1. Geriatric Palliative Care: Transforming the Care of Serious Illness Diane E. Meier, MD Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai Director, Center to Advance Palliative Care diane.meier@mssm.edu diane.meier@mssm.edu www.capc.org www.getpalliativecare.org @dianeemeier

2. No Disclosures

3. Objectives The case for integrated geriatric and palliative care strategies What works to improve quality and reduce costs for vulnerable old people? Limitations of our taxonomy and tribalism How to face outwards towards needs of: –Our patients, their families –Policy makers, payers, health system leadership

4. Concentration of Spending Distribution of Total Medicare Beneficiaries and Spending, 2011 Total Number of FFS Beneficiaries: 37.5 million Total Medicare Spending: $417 billion Average per capita Medicare spending (FFS only): $8,554 Average per capita Medicare spending among top 10% (FFS only): $48,220 NOTE: FFS is fee-for-service. Includes noninstitutionalized and institutionalized Medicare fee-for-service beneficiaries, excluding Medicare managed care enrollees. SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost & Use file, 2011.

5. Value= Quality/Cost Because of the Concentration of Risk and Spending, and the Impact of Palliative Care on Quality and Cost, its Principles and Practices are Central to Improving Value

6. Mr.B An 88 year old man with mild dementia admitted via the ED for management of back pain due to spinal stenosis and arthritis. Pain is 8/10 on admission, for which he is taking 5 gm of acetaminophen/day. Admitted 3 times in 2 months for pain (2x), weight loss+falls, and altered mental status due to constipation. His family (83 year old wife) is overwhelmed.

7. Mr. B: Mr. B: “Don’t take me to the hospital! Please!” Mrs. B: “He hates being in the hospital, but what could I do? The pain was terrible and I couldn’t reach the doctor. I couldn’t even move him myself, so I called the ambulance. It was the only thing I could do.” Modified from and with thanks to Dave Casarett

8. Before and After Usual Care 4 calls to 911 in a 3 month period, leading to 4 ED visits and 3 hospitalizations, leading to Hospital acquired infection Functional decline Family distress Palliative Care Pain management 24/7 phone coverage Housecalls referral Support for caregiver Meals on Wheels Friendly visitor program No 911 calls, ED visits, or hospitalizations in last 18 months

9. The Modern Death Ritual: The Emergency Department Half of older Americans visited ED in last month of life and 75% did so in their last 6 months of life. Smith AK et al. Health Affairs 2012;31:1277-85.

10. Concentration of Risk Functional Limitation Frailty Dementia +/- Serious illness(es)

11. Gómez-Batiste X, et al. BMJ Supportive & Palliative Care 2012;0:1–9. doi:10.1136/bmjspcare-2012-000211

12. Most of Costliest 5% have Functional Limitations http://www.cahpf.org/docuserfiles/georgetown_trnsfrming_care.pdf

13. Jones et al. JAGS 2004;52

14. Dementia Drives Utilization Prospective Cohort of community dwelling older adults Callahan et al. JAGS 2012;60:813- 20. DementiaNo Dementia Medicare SNF use44.7%11.4% Medicaid NH use21%1.4% Hospital use76.2%51.2% Home health use55.7%27.3% Transitions11.23.8

15. Dementia and Total Spend 2010: $215 billion/yr By comparison: heart disease $102 billion; cancer $77 billion 2040 estimates> $375 billion/yr Hurd MD et al. NEJM 2013;368:1326-34.

16. In case you are not already worried… The Future of Dementia Hospitalizations and Long Term Services+Supports 10 fold growth in dementia related hospitalizations projected between 2000 and 2050 to >7 million. Zilberberg and Tija. Arch Int Med 2011;171:1850. 3 fold increase in need for formal LTSS between now and 2050, from 9 to 27 million. Lynn and Satyarthi. Arch Int Med 2011;171:1852.

17. Why? Low Ratio of Social to Health Service Expenditures in U.S. for Organization for Economic Co-operation and Development (OECD) countries, 2005. Bradley E H et al. BMJ Qual Saf 2011;20:826-831 Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.

18. Surprise! Home and Community Based Services are High Value Improves quality: Staying home is concordant with people’s goals. Reduces spending: Based on 25 State reports, costs of Home and Community Based LTC Services less than 1/3 rd the cost of Nursing Home care.

19. Study: Having meals delivered to home may reduce need for nursing home 10/14/2013 | HealthDay News A study published today in Health Affairs found if all 48 contiguous states increased by 1% the number of elderly who got meals delivered to their homes, it would prevent 1,722 people on Medicaid from needing nursing home care. The Brown University study found 26 states would save money because lower Medicaid costs would more than offset the cost of providing the meals.

