Saas Advancing _ Shared Decision Making for Older Adults " In New York City: Lessons from FAIR Health's Provider-Oriented Shared Decision-Making Initiative A FAIR Health Brief, February 1, 2022 FAIRGESI DAU mice: Copyright 2022, FAIR Health, Inc. All rights reserved. Summary Shared decision making (SDM) involves patient-clinician communication to decide on tests, treatment and care based on clinical evidence, balancing risks and outcomes with patient and caregiver preferences and values.' SDM shows promise for engaging patients in their healthcare decisions and promoting communication with, and trust in, physicians. Generally involving evidence- based strategies and decision aids (DAs), SDM has been associated with lower medical costs, and fewer preference-sensitive procedures and hospital admissions." Incorporating patients' values and preferences into discussions of care through SDM is particularly important for older adults, whose priorities often differ from those of younger patients and may be overlooked by physicians.? Indeed, results from a qualitative study suggested that older adults prefer an active role in the decision- making process to ensure their opinions are heard. 1 "Shared Decision Making," National Learning Consortium, December 2013. 2 David Veroff, Amy Marr and David E. Wennberg, "Enhanced Support for Shared Decision Making Reduced Costs of Care for Patients with Preference-Sensitive Conditions,' Health Affairs 32, no. 2 (February 2013), https://doi.org/10.1377/hithaff.2011.0941. 3 Judith Graham, "The Talk Seniors Need To Have with Doctors Before Surgery,' Kaiser Health News, August 1, 2019, https://khn.org/news/the-talk-seniors-need-to-have-with-doctors-before-surgery/. 4 Winne C. Chi et al., "Multimorbidity and Decision-Making Preferences among Older Adults," Annals of Family Medicine 15, no. 6 (November 2017): 546-552, https://doi.org/10.1370/afm.2106. Health ADVANCING SHARED DECISION MAKING FOR OLDER ADULTS IN NEW YORK CITY Know Your Source 2 Summary Although there is ample evidence of SDM's value, its adoption has been limited. FAIR Health recognized that an effective way to advance SDM as a critical component of healthcare decision making for older adults was to focus on educating healthcare providers (e.g., physicians, nurse practitioners, social workers and home health professionals) about SDM. In June 2020, the Board of Directors at The Fan Fox & Leslie R. Samuels Foundation (Samuels Foundation) awarded a grant to FAIR Health to develop and disseminate a curriculum on SDM to providers and clinicians in New York City who serve older adults facing critical palliative care decisions. In April 2021, following an initial phase of research and development, FAIR Health officially announced the launch of FAIR Health's free provider-oriented platform, fairhealthprovider.org (FAIR Health Provider). Through this platform, providers (e.g., physicians, nurse practitioners, social workers and home health professionals) and clinicians can access educational content that guides providers in having patient-provider discussions, as well as in the use of SDM tools that outline various treatment possibilities and associated costs. In this brief, FAIR Health presents salient program learnings that can help inform current and future SDM initiatives, whether focused on older adults or other patient populations. Among the key lessons learned: * Acceptability and Utility of SDM Educational Content and Resources on FAIR Health Provider. Based on qualitative insights and quantitative results we collected, providers deemed the website acceptable and useful for facilitating SDM with older adults. * Provider Awareness and Buy-In. The project evaluation indicated provider interest in utilizing SDM for older adult care. * Key Challenges Confronting Providers concerning SDM. Notwithstanding providers' keen interest in SDM, challenges remain in the uptake of SDM due to time constraints and access to clinical and educational resources. Health ADVANCING SHARED DECISION MAKING FOR OLDER ADULTS IN NEW YORK CITY 3 Know Your Source Background SDM shows promise for reducing unnecessary spending? and healthcare costs,° and for improving decision making without an adverse effect on clinical outcomes.' It has been found to be particularly effective in scenarios involving preference-sensitive conditions (those for which the clinical evidence does not clearly support one treatment option and the appropriate course of treatment depends on the values or preferences of the patient) and patients with serious illnesses facing palliative