Strategies for identifying, sharing, disseminating and implementing best practices in the care of patients with multiple chronic conditions and end-of-life care needs

Background: Achieving the triple aim of better health outcomes, improved quality of care and lower per capita costs is a key goal of the ACA.  SCAN Health Plan partnered with UCLA School of Medicine to identify five best practices in caring for high-risk, geriatric patients with end-of-life care needs and multiple chronic conditions, and disseminated these practices to other contexts.  

Methods: Medical groups working with SCAN Health Plan received a survey followed by semi-structured interviews to identify promising interventions.  A set of criteria was developed to judge the best practices on addressing an identified need, demonstrating evidence of achieving the triple aim, scalability and sustainability.  The selected best practices were presented in a Summit, where attendees selected one of the practices, worked with experienced physician coaches to draft an action plan with specific, measurable, achievable, realistic and timely goals and a timeline to implement their selected innovation using quality improvement principles. Following the Summit, coaches met with their teams every two weeks to guide implementation.

Results:  The five best practices included outpatient palliative care, palliative nurse training, advanced care planning for high-risk patients, complex care management and a virtual care team. Each one of the best practices was selected by at least one medical group in the Summit. Preliminary results indicate that 64% of the participating groups carried out implementation activities.

Conclusions: Preliminary results indicate that structured action planning and coaching improves adoption of innovations. Further study of long-term outcomes, patient satisfaction, utilization, sustainability and scalability is needed.