1. Palliative Care 2012: Matching Care to Patient’s Needs
Diane E. Meier, MD
Director
Center to Advance Palliative Care 1

2. Objectives
How is palliative care important to improving value (quality and cost) in health care reform?
Changing the delivery system to improve access to quality palliative care in and beyond the hospital

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

4. 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 4 4

5. 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.

7. Value of health care = Quality Cost
The Value Equation-1
Value of health care = Quality
Cost
Numerator 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

8. Value of health care = quality cost
The Value Equation- 2
Value of health care = quality
cost
Denominator 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.

9. International Comparison of Spending on Health, 1980–2009
EFFICIENCY
International Comparison of Spending on Health, 1980–2009
Average spending on health per capita ($US PPP*)
Total expenditures on health as percent of GDP
* PPP=Purchasing Power Parity.
Data: OECD Health Data 2011 (database), version 6/2011.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 9 9

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

12. 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.

13. Cost: Hospital Spending per Discharge, 2009 Adjusted for Cost of Living
Dollars
Source: OECD Health Data 2009 (June 2009).

14. 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
Health Affairs 2005;24:
CBO May 2009 High Cost Medicare Beneficiaries
nchc.org/facts/cost.shtml
Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only. 14

15. 15

16. Palliative Care is Central to Improving the Value Equation
Because our patient population is driving most of the spending 16 16 16

17. Conceptual Shift for Palliative Care17

18. Palliative Care Language
Endorsed by the Public
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.
This revised definition, based on the qualitative research, had a significant positive impact. 18 18

19. Exceptionally High Positives
Once informed, consumers are extremely positive about palliative care and want access to this care if they need it:
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. 19 19

20. Palliative Care Hits the High Notes Better health. Better care
Palliative Care Hits the High Notes Better 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 sees the person beyond the cancer treatment. It gives the patient control. It brings trained
specialists together with doctors and nurses in a team-based approach to manage pain and other symptoms,
explain treatment options, and improve quality of life during serious illness. 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.
Support palliative care legislation (HR. XX & S. XX). Bring quality of life and care together for the millions facing cancer.

21. Palliative Care Teams Address 3 Domains
Physical, emotional, and spiritual distress
Patient-family-professional communication about achievable goals for care and the decision-making that follows
Coordinated, communicated, continuity of care and support for practical needs of both patients and families across settings

22. 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 22

23. Palliative Care Across the Continuum
Inpatient Consult Service
Outpatient Specialty Clinics
Cancer Center
Outpatient PCP Clinics
SNF Consult Service
Provider Home Visits
Inpatient Unit

24. 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: 24

25. December 7, 2010
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
KP Study Brumley, R.D. et al. JAGS 2007

26. 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 26

27. 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

29. Effect of Palliative Care on Hospital Costs29 29

30. 30

31. 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

32. Palliative Care Growth
Source: Center to Advance Palliative Care, capc.org/reportcard 32 32

33. 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, capc.org/reportcard 33 33

34. % “Great Deal” or “Some” Exposure to Palliative Care
Hope for the Future: Younger physicians exposed to palliative care more than their predecessors.
% “Great Deal” or “Some” Exposure to Palliative Care
by Physician Age
− 34 −

36. National Quality Forum: Palliative Care is One of Six National Priorities for Action 36

37. NQF-Endorsed Palliative Care Measures 02/14/2012 http://www
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
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

38. 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.

39. 39

40. Palliative Care: “on the map” with IHI 40

41. Strategic Partnerships41

42. 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

43. Payers Get It
Examples of private sector approaches to community-based palliative care

44. Matching (Payer) Resources to Needs
Threshold Effect: Unless you make an order-of-magnitude shift in intensity of time spent with a CCM patient - you’ll have diminishing return. FHI has defined factors in getting over the threshold.
Demand Management DM/CM CCM-palliative care
NEEDS

45. Payer Models

46. Although the world is full of suffering, it is full also of the overcoming of it.
Helen Keller
Optimism 1903

47. Appendices
Practical steps and resources

48. 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

49. 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:

50. 2012 New ICU/ED/OPT Resources

51. Metrics: The CAPC Registry
Your data, local use
Your data, compared
Your data, compared and combined -
Provides outside perspective & validation to plans
Leverages data you collect for several purposes
Builds consistency and critical mass for field & research

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

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

55. The Challenge
Most 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

56. Why Develop Triggers? Improve patient/family outcomes
Reduce variation in care
Make palliative care part of a systems-based approach to care
Culture change

57. 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

58. 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.

59. Other Resources 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
for Patients and Families
And more

60. Recent Blog Post on How to Improve Access to Palliative Care

61. Suggestions for Action

62. 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

63. 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 ( )

64. 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.

65. 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 wheel