[Need to check contents and formatting against original in Roadmap appendix]
The Future Vision Workgroup was established by the ACTS Stakeholder Community to define the future vision from the four perspectives listed above. The Future Vision Workgroup consisted of 29 members from a wide range of CDOs, informatics researchers, clinical IT developers, CDS content developers, and policy organizations. Subgroups within the Future Vision Workgroup addressed each of the four perspectives (both LHS perspectives were developed by a single subgroup) and vetted the care delivery future vision with patients, care teams, and CDO leaders.
The Future Vision Workgroup met weekly by web conference to review the developing documents, provide feedback, and exchange ideas among the groups. The purpose of the Future Vision Workgroup was to create a consensus future vision for the four perspectives to serve as the destination to be reached by executing the stakeholder-driven ACTS Roadmap. Each perspective subgroup added specificity to the broader healthcare goal of achieving the Quintuple Aim. The Future Vision Workgroup sought to define a future state of healthcare that is so compelling that anyone with a stake in the future vision perspectives would be motivated to work toward achieving that future vision as part of Roadmap execution efforts.
The guiding principles of the future vision are to:
Staff from three organizations, VCU, the NACHC, and Health Hats (see Acknowledgements), shared the care delivery future vision for feedback with various clinical and lay stakeholders outside the Stakeholder Community to validate its core concepts and identify issues in achieving this vision:
Respondents were sent a high-level summary of key care delivery future vision elements, a narrative of current primary care for a fictitious patient, “Mae,” a second narrative of how Mae would receive and participate in her care in a future vision context, and discussion questions soliciting feedback on the future vision, what elements are already feasible, what new elements should receive priority, and obstacles to overcome.
Processes used in this outreach and resulting findings are summarized in aggregate, then followed by more details for each.
In general, clinicians and patients felt the future vision was desirable, with caveats. Both groups felt attention to social needs, like social isolation, was critical. Clinicians wanted reasonable expectations and appropriate support for new care paradigms. Patients felt that there needed to be more explicit attention to patient and caregiver assumptions, concerns, and goals.
The high-tech aspects of the future vision are not uniformly available (e.g., reliable internet access). Not all patients would be able or want to use them even if they were available, so workflow, paper, and relationship remain important tools. Decision aids must support true shared decision making, including attention to cost. Care plans must be functional, living documents. Any new tools and technology should make it easier for clinicians to deliver care as they are already suffering from information overload and unwieldy EHR function. The future vision also depends upon an adequate primary care workforce that is receiving support to deliver idealized models of primary care in partnership with patients and communities.
Respondents indicated parts of the care delivery future vision that could be accomplished today include communication via portal, team care models, systematic attention to prevention and chronic disease management that is evidence-based, and continued attention to longitudinal relationships between clinicians and patients as well as team-based care.
Respondents indicated the most important thing necessary to achieve the future vision is a commitment to address all the challenges listed. Some of this will require policy changes, payment, and new technology systems that must be supported or demanded by the electorate.
Those exposed to the ACTS Future Vision included primary care clinicians from across Virginia, both health-system-owned and independently owned. Altogether, eight practices were visited from northern and southeastern Virginia, along with a focus group of the ambulatory QI committee for a large system in southwest Virginia.
Staff shared the Mae current scenario, the Mae future vision scenario, and the questions that made up our interview guide in advance of a site visit. Staff recorded all interviews, had them transcribed, and provided the transcripts to qualitative researchers in our department (Family Medicine and Population Health) who did the primary analysis. Tony Kuzel and Alex Krist did secondary analyses and edited the final report.
All site visits and interviews were conducted in late July and most of August 2019.
Respondents listed tools and strategies currently in use for similar patients, feedback on the future vision, essential steps to achieve it (short- and long-term), and knowledge/use of AHRQ tools to enhance primary care.
All respondents felt the future vision was desirable and would result in better care for Mae and a better care experience for her, her lay support team, and professional care team. Some thought that a subset of patients would only want in-person interactions and would struggle with IT-based interventions.
Respondents cited several challenges: lack of adequate attention to non-medical needs that affect health; lack of universal internet access; lack of IT interoperability; inadequate primary care workforce; inadequate support for primary care function; current technology often not easy to use and doesn’t support needs; lack of payment models to support future vision care.
Respondents indicated the following could be accomplished with tools available today: communication via portal, team care models, systematic attention to preventive services, and chronic disease management that is evidence-based.
Respondents indicated the future vision could only be achieved with a commitment to address all the challenges listed above, some of which will require public support (electorate) for needed policy changes.
Respondents indicated the care delivery future vision should also address the linkage between the self-directed IT-based interventions with direct support from the personal clinician and care team.
NACHC extended the opportunity for feedback to its 15-member QI Advisory Board, representing a geographically diverse, national cross-section of health centers, primary care associations, and health-center-controlled networks.