20. What is Palliative Care? Specialized medical care for people with serious illness and their families Focused on improving quality of life as defined by patients and families. Provided by an interdisciplinary team that works with patients, families, and other healthcare professionals to provide an added layer of support. Appropriate at any age, for any diagnosis, at any stage in a serious illness, and provided together with curative and life-prolonging treatments. Definition from public opinion survey conducted by ACS CAN and CAPC http://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion- research/2011-public-opinion-research-on-palliative-care.pdf

21. Conceptual Shift for Palliative Care Goals Medicare Hospice Benefit Life Prolonging Care Old Palliative Care Bereavement Hospice Care Life Prolonging Care New DxDeath 21

22. Palliative and Geriatric Care Models Improve Value Quality improves –Symptoms –Quality of life –Length of life –Family satisfaction –Family bereavement outcomes –MD satisfaction –Care matched to patient centered goals Costs reduced –Hospital costs decrease –Need for hospital, ICU, ED decreased –30 day readmissions decreased –Hospitality mortality decreased –Labs, imaging, pharmaceuticals reduced

26. 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.

27. 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

29. Person-Directed Approach to Care –Promotes personal comfort at all times –Incorporates each person’s life story into the care plan –Creates a personalized homelike environment –Anticipates needs rather than waiting for agitation or distress –Empowers staff to do whatever is needed to make each person comfortable

30. Comfort First Care http://www.comfortfirstcare.org/ http://www.jewishhome.org/our-services/palliative- care/jewish-home-lifecare-adopts-comfort-first- model-of-palliative-care-for-elders-with-dementiahttp://www.jewishhome.org/our-services/palliative- care/jewish-home-lifecare-adopts-comfort-first- model-of-palliative-care-for-elders-with-dementia http://www.newyorker.com/reporting/2013/05/20/1 30520fa_fact_meadhttp://www.newyorker.com/reporting/2013/05/20/1 30520fa_fact_mead Supported by NY+Chicago Alzheimer’s Association, Samuels Foundation in NYC

32. Key Characteristics of Effective Models 1: Targeting Demand Management DM/CM CCM-palliative care RESOURCES NEEDS

33. Key Characteristic 2: Goal Setting “Don’t ask what’s the matter with me; ask what matters to me!” Ask the person and family, “What is most important to you?” “Ultimately, good medicine is about doing right for the patient. For patients with multiple conditions, severe disability, or limited life expectancy, any accounting of how well we’re succeeding in providing care must above all consider patients’ preferred outcomes.” Reuben and Tinetti NEJM 2012;366:777-9.

34. Priorities for Care Survey of Senior Center and AL subjects, n=357, dementia excluded, no data on function Asked to rank order what’s most important: Overall, independence ranked highest (76% rank it most important) followed by pain and symptom relief, with staying alive last. Fried et al. Arch Int Med 2011;171:1854

36. Key Characteristic 3: Can We Deliver on People’s Goals? Not When Families are Home Alone 40 billion hours unpaid care/yr by 42 million caregivers worth $450 billion/yr Providing “skilled” care Increased morbidity/mortality/ban kruptcy aarp.org/ppi http://www.nextstepincare.org/

37. Payers Are Already Bringing the Care Home

38. www.theatlantic.comwww.theatlantic.com 02.25.13 MA Full Risk PMPM contract with HealthCare Partners/DaVita 15%+margin. >700K patients “Now instead of 30-40 patients/day, Dr. Dougher sees 6- 8.” “Now instead of 30-40 patients/day, Dr. Dougher sees 6- 8.”

39. Key Characteristic 4: Pain and Symptoms – Disabling pain and other symptoms reduce independence and quality of life. HRS- representative sample of 4703 community dwelling older adults 1994-2006 Pain of moderate or greater severity that is ”often troubling” is reported by 46% of older adults in their last 4 months of life and is worst among those with arthritis. Smith AK et al. Ann Intern Med 2010;153:563-569

40. What do we need to do to provide care that matches our patient’s needs? Change how we pay. ACOs, bundling, P4P, shared risk Change how we regulate. Reward keeping people safe at home. Train our workforce. Not even close to enough clinicians with specialty training to meet the needs We must train all clinicians in expert symptom management; communication about achievable goals; and coordination across settings. (www.capc.org/membership)

41. Transforming 21 st Century Care of Serious Illness Gomez- Batiste et al.2012 Change from:Change to: Terminal ……………………………………Serious & chronic Prognosis weeks-month…………………..Prognosis months to years Cancer……………………………………..All chronic progressive diseases Disease……………………………………..Condition (frailty, fn’l dep, MCC) Mortality…………………………………….Prevalence Cure vs. Care………………………………Synchronous shared care Disease OR palliation……………………..Disease AND palliation Prognosis as criterion……………………..Need as criterion Reactive…………………………………….Screening, Preventive Specialist……………………………………Palliative/Geriatric Care Everywhere Institutional………………………………….Community No regional planning……………………….Public health approach Fragmented care……………………………Integrated care

42. (Present) and Future “The future is here now. It’s just not very evenly distributed.” William Gibson The Economist, 2003