Minnesota Clinic Spreads Shared Decision Making to Primary Care

Stillwater Medical Group, a large multispecialty practice in Stillwater, Minn., is starting to use shared decision making with primary care patients who have benign prostatic hyperplasia (BPH) through a demonstration project funded by the Foundation for Informed Medical Decision Making (FIMDM).

“It’s actually more difficult to introduce shared decision making in primary care than in specialty care because there are more providers and varying approaches to the treatment of BPH,” says Joyce Kramer, RN, BA, BCC, a clinical care coordinator for the group. “I would highly recommend that organizations start with a specialty population and borrow from their successes when they are ready to move into primary care.”

Customizing Decision Aids

Urologists at Stillwater Medical Group started using decision tools with prostate cancer patients as part of an earlier FIDDM demonstration project. When the decision aids were introduced for prostate cancer, it was clear that they wouldn’t be a one-size-fits-all solution. For example, the off-the-shelf video on prostate care treatment did not cover cryoablation, which irked some specialists. So the clinic decided to supplement the videos with more patient education.

Now, all patients with a prostate cancer or breast cancer diagnosis receive coordinated support that helps them make treatment decisions. Before their initial consultation with a specialist, breast and prostate cancer patients meet with Kramer, who is a clinical care coordinator.

“My role is to assess their knowledge of the disease, review their treatment options, and help them coordinate their treatment after biopsy and navigate the system,” says Kramer, who was hired initially to work with breast cancer patients to help increase their loyalty to this large group practice that provides primary and subspecialty care.

Patients are given a DVD/booklet and additional information to review before their treatment planning session with the specialist. Kramer documents patients’ concerns in the medical record, so that the specialist can review the information during the patient consult.

Expanding to Primary Care

Following the same process as with prostate cancer and breast cancer patients, men with BPH will meet with a nurse care coordinator to review videos and complete questionnaires before they return to their primary care physician to discuss their treatment options.

When starting with the BPH population, Stillwater focused on the primary care providers with the highest volumes in this population. “We found that there wasn’t a lot of consensus among providers on when to send patients with BPH to the urologist,” says Kramer says. “Our plan is to meet with patients after their initial diagnosis of BPH and before referral to a urologist. That’s actually good for urologists, who will see the more complex cases that require invasive treatments.”

The approach also allows primary care physicians to continue caring for those patients that choose less invasive treatments, such as watchful waiting or medications.

Retaining Loyal Patients

Kramer sees a growing role for nurses as personal coaches who can help walk patients through difficult treatment decisions. But they can’t do it on their own. “The most important thing is to have a physician champion willing to try a process that works for his or her practice and who is willing to pilot a program,” says Kramer.

In addition, she says it’s critical to have a data tracking system that can demonstrate how using a clinical care coordinator for decision support can help increase volumes, patient satisfaction, and physician satisfaction. “Improving patient flow and productivity can prove the value of these programs to the organization, which leads to the administration’s continued support.”

Currently, the services that Kramer provides are not billable. However, the clinic is seeing improved revenue through better patient retention. From 2007 to 2008, the clinic improved its retention of breast cancer patients from 70 percent to 91 percent. In addition, patient volumes increased by 10 percent over that time period. “The value of a nurse providing this service is very high, just in terms of keeping patients in the system,” she says.

In the coming months, the Stillwater Medical Group plans to coordinate decision-making resources for patients with diabetes and back pain.