1. Moving Palliative Care Upstream
David E. Weissman, MD
Professor Emeritus
Medical College of Wisconsin
Consultant, Center to Advance Palliative Care

2. Objectives
List three benefits of integrating palliative care principles early into the course of chronic disease management.
Describe three new models of palliative care service delivery that seek to engage patients early in the disease course.
Characterize national efforts to impact health care policy concordant with palliative care principles.

3. Historical Perspective
Phase I Hospice s-80s
Phase 2 Palliative Care 1990s-2000s
Phase 3 Spread s-

4. The Palliative Care Intervention
Interdisciplinary teams
Patient-centered goals of care discussion
Realistic prognostication
Pain and symptom relief
Disposition planning reflecting patient goals
Patient/Family support
Bereavement support

5. Key Palliative Care Outcomes
Reduced ICU length of stay
Rapid symptom relief
Earlier referral to hospice services-longer
Greater patient/family satisfaction
Lower hospital cost
Prolonged survival (outpatient intervention)

6. Standards and Certification
Joint Commission Certification (2011)
NQF Palliative Care Care Standards (2012)
Commission on Cancer requirement, Cancer Center Accreditation (2011)
Board Certification, Hospice and Palliative Medicine
Physicians
Nurses: AP, RN, LPN
Social workers
Chaplains (pending)

7. What is left to accomplish?
In hospitals, at best, only 25-50% of palliative care needs are being met.
Variable penetration to areas of highest need:
ICUs, ED, Oncology, Neurology, Renal
Between hospitals and hospice there is a large gap of palliative care needs across the Continuum of health care.
Outpatient services
Long-term and Home care
Home care

8. Hospitals Not all hospitals have consult services
Those that do are typically overworked
High rate of stress/burnout
Many “martyrs”
Adding more staff is problematic
More staff leads to more consults

9. The Referral Conundrum
Consults predominantly occur based on clinician values, rather than patient needs
Clinician values/attitudes inhibit provision of excellent palliative care services
My patient isn’t ready; my patient is not dying
I’m not ready for palliative care
I will not give up on my patient
Education alone will not fix this problem.

11. Reality Check
There will never be enough palliative care specialists (all disciplines) to meet the demand.
Overall health care dollars will be shrinking.

12. Solutions Increase team efficiency: Accountability and Value
New team models
Integrate palliative care principles into high-risk locations
Identify unmet needs
Expand Generalist Palliative Care
Improve care across the continuum

13. 1. Increase Team Efficiency
Close examination of the process of care delivery
Staff time studies
Determine cost/case
Use metrics to determine efficiency and value

14. 2. New Team Models “Counselor” Model Staff Intervention
Med Center Central Georgia/UMDNJ
Staff
Specially trained communication “counselors” (Nursing, Mental health background)
Intervention
Manage most goal of care discussions
Work in both parallel and series with PC team

15. 3. Integration Projects
Efforts to broaden the spread of palliative care principles into locations of high unmet needs, through …
setting collaborative goals
early patient identification (triggers)
systems change to guide right care at right time—routine family meetings
quality improvement-data driven change

17. 4. Find the Unmet Needs A patient-centered approach would be to
design a system where palliative care interventions are based on patient and/or disease factors, rather than clinician attitudes/values.
Patients are fully informed about treatment options.
Patients have equal access to all hospital resources.
Patients receive only the life-sustaining treatments
they desire/are appropriate to their medical
condition/prognosis.

18. Common trigger systems
ICU
Length of stay
Multi-organ failure
Metastatic cancer
Prolonged unconsciousness
Nursing home admission
Emergency department
Oncology clinic
Special populations
LVAD/CHF
Nursing home admits
PEG or trach consideration

19. 5. Generalist Pall. Care
Need to imbed Palliative Care principles into the system of health care delivery
Commitment: time/$
Assessment: case finding—all patient screen
Responsibility: QI
Education: all clinical staff
Standards: who/what/when

20. Primary/Specialty Care
Primary Pall Care: all clinicians
Routine communication/symptom control
Specialty Pall Care
Family meetings—esp. “difficult cases”
Complex symptom management
Time management
Support for difficult decisions

21. 6. Move into the Continuum
Outpatient Palliative Care
Free-standing
Co-management clinics: oncology, other
Home visits
IPAL-OP
Long Term Care
Dedicated Pall Care staff
Geriatric NP model
Consultative external team

22. What else is new?

23. The Joint Commission The Joint Commission:
Palliative Care Advanced Certification Program

24. HEALTH REFORM

25. Palliative Care is Central to the Success of Health Reform
>95% of all health care spending is for the chronically ill
64% of all Medicare spending goes to the 10% of beneficiaries with 5 or more chronic conditions
Despite high spending, evidence of poor quality of care 25

26. Palliative Care, Health Reform and Chronic Disease Care
Health reform initiatives
Reduce readmissions
Reduce cost
Improve quality/Reduce variation
Shift chronic disease care out of the hospital
Care coordination/Bundling/ACOs
Palliative Care services/outcomes are perfectly aligned with all these priorities!

27. Payers are getting into Palliative Care

28. What can you do? Seek information:
What health reform initiatives are your administrators concerned about?
What committees are working on health reform topics?
Offer to participate; share information on palliative care role/impact
Mortality and readmission reduction
Cost control

29. What can you do? Push for collaborative initiatives
ICU/ED/Cardiology/Cancer/Hospitalists
Focus on improving generalist palliative care rather than striving for more consults
Remind everyone about the 50%!
Seek opportunities identify patients with unmet needs

30. CONTACT ME