Presentation on theme: "Moving Palliative Care Upstream"— Presentation transcript:
1 Moving Palliative Care Upstream David E