, which may ease hesitation around buy-in. Washington’s certification process for PDAs involves the Health Care Authority identifying a priority area and calling for submissions for PDA certifications. These submissions are reviewed both by its medical director and an advisory panel and are assessed on their ability to satisfy the certification requirements. Certification requirements are developed based on the standards developed by the International Patient Decision Aids Standards Collaboration, which include, but are not limited to, adequacy in identifying the eligible or targeted population; describing the health condition or problem, all medically reasonable options, and benefits and disadvantages of each option; and helping the patient elucidate their values and how the different options would align with these.
Although Washington is the only state to certify PDAs, states can adapt a similar approach through the following strategies:
- Promote person and family-centered planning through requirements around quality measures in contracts with managed care organizations and public/school employee health carriers. Washington’s Accountable Care program and Centers of Excellence highlight shared decision-making as a core principle to strive toward in these alternative payment models.
- Develop training and support for providers on implementing person-centered-planning and shared decision-making to develop nuance and awareness around these techniques beyond informed consent. The Washington legislature built in additional protections for providers and defines share-decision-making and patient decision aids in statute, reducing liability for providers who choose to use either signed consent forms or signed acknowledgements of shared decision-making.
- Convene workgroups or discussion opportunities to discuss integrating person-centered planning into health systems. The Bree Collaborative, a private-public stakeholder group and foundation established by the Washington Legislature, developed recommendations on shared-decision-making implementation. The HCA participated in this development and in helping to disseminate these recommendations.
- Collaborate with other stakeholders on disseminating recommendations around person-centered-planning to practices and providers.
On a recent NASHP webinar, Washington State HCA officials reported that they have found[1][2] that the use of patient decision aids can support high-quality shared decision-making, which in addition to improving patient experience and health outcomes, can improve health equity by reducing variation in outcomes among patients and supporting value-based care and appropriateness in utilization.
Acknowledgements: NASHP would like to thank Dr. Emily Transue and Laura Pennington (both Washington State Health Care Authority). This resource was developed with the generous funding from The John A. Hartford Foundation, and many thanks to Rani Snyder, Amy Berman, and Scott Bane for their continuing guidance and support.
[1] Shay LA, Lafata JE. Where is the evidence? A systematic review of shared decision making and patient outcomes. Med Decis Making. 2015;35:11431. 5
[2] Stacey D, Légaré F, Col NF, Bennett CL, Barry MJ, Eden KB, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014 Jan 28;(1):CD001431. 7
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