Palliative Care 2012: Matching Care to Patient’s

Needs

Diane E. Meier, MDDirector

Center to Advance Palliative Care

diane.meier@mssm.eduwww.capc.org

www.getpalliativecare.org

Objectives

1. How is palliative care important to improving value (quality and cost) in health care reform?

2. Changing the delivery system to improve access to quality palliative care in and beyond the hospital

Core Principle

1. “The secret of the care of the patient is caring for the patient.” Francis Peabody, Harvard University, 1921

The Ends of Medicine: Our Professional Obligations

“I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients”

-Oath of Hippocrates, 400 BC

“May I never see in the patient anything but a fellow creature in pain.”

- Maimonides, 12th century AD

Health care in the U.S.

• What are the ends of medicine?– What are they in the U.S.?

• What should they be? “To cure sometimes, relieve often, comfort always.”

• The problem: “The nature of our healthcare system- specifically its reliance on unregulated fee-for-service and specialty care- …explains both increased spending and deterioration in survival.” Muenning PA, Glied SA. What changes in survival rates tell us about

U.S. health care. Health Affairs 2010;11:1-9.

The Value Equation-1

Value of health care = Quality CostNumerator problems

– 100,000 deaths/year from medical errors– Millions more harmed by overuse, underuse, and

misuse– Fragmentation– Medical practice based on evidence <50% of the time– 50 million Americans (1/8th) without access– U.S. ranks 40th in quality worldwide

The Value Equation- 2

Value of health care = quality costDenominator problems• Insurance premiums increased by 181% in the

last 10 years.• U.S. spending 17% GDP, >$8400 per capita/yr • Nearing 30% of total State spending• Despite high spending, 15% of our population

has no insurance, and half are underinsured in any given year.

• Health care spending is the #1 threat to the American economy and way of life.

International Comparison of Spending on Health, 1980–2009

* PPP=Purchasing Power Parity.Data: OECD Health Data 2011 (database), version 6/2011.

Average spending on healthper capita ($US PPP*)

Total expenditures on healthas percent of GDP

9Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.

EFFICIENCY

9

Sun Sentinel (Broward County edition)Tuesday, August 9, 2011

Health Care vs Determinants of HealthGrowth in Massachusetts State Budget Spending FY2001 to FY2012

(Inflation adjusted)

Source: Massachusetts Budget & Policy Center Budget Browser

-60%

-40%

-20%

0%

20%

40%

60%

80%

100%

Health Care Primary-SecondaryEducation

Law andPublic Safety

Public Health Environmentand

Recreation

HigherEducation

Local Aid

%

What is this money buying us?

Organization for Economic Development and Cooperation

Among OECD member nations, the United States has the:

• Lowest life expectancy at birth.• Highest mortality preventable by health

care.

Cost: Hospital Spending per Discharge, 2009Adjusted for Cost of Living

17,206

12,163 11,988

9,398 9,131 9,026

7,312 7,312 7,295

4,667 4,527

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

US* CAN* NETH SWITZ NOR* SWE NZ OECDMedian

AUS* FR GER

Source: OECD Health Data 2009 (June 2009).

Dollars

Medical Spending in the U.S.$2.9 trillion in 2010

The costliest 5% account for 50% of all healthcare spending

Medicare Payment Policy: Report to Congress. Medpac 2009 www.medpac.gov

Health Affairs 2005;24:903-14.

CBO May 2009 High Cost Medicare Beneficiaries www.cbo.gov

nchc.org/facts/cost.shtml

Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.

Palliative Care is Central to Improving the Value Equation

• Because our patient population is driving most of the spending

Conceptual Shift for Palliative Care

Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis.

The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.

Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis.

The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.

Palliative Care Language Endorsed by the Public

95% of respondents agree that it is important that patients with serious illness and their families be educated about palliative care.

92% of respondents say they would be likely to consider palliative care for a loved one if they had a serious illness.

92% of respondents say it is important that palliative care services be made available at all hospitals for patients with serious illness and their families.

Once informed, consumers are extremely positive about palliative care and want access to this care if they need it:

Exceptionally High Positives

Palliative Care Hits the High NotesBetter health. Better care. Lower cost.

Key Messages:Palliative care sees the person beyond the cancer treatment.

Palliative care is all about treating the patient as well as the disease.

It’s a big shift in focus for health care delivery—and it works.

Palliative Care Teams Address 3 Domains

1. Physical, emotional, and spiritual distress2. Patient-family-professional

communication about achievable goals for care and the decision-making that follows

3. Coordinated, communicated, continuity of care and support for practical needs of both patients and families across settings

Palliative Care Improves Value

Quality improves– Symptoms– Quality of life– Length of life– Family satisfaction– Family bereavement

outcomes– Care matched to

patient centered goals

Costs reduced– Hospital costs

decrease– Need for

hospitalization/ICU decreases

Palliative Care Across the Continuum

Inpatient Consult Service

Outpatient Specialty Clinics

Cancer Center

Outpatient PCP Clinics

SNF Consult Service

Provider Home Visits

Inpatient Unit

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Palliative Care Improves Quality in Office Setting

Randomized trial simultaneous standard cancer care with palliative care co-management from diagnosis versus control group receiving standard cancer care only:

– Improved quality of life – Reduced major depression – Reduced ‘aggressiveness’ (less chemo <

14d before death, more likely to get hospice, less likely to be hospitalized in last month)

– Improved survival (11.6 mos. vs 8.9 mos., p<0.02)

Temel et al. Early palliative care for patients with non-small-cell lung cancer NEJM2010;363:733-42.