care decisions. Using DAs during the decision-making process allows patients to compare two to three clinical options at once and choose the care they prefer. To date, most DAs have not included cost information alongside the clinical options provided. In March 2020, FAIR Health launched a set of DAs that integrate cost information with clinical information® for three specific palliative care scenarios on the FAIR Health Consumer website: kidney dialysis, breathing assistance and nutritional assistance. The groundbreaking project, funded generously by The New York Community Trust, involved a shared decision-making expert at Dartmouth College's Institute for Health Policy and Clinical Practice and an expert in palliative care.° > Emily Oshima Lee and Ezekiel J. Emanuel, "Shared Decision Making to Improve Care and Reduce Costs," New England Journal of Medicine 368 (January 2013): 6-8, https://doi.org/10.1056/NEJMp1209500. 6 David Arterburn et al., "Introducing Decision Aids at Group Health Was Linked to Sharply Lower Hip and Knee Surgery Rates and Costs," Health Affairs 31, no. 9 (September 2012): 2094-2104, https://doi.org/10.1377/hlthaff.2011.0686. 7 Megan E. Branda et al., "Shared Decision Making for Patients with Type 2 Diabetes: A Randomized Trial in Primary Care," BMC Health Services Research 13, no. 301 (August 2013): https://doi.org/10.1186/1472-6963-13-301. 8 FAIR Health licensed Option Grid™ patient decision aids, which feature clinical information, from EBSCO. ° We thank Professor Glyn Elwyn and Dr. Diane Meier for their involvement in this project. Health ADVANCING SHARED DECISION MAKING FOR OLDER ADULTS IN NEW YORK CITY 4 Know Your Source Background Since its launch, the SDM section on the consumer website has received more than 70,000 unique visitors nationwide, indicating a strong appetite for such tools. The evaluation data from this initiative made it evident that the decision-making process was simplified by FAIR Health's SDM tools, and that the cost information was particularly helpful. The program evaluation, highlighted in this brief, also underscored that providers are an important conduit for promoting SDM. However, despite some awareness of SDM as an approach to clinical practice, the idea did not appear to be very familiar among palliative care providers. SDM's limited adoption among providers may be due to time constraints during clinical encounters, lack of physician training and the absence of consensus regarding what SDM should comprise.'° Beliefs among physicians regarding SDM, such as that the process is too demanding and time- consuming,'" '2 also may impede SDM adoption. Studies have shown that dispelling these beliefs through physician-centered training results in increased adoption of SDM." 10 Fiona Ryan and Susan Cunningham, "Shared Decision Making in Healthcare,' Royal College of Surgeons of England 5, no. 3 (July 2014): 124-127, https://doi.org/10.1308/204268514X14017784505970. ™ France Légaré and Philippe Thompson-Leduc, "Twelve Myths about Shared Decision Making," Patient Education and Counseling 96 (2014): 281-286, https://doi.org/10.1016/j.pec.2014.06.014. 12 France Légaré and Holly O. Witteman, "Shared Decision Making: Examining Key Elements and Barriers to Adoption into Routine Clinical Practice," Health Affairs 32, no. 2 (February 2013): https://doi.org/10.1377/hlthaff.2012.1078. 13 Légaré and Witteman, "Shared Decision Making." Health ADVANCING SHARED DECISION MAKING FOR OLDER ADULTS IN NEW YORK CITY Know Your Source 5 The FAIR Health Provider SDM Initiative To address SDM's limited adoption among providers, FAIR Health built on its existing efforts to bring SDM to consumers by focusing on educating providers who serve older adults in New York City about SDM. The 18-month initiative, generously supported by the Samuels Foundation, aimed to enhance general knowledge of how providers can incorporate SDM into their clinical practice by developing a web-based curriculum and training materials, housed on a provider-oriented website, FAIR Health Provider. The website instructs physicians and other healthcare providers in the use of DAs to support patients in considering both the clinical and cost-related aspects of their healthcare decisions. FAIR Health recognized that the increased adoption of SDM through provider-oriented training may help improve care for older adults, as well as support family caregivers by stimulating greater patient and caregiver engagement in the decision-making process. We decided to offer this provider- oriented education through a free, user-friendly