Collaborative Guidelines for Health Care Transformation

In 2011, the Washington State Legislature established the Dr. Robert Bree Collaborative so that public and private health care stakeholders would have the opportunity to identify specific ways to improve health care quality, outcomes, and affordability in Washington State. These stakeholders are appointed by the Governor as collaborative members and represent public health care purchasers for Washington State, private health care purchasers (employers and union trusts), health plans, physicians and other health care providers, hospitals, and quality improvement organizations.

The home of the Bree is the Foundation for Health Care Quality, located in Seattle, WA. More information about the foundation and its other health care quality programs can be found  HERE .

Lack of evidence-based best practices for new treatments, diseases, emerging public health issues, and for health topics that are difficult to gather evidence for can lead to unintentional patient harms, a lack of patient-centric care, and to waste in the health care system that costs in terms of health outcomes and financial burden.

Without a mechanism for collaboration the health care system in Washington State had no way to create agreed upon best practice recommendations that could be implemented across the health care ecosystem.

The Bree Collaborative was created to provide a forum where health care ecosystem partners could come together to identify and promote strategies that improve patient health outcomes by identifying best practices across multiple sectors. This is achieved by convening work groups that leverage existing expertise (define more) and scientific literature where it exists.

In alignment with many legislative priorities, some of the initiatives that have been driven, in whole or part, by the Bree Collaborative are: changes to opioid prescribing, clarification on best practices and needed capacity for opioid treatment, reduction of c-section rates and identification of other surgery best practices, defining primary care in order to change health care spending, identification of best practices for youth behavioral health, creating foundations for collecting and using Social Determinants of Health and Health Equity data, strategy recommendations for increases to access to care, and the development of coordinated care pathways. In 2024, the Bree has created a process for continued updating of reports in important topic areas and will venture into emerging areas of concern, such as environmental impacts on health and the health care system.

Over it's thirteen year history, the Bree has proven that health system actors can reach a consensus and use the Washington State Health Care Authority's (HCA) contracting power as a lever to create system-wide change. Outside of HCA contracting, the Bree has demonstrated that patient-centered, consensus-driven guidelines are readily adopted as a trusted source of current information and best practices.

A Multi-sector Roadmap for Ecosystem Improvement was developed by Bree staff to illustrated the change pathways guidelines take to improve care in Washington State. These "four pillars of transformation" are Equity, Data Usability, Integrated/Holistic care and Financing. These areas are foundational to all Bree reports and provide a framework for adoption that assures that our guidelines are effective for all patients in Washington State.

Our multi-sector roadmap illustrates how the Bree starts with a concept of what quality care should look like for each of the actors in the system (delivery sites, health plans, purchasers, etc.), in what areas improvement should occur, and how actors can leverage the Bree guidelines to create positive change in care processes and outcomes for patients. Below are some examples of how the Bree has acted on these "four pillars of transformation".

The Bree guidelines include recommendations for may different actors in the health care system, from clinicians and health care delivery organizations, to payers, to schools and community groups, and even various State agencies. Although the Bree has limited ability to require the use of our guidelines, organizations that have participated in creating them are more invested and more likely to implement them. However, the Bree also has little capacity to evaluate the extent to which organizations changes to care have fidelity with our recommendations.

In 2022 the Bree was given limited funding to develop and evaluation program, and in 2022-23 we designed and conducted an evaluation of previous reports to better understand 1) how concordant is the current system with our reports, 2) what happens after guidelines are published (who adopts them and why), and 3) how we can improve our guideline development process. This first phase of our evaluation program aims to help us understand how the Bree can improve it's processes and reach of the guidelines we produce. Future evaluation activities are being designed to better measure progress towards full implementation across the state and to help understand the impact of our recommendations on patients.

What do we mean by "concordance of care"? We asked each participating organization to measure themselves on the extent to which their policies, programs, workflows and metrics collections were consistent with those recommended in each report.

The map below illustrates a comparison between the existing ecosystem and the Bree Evaluation. The areas represent the counties where our evaluation took place and which had the largest portion of participants. The dots represent the distribution of health systems, clinics, dental providers, and critical access hospitals in Washington State overall.

Building on a previous, one-time evaluation of Bree guidelines in the hospital setting in 2016 (found  HERE ), our 2023 evaluation use the same measurement methods to understand fidelity or concordance with guidelines for health systems and health plans. For both surveys in 2016 and 2023 we used 0-3 point scale, self-assessed by each organization: 0 -No action taken; 1 -Actively considering adoption; 2 -Some/similar adoption; 3 -Full adoption

Full adoption of the recommendations of the Bree Collaborative varied between health delivery and health plans as well as between large health systems and smaller care delivery organizations. The lever of payment reform did not create the same kind of comprehensive change for health care delivery site processes as it did for health plans, however both showed robust concordance for most Bree topic areas.

A sub-set of those who participated in 2016 also participated in the 2023 evaluation work and we were able to measure any changes or progress among these organizations. These measures represent changes in concordance of care with 8 Bree reports in 16 large hospitals and 60+ clinics located in King, Pierce, Thurston, Spokane, Kitsap, Clark, Whatcom, Snohomish, Cowlitz, and Yakima Counties.

The scores below were calculated for those organizations that participated in both the 2016 and the 2022-23 evaluations. In addition to reflecting improvements, scores may also reflect sustainability of change within a changing landscape of health care that includes mergers and acquisitions, demographic changes, and effects of the COVID-19 pandemic.