Palliative Care at Home for the Chronically Ill Improves Quality, Markedly Reduces Cost

RCT of Service Use Among Heart Failure, Chronic Obstructive Pulmonary Disease, or Cancer Patients While Enrolled in a Home Palliative Care Intervention or Receiving Usual Home Care, 1999–2000

13.211.1

2.3

9.4

4.6

35.0

5.3

0.92.4

0.90

10

20

30

40

Home healthvisits

Physicianoffice visits

ER visits Hospital days SNF days

Usual Medicare home care Palliative care intervention

KP Study Brumley, R.D. et al. JAGS 2007

RCT of Nurse-Led Telephonic Palliative Care Intervention

• N= 322 advanced cancer patients in rural NH+VT• Improved quality of life and less depression

(p=0.02)• Trend towards reduced symptom intensity

(p=0.06)• No difference in utilization, (but v. low in both

groups)• Median survival: intervention group 14 months,

control group 8.5 months, p = 0.14

Bakitas M et al. JAMA 2009;302(7):741-9

Consequences of Late Referral to Palliative Care

Serious Adverse Outcomes for Bereaved Caregivers:

Compared to care at home with hospice, • Care in ICU associated with 5X family risk

of Post Traumatic Stress Disorder; and • Care in hospital associated with 8.8X

family risk of prolonged grief disorder

Wright A et al. Place of death: Correlation with quality of life of patients with cancer and predictors of bereaved caregivers mental health. JCO 2010; Sept 13 epub ahead of print

Effect of Palliative Care on Hospital Costs

How Palliative Care Reduces Cost

• Improved resource use• Reduced bottlenecks in high cost units• Improved throughput and consistency

The Conceptual Model: Dedicated medical team =

Focus + Time = Decision Making / Clarity / Follow

through

Source: Center to Advance Palliative Care, 2011 capc.org/reportcard

Palliative Care Growth

America’s Care for Serious Illness

A State-by-State Report Card on

Access to Palliative Care in Our Nation’s Hospitals

Source: Center to Advance Palliative Care, 2011 capc.org/reportcard

Hope for the Future: Younger physicians exposed to palliative care more than their predecessors.

− 34 −

% “Great Deal” or “Some” Exposure to Palliative Care by Physician Age

National Quality Forum: Palliative Care is One of Six National Priorities for Action

http://www.nationalprioritiespartnership.org/Priorities

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NQF-Endorsed Palliative Care Measures 02/14/2012

http://www.qualityforum.org/Measures_List.aspx#e=1&s=n&so=a&p=1&cs=148

• CARE: Consumer Assessments and Reports on End of Life Care

• Pain Screening• Pain Assessment• Dyspnea Screening• Dyspnea Treatment• Treatment Preferences

For hospice only:• Proportion with spiritual

assessment• Family Evaluation of Hospice

Care

For cancer only:• Proportion getting chemo last

14 days of life• Proportion in ED last week of

life• Proportion >1 hospital stay in

last 30 days of life• Proportion admitted to hospice

<3 days• Proportion not admitted to

hospice before death

National Recognition of Importance of Palliative Care to

Healthcare Value

MedPAC: Called a meeting of national experts in palliative care in May 2011 to understand what Medicare payment policies might advance access and quality

The Joint Commission: September 2011 release of a Palliative Care Advanced Certification Program.

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Palliative Care: “on the map” with IHI

http://www.ihi.org/IHI/Programs/ImprovementMap

Strategic Partnerships

Major Health Systems Get It

Making multimillion dollar investments in palliative care integration across settings:• Partners Health System/ Harvard Medical

School• U. of Pittsburgh Health System• Duke U. Health System• North Shore-LIJ Health System

Payers Get It

Examples of private sector approaches to community-based

palliative care

Matching (Payer) Resources to Needs

Demand Management DM/CM CCM-palliative care

RE

SO

UR

CE

S

NEEDS

Payer Models

Although the world is full of suffering, it is full also of the

overcoming of it.

Helen Keller

Optimism 1903

Appendices

• Practical steps and resources

Emerging Initiatives

• Palliative care in the ICU, ED and OPT settings• “Primary” palliative care, raise all boats• Development of service standards & comparative

data through Registry• “Triggers” and Checklists• Community based palliative care

– Long term care– Home care– Office practices– Cancer Centers

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Palliative Care in the ICU

Principle:

Integration of palliative care should be part of comprehensive critical care for all patients beginning at ICU admission- regardless of prognosis

Options:

“Consultative Model”: Increase involvement of palliative care consultants in ICU, particularly for patients/families at highest risk

“Integrative Model”: Embed palliative care principles and interventions in daily ICU practice for all ICU patients

-> depending on institutional and ICU resources, a combined model is usually preferred.