NACHC sent its advisory board a version of the future vision, including the Mae current state and future vision scenarios adapted from VCU’s write-up.
NACHC hosted a virtual feedback session August 26, 2019. QI Advisory Board members received a future vision concept document in advance of the call, which included discussion questions.
QI Advisory Board members were asked to provide feedback on the areas outlined by the workgroup (desirability, challenges, what’s missing, etc.). Jerry Osheroff facilitated the discussion. NACHC opened the call, managed logistics, took notes, recorded the discussion, and shared notes back with the ACTS Project team.
Participating members of NACHC’s QI Advisory board expressed overall interest in the proposed future vision state, with one individual noting, “It is a wonderful case study, and the person-centered approach is very much aligned with the care delivery model we are working hard to create.” Another stated: “As a primary care provider, I always very much enjoy seeing what the future can look like and what could potentially be supported. It's very exciting to see where you're going with this.”
A majority of members expressed caution, pointing to issues of accessibility, patient-centeredness, resource constraints, and community integration. There was consensus that the vision was “highly digitized,” with a potential overreliance on technology that might be supplemented by greater consideration of workforce, policies, and community resources.
Nearly all participating QI Advisory Board members highlighted potential accessibility barriers for patients in the future vision. Comments pointed to the importance of considering health literacy, language, and patient access to and comfort level with technology. Key ideas included:
Multiple advisory board members raised the question of reimbursement, recognizing that discussion of a future vision of care cannot be wholly separated from resource considerations—both in terms of money and time. They encouraged ACTS to acknowledge that implementing comprehensive interventions requires time and to consider how proposed services could be reimbursed.
Participants stressed that an ideal future vision state must integrate community-based resources and facilitate partnerships between care teams and community services to better address patients’ comprehensive needs, including SDOH.
One individual specifically identified “home visits by community health workers” as a missing element of the proposed vision: “Health centers are working to address social determinants of health of patients and working a lot with community partners outside the four walls of the health center. How the care team can have those very productive relationships with community partners will be an important part [of the Roadmap] as well.”
Advisory board members commented on the importance of framing the future vision around the patient and her needs and preferences. One individual identified his highest priority interventions as: 1) shared decision-making tools, and 2) patient education and self-management tools. Another participant observed that the current and future states described in the sample patient scenario both put the onus on the patient to take action; instead, she suggested that the future vision present a more proactive role for providers.
Advisory board members also stressed that a roadmap for transformation must accommodate different care settings and have the ability to be applied flexibly depending on workflows and needs: “... a lot of these tools were developed in more of a research type of setting and so translating them into primary care with a safety net population... there's going to be some nuances for how that needs to happen...Just having those tools laid out so that they can be implemented in such a way that works best for the care team... and some examples or model practices that an organization could consider depending on their workflows because it's going to look different depending on their workflow.”
Another participant commented that the proposed “Integrated Care Plan” lacked standardization: “seems like there's no standard, nor standard definitions, nor standard terminology, nor standard way of sharing that.”
Participants also observed that, in many senses, they were already familiar with the components that are described in the proposed future vision state. One individual suggested that instead of identifying what care elements we should be moving toward the question would be better framed as, “why aren’t we there yet?”
“When I look at the list that's in the table that has 19 items on them, all of those actually seem pretty familiar to us in the health center world. I don't mean to speak for everyone, but I think that we all look at these and we know what they mean. What that says to me is, to some degree, the future is already here, it's now, and so what's the reason why we're not really realizing the full benefits of all these things?”
See Challenges: Issues, Concerns, Requirements & Gaps to Address to Successfully Implement Future Vision Workflows/Tools.
One advisory board member also raised the importance of better leveraging AHRQ’s evidence-based resources to inform public policies that impact patients: “There's a lot that we know that's evidence-based that could actually better inform public policy... things like policies that could better promote physical activity or access to healthy foods...[that] have more to do with what the community structure and infrastructure is like.” Please also see B.188.8.131.52.2, Challenges: Issues, Concerns, Requirements & Gaps to Address to Successfully Implement Future Vision Workflows/Tools..
Respondents were exposed to the ACTS Future Vision via LinkedIn (1,700 connections, 414 views, patient/caregiver activists, clinicians, academics, developers), Twitter (710 followers, 430 reads), Facebook (HealtheVoices (23 reads), Society for Participatory Medicine (15 reads), PPICOnline (91 reads), Engagement Buddies (21 reads), WEGO Health), and 30 other substantive comments were received via mediums used, emails, and phone calls.
Health Hats posted the Mae current state and future vision scenarios and discussion questions.
Respondents could access the future vision materials July 30–August 9, 2019 on social media (LinkedIn, Twitter, and Facebook).
Health Hats complied replies collected via direct message, text, and email.
In general, this future vision was considered desirable.