website to provide healthcare providers with quick access to information and SDM-related tools and resources. To assure the site's appeal to providers, we conducted a beta test prelaunch, in which we solicited feedback on the site from a range of healthcare providers, including a hospital-based palliative care nurse, a hospital-based palliative care physician and the head of a palliative care advocacy group, among others. The feedback was then utilized to make enhancements to the site prior to the formal launch. Prewidar Educational Content Introduction to FAIR Health Provid icome bewaltin Leam more Health ADVANCING SHARED DECISION MAKING FOR OLDER ADULTS IN NEW YORK CITY Know Your Source 6 The FAIR Health Provider SDM Initiative After the April 2021 official launch of the FAIR Health Provider site, we embarked on a robust dissemination campaign to raise providers' awareness of its content and tools. This campaign consisted of targeted email outreach to providers, Facebook ads and press circulation-reaching tens of millions of individuals-in outlets including Crain's Health Pulse, News Medical Life Sciences and BadCredit.org. FAIR Health also conducted dedicated email outreach to 300 associations and organizations nationwide, including: * Palliative care and aging associations and organizations; ¢ Leading medical and public health schools; * Top hospitals for geriatrics; ¢ Philanthropic organizations and agencies dedicated to health and aging; ¢ Nursing homes; and * State health departments and offices. In the following months, FAIR Health conducted quantitative and qualitative evaluations to assess the utility and value of the SDM tools and instructional materials to patients and providers. The results of the mixed methods evaluation are described below. 1 iHealth Abou FAIR Heat «= About Shared Decisian Making © Shared Decision-Making Toole © FH FeeEstmaor® «© ®arientEducationalConment «= Resouces ES] QQ Provider About Shared Decision Making Shared Decision Making With a gene m the prot slice ele ner ct Ee sete aps] El Ke Dialysis for People Who Are Seriously Ill ly Nutrition Options for People Who Are Seriously ill; and I Ale) Ventilator for People Who Are Seriously tL (la) ated ta the three Health ADVANCING SHARED DECISION MAKING FOR OLDER ADULTS IN NEW YORK CITY Know Your Source 7 Program Learnings FAIR Health's program evaluation offered a unique opportunity to learn about the impact of the SDM resources on the FAIR Health Provider site and to better understand points in the decision-making process where the resources would be most helpful. We collected qualitative and quantitative data over several months. Qualitative methods included informal interviews/discussions with providers and questionnaires with "free text" boxes to encourage feedback from those with limited time. Quantitative methods included calculating usage analytics on social media (e.g., Facebook, Twitter), tracking website visits using digital platforms and receiving feedback from surveys. Acceptability and Utility of SDM Educational Content and Resources on FAIR Health Provider The acceptability and utility of the FAIR Health Provider SDM section as a resource for providers and caregivers was highlighted by the qualitative and quantitative data we collected over the program period. Responses to the FAIR Health Provider survey revealed that, of the content available on the site, providers found the most useful sections to be the SDM toolkit, patient resources, decision tools and information about SDM. Providers reported that this content was valuable, or would be valuable, in a clinical setting with older adults and their caregivers. In fact, nearly 87 percent of provider survey respondents noted that the site's SDM content was "useful" or "very useful," and close to 79 percent reported that they will "likely" or "very likely" engage in SDM after visiting the site. Providers' qualitative feedback-such as the increased need to discuss cost information with patients during appointments, and that FAIR Health Provider would be a great way to facilitate those discussions-reinforced quantitative findings. Health ADVANCING SHARED DECISION MAKING FOR OLDER ADULTS IN NEW YORK CITY Know Your Source 8 Program Learnings Though understanding the long-term impact of the educational content and tools on FAIR Health Provider about older patient care will require more time, the evaluation findings pointed to the continued acceptability and perceived utility of the DAs and ancillary resources to consumers. Additional visits to the FAIR Health Consumer SDM