- Nelson, J.E. et al Critical Care Medicine 2010, 38: 1765-72

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2012 New ICU/ED/OPT Resources

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http://www.capc.org/ipal-icu

Metrics: The CAPC Registry

Your data, local use

Your data,

compared

Your data, compared

and combined -

Provides outside perspective & validation to plans

Builds consistency and critical mass for field & research

Leverages data you collect for several purposes

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https://registry.capc.org

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Uses of the Registry

NQF Operational Features as adapted by CAPC. Reference: Weissman DE, Meier DE: Operational features for hospital palliative care programs: consensus recommendations. J Palliat Med 2008;11:1189–1194.

Note: There are more operational features listed in the Registry than shown here. Other features are not shown due to PowerPoint size restraints.

Registry Report

Focus on operational features that palliative care programs have in place.

Will provide data on total of programs that have a feature in place to allow for comparative analyses.

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Tables include:

• Primary Palliative Care Assessment Components

• Criteria for a Palliative Care Assessment at the Time of Admission

• Criteria for Palliative Care Assessment during Each Hospital Day

New 2011 Tool to Help “Move Upstream” with Triggers & Checklists

The ChallengeMost teams get late referrals or never see patients with …

- Multiple co-morbid conditions and declining

function

- Difficult-to-control physical or psychological

symptoms

- Long length-of-stay, especially in the ICU

- Multiple admissions, ED visits

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Why Develop Triggers?

Improve patient/family outcomes

Reduce variation in care

Make palliative care part of a systems-based approach to care

Culture change

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Approach to Triggers

Use a risk assessment pathway to indentify patients who are most likely to have palliative care needs based on . . .

Disease variables Patient variables

• Metastatic cancer

• Advanced dementia

• Class IV CHF

• More than 2 hospitalizations within 3 months• Unintentional loss of more than 10% of body weight

• ICU length of stay greater than

X days

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Principles Behind the Checklist

Identify patients at greatest risk of unmet palliative care needs on admit and daily during stay. Standardize/improve assessment/documentation and basic palliative care management skills by primary clinicians (nurse, social worker, chaplain, physician). Reserve specialist palliative care for complex problems.

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www.capc.org

• Annual National Seminar• The IPAL Project: Improving Palliative Care in the ICU/ED/OPT• National Palliative Care RegistryTM

• Audio-Conferences and Webinars• CAPCconnectTM Online Discussion Forum• Palliative Care Leadership CentersTM Training and Mentoring• CAPC Campus OnlineTM

• Tools, Toolkits and Crosswalks• State-by-State Report Card• www.getpalliativecare.org for Patients and Families• And more

Other Resources

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Recent Blog Post on How to Improve Access to Palliative Care

• http://healthaffairs.org/blog/2012/04/30/learning-from-amy-berman-barriers-to-palliative-care-and-how-we-might-overcome-them/

Suggestions for Action

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Getting started – Planning for a new program

• Use The Guide & CAPC Tools for orientation• Identify sponsors & clinical advocates• Conduct a Needs Assessment, Systems Assessment• Prepare a draft plan to estimate patient volume & staffing

needs• Identify skill development needs & IDT staffing needs• Start a pilot in a focused area• Plan for growth; establish metrics; define funding criteria

& sources

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Actions to Align Palliative Care with Mission & Organizational Goals

• Include palliative care specialists on QI workgroups /ACO, ICO, IHI projects / redesign work

• Review the IPAL materials & set goals with ICU, ED, ambulatory setting

• Do a needs assessment baseline using the criteria in the “Triggers” article

• Review all patients discharged with “mortality risk score of 4” (APR DRG) - find actionable outreach & follow up (tie to Re-Admissions & Transitions projects)

• Initiate POLST style community initiatives & connect to inpatient initiatives –include community providers, consumers, and health system (http://www.ohsu.edu/polst/ )

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Actions to refresh an existing Palliative Care Program

• Apply for Advanced Certification in Palliative Care from The Joint Commission

• Adopt the NQF ‘Preferred Priorities” / do a GAP analysis & a plan for QI

• Identify unmet patient needs & launch a pilot – Examples: CHF patients, LVAD patients, Dialysis, or Dementia.

• Review activity data & educational & collaboration efforts that integrate skills vs. promote referrals (to create capacity for new initiatives); utilize EPERC, EPEC, and ELNEC. Set goals for team that are not tied to patient consult volume.

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Summary

• Alignment between patient needs, palliative care, and readiness for bundled payments or ICO/ACO systems integration models

• Brand palliative care separately from hospice and EOL, to improve access, quality, survival, efficiency (and EOL care)

• Tools exist; don’t recreate the wheel65