In order to demonstrate clear improvements to the quality of care due to guideline adoption, the Bree is in the process of developing case studies. The first group of case studies focus on Opioid prescribing and Opioid Use Disorder Treatment.

Delta Dental of Washington adopted the Bree Guidelines on Dental Opioid Prescribing, providing training, education and monitoring that demonstrated strong success in changing the prescribing habits of dental providers. Outcomes of this implementation effort included training for 422 dentists, patient education services to 52,300 patients, 3 in-person trainings for Federally Qualified Health Centers, Thurston County Dental Society, and Snohomish County Public Health Department. There is no indication in the data that providers have reverted to previous prescribing practices.

In order to understand what the biggest barriers to adopting Bree Guidelines are for organizations, we employed a health system-wide survey through multiple channels. The most common barriers to implementation were:

1. Lack of a business case or multiple critical business needs (such as staffing) remained a common challenge for all organizations from 2016 through 2023.
2. For both health plans and health care delivery, regulatory constraints (such as scope of practice) was the second most common barrier, but within health care delivery organizations it was tied with internal awareness of Bree guidelines.
3. Data was the third most common barrier for organizations, both the collection of it and the availability of it from other sources.

A clear business case and internal awareness of the Bree guidelines were also seen as the key factors in the successful implementation of recommendations, especially for health care providers.  Other enabling factors varied by the type of organization. For health plans, partnerships for value-based purchasing was also a key factor in their ability to implement guidelines.

Bree guidelines often include recommendations for the improvement of equity along side improvements in quality of care. Understanding gaps in equity is aided by the use of data standards, ability to stratify metrics, appropriate staffing and staff training, Electronic Health Records System (EHR) capabilities, and funding, which all play roles in an organizations ability to collect and use equity data to improve the quality of care for everyone in Washington.

Many of the opportunities identified through our evaluation work can support continued identification of equity gaps and improvements in equity for access, treatment, and outcomes.

Although standards for Continuity of Care and Data Analytics exist, not all health delivery systems have the financial or staffing capacity to develop these standards. Internal data capacity often depends on staffing and the Electronic Health Records System (EHR) and vendor a provider organization uses. Barriers for external data capacity depends on common metrics with discrete data elements that can be exchanged in a secure and standardized manner, such as Health Level 7 (HL7).

The organizations that answered questions about HL7's Continuity of Care Model (CCMM) indicated a range from Stage 4 (Care coordination based on actionable data using a semantic interoperable patient record) to Stage 7 (Knowledge driven engagement for dynamic, multi-vendor, multi-organizational interconnected healthcare delivery model), however these were mostly large, well funded health systems. By contrast, there was much greater variation for HL7's Analytics Model or Analytics Maturity (AMAM), even among large organizations. R

Improvement in these world-wide standards is a key factor in an organizations ability to implement data sharing and collaborative care recommendations from the Bree. More information on HL7 Data Maturity Models can be found  HERE .

In 2023 the Bree Collaborative and its parent organization, The Foundation for Health Care Quality, developed awards programs to incentivize participation in evaluation activities. Awards are open to any organizations that submits information about their Bree implementation efforts. Two awards levels were launched in 2023/2024 - The Trailblazer Award for concordance of care with Bree Guidelines and the Mountain Climber Award for Excellence in Health Equity.

In 2024, eight organizations won awards in 22 different topics areas and five of these organizations have applied for additional recognition for their efforts to embed equity into their care programs.

In 2025 the Bree Collaborative will be expanding their awards program with a new Pathfinder Award, to encourage health care partners to begin implementation work.

Opportunity 1: The state legislature has an opportunity to increase the awareness and use of the Bree Guidelines by making changes to RCW  70.250.050  to increase the number and type of appointed members such as: a Tribal Liaison, more Federally Qualified Health Center representatives, representative from other disciplines (behavioral health, dental), more community representatives (such as schools), more rural representatives, etc.

Opportunity 2: The governor's office or other state agencies have an opportunity to use the Bree Collaborative process to bring together organizations for the purpose of business case development that puts patient health outcomes at the center.

Opportunity 3: The state legislature has an opportunity to create other levers for implementation through further financial support of the Bree implementation and evaluation programs, requirements for other state departments or entities (such as the Department of Health or ACH's) to implement guidelines, and/or funding support for new Care Outcomes Assessment Programs for topics such as Primary Care, Behavioral Health, or Pediatric Medical and Behavioral Health.

Opportunity 4: The Bree recommendations for coverage and payment models already reach the majority of Medicaid patients through Community Health Plan of Washington and the HCA's Medicaid contracts, however gaps still exist in the implementation of Bree process recommendations. The state legislature has an opportunity to further support small clinics, Federally Qualified Health Centers, and rural providers, through financing, training, or other resources, in order to close the loop on the implementation of best practices.

Opportunity 5: The state legislature has an opportunity to use the Bree recommendations to inform policy on social needs as they relate to health care, such as including the Bree in legislative work sessions to discuss.

Opportunity 6: The state legislature and state agencies have an opportunity to leverage the HL7 FHIR data standards. The state legislature could build on initiatives by philanthropic organizations to improve health data capture to support seamless data exchange, a reduction in health care workload, and improve data transparency.