feature and responses received on the DA- specific surveys further suggest consumer interest in SDM tools for scenarios relevant to serious illnesses. Cost Information Comments from the FAIR Health Provider survey uncovered providers' perceptions of the utility of the cost information on the DAs. One provider, for example, observed: "/ think the cost information in particular is useful. The other information wasn't as new to me." Another provider comment in response to what would be most helpful on the site was: "The cost of specific interventions (not easy information to find, even as a clinician)." A smaller portion of provider respondents who used the DAs noted that they discussed the cost portion of the DAs with patients. The qualitative data collected from providers' and consumers' survey responses illuminate the utility of the cost information in the DAs and underscore the need for cost information in SDM discussions that concern individual preferences and situations with older patients and caregivers. re $ DP 4 | think the cost information in particular is useful. } = Health ADVANCING SHARED DECISION MAKING FOR OLDER ADULTS IN NEW YORK CITY Know Your Source Program Learnings Provider Awareness and Buy-In: A Critical Pathway for Greater Adoption of SDM FAIR Health's 2020 brief on lessons learned from a consumer-facing SDM initiative noted that provider acceptability of SDM tools was a critical pathway for promoting SDM, and that clinicians welcomed the guidance of SDM tools when having difficult discussions. Early results pointed to the acceptability of DAs among consumers; nevertheless, providers were deemed an important conduit for advancing SDM. The findings from this initiative's evaluation reinforced those earlier observations. Notably, a portion of the providers who responded to the survey had been aware of and conducted SDM discussions. The increased adoption of SDM through provider-oriented training may help improve care for older adults and support familial and nonfamilial caregivers/care partners by stimulating greater patient and caregiver/care partner engagement in the healthcare decision- making process. While the evaluation demonstrated real-world challenges that providers face in conducting SDM (e.g., time constraints, need for resources), it also revealed provider interest and concomitant consumer interest in opening the door to SDM pertaining to older adult care. The evaluation underscored that offering easily accessible information and tools (e.g., DAs, checklists and toolkits) that support SDM discussions can be helpful. In addition, another critical avenue for improving SDM uptake among providers may involve dedicated reimbursement for conducting such discussions." 14 Glyn Elwyn et al., "Many Miles to Go ..': A Systematic Review of the Implementation of Patient Decision Support Interventions into Routine Clinical Practice,' BMC Medical Informatics and Decision Making 13, suppl. 2 (November 29, 2013): S14, https://doi.org/10.1186/1472-6947-13-S2-S14. Health ADVANCING SHARED DECISION MAKING FOR OLDER ADULTS IN NEW YORK CITY 10 Know Your Source Program Learnings Importance of a Targeted, Multichannel and Flexible Dissemination Strategy FAIR Health's dissemination strategy initially centered on outreach and training to providers who care for older adults throughout the New York City metropolitan area. During the implementation of the dissemination plan, the FAIR Health project teams noted that awareness and use of the FAIR Health Provider site's SDM content and tools could be increased through Facebook ads. From June to October 2021, FAIR Health ran Facebook ads that reached 137,303 individuals. Building a targeted, multichannel and flexible dissemination plan is key to maximizing awareness and use of the FAIR Health Provider site. Offering Incentives to Increase Provider Survey Response FAIR Health encountered a well-known challenge when seeking survey feedback from providers: low survey response rates.'° A potential solution to increase provider responsiveness is through compensation in exchange for participation,'© which has been noted in the literature. FAIR Health incentivized feedback by working with a palliative care provider and the head of a palliative care advocacy group to offer gift cards to initial survey respondents. The additional responses generated through this effort underscored the value of offering incentives for feedback, especially for those with time constraints. 15 S. M. Cummings, L. A. Savitz and T. R. Konrad, "Reported Response Rates to Mailed Physician Questionnaires," Health Service Research 35, no. 6 (February 2001): 1347-1355, https://www.ncbi.nlm.nih.gov/pmce/articles/PMC1089194/. 16 K, Carrie et al., "Facilitators and Barriers to Survey Participation by Physicians: A Call to Action for Researchers,' (2013), http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.866.2647&rep=rep1 &type=pdf. Health ADVANCING SHARED DECISION MAKING FOR OLDER ADULTS IN NEW YORK CITY 1 1 Know Your Source Conclusion SDM holds great potential for improving the quality of care that older adults, especially those with serious illnesses, receive. The initiative that was generously funded by the Samuels Foundation enabled FAIR Health to develop and disseminate a provider-centered website with educational content and tools pertaining to SDM, thereby advancing a critical component of the SDM discussion loop. The evaluation findings indicated the acceptability and perceived utility to providers of the tools and content on FAIR Health Provider, and the acceptability and perceived utility to consumers of DAs and supporting materials. These findings also support increasing adoption of SDM with additional dedicated provider training initiatives, general awareness of SDM and dedicated reimbursement for providers who engage in these discussions. Having met the goals of this initiative, FAIR Health will enhance and maintain the SDM section of FAIR Health Provider, using a combination of in-kind resources and subsequent grant funding. In spring 2022, FAIR Health will launch three new SDM tools on FAIR Health Provider as part of an initiative funded by the New York State Health Foundation meant to advance SDM among patients of color in New York State. With a grant from The John A. Hartford Foundation, in mid-2022, FAIR Health will build on resources offered to older patients and their caregivers/care partners by introducing new SDM tools and total treatment cost scenarios on FAIR Health Consumer. We will promote the tools through a robust dissemination campaign. In time, SDM may serve an increasingly important role in assuring that older patients and their caregivers have the tools to make informed decisions as they navigate the healthcare system. This, in turn, may lead to greater patient satisfaction, engagement and care quality on both the micro and macro levels. With our continued focus on bringing greater transparency to healthcare costs and healthcare information, FAIR Health will continue to equip consumers and providers with the tools and information they need to achieve better care through informed decision making grounded in clear, objective information-a win-win-win for older patients, their caregivers and their providers. Health ADVANCING SHARED DECISION MAKING FOR OLDER ADULTS IN NEW YORK CITY 12 Know Your Source About FAIR Health FAIR Health is a national, independent nonprofit organization dedicated to bringing transparency to healthcare costs and health insurance information through data products, consumer resources and health systems research support. FAIR Health qualifies as a public charity under section 501(c)(3) of the federal tax code. FAIR Health possesses the nation's largest collection of private healthcare claims data, which includes over 35 billion claim records and is growing at a rate of over 2 billion claim records a year. FAIR Health licenses its privately billed data and data products-including benchmark modules, data visualizations, custom analytics and market indices-to commercial insurers and self-insurers, employers, providers, hospitals and healthcare systems, government agencies, researchers and others. Certified by the Centers for Medicare & Medicaid Services (CMS) as a national Qualified Entity, FAIR Health also receives data representing the experience of all individuals enrolled in traditional Medicare Parts A, B and D; FAIR Health includes among the private claims data in its database, data on Medicare Advantage enrollees. FAIR Health can produce insightful analytic reports and data products based on combined Medicare and commercial claims data for government, providers, payors and other authorized users. FAIR Health's free, award- winning, national consumer websites are fairhealthconsumer.org and fairhealthconsumidor.org. For more information on FAIR Health, visit fairhealth.org. FAIR Health, Inc. 530 Fifth Avenue, 18th Floor New York, NY 10036 212-370-0704 fairhealth.org fairhealthconsumer.org fairhealthconsumidor.org. Copyright 2022, FAIR Health, Inc. All rights reserved. Health ADVANCING SHARED DECISION MAKING FOR OLDER ADULTS IN NEW YORK CITY Know Your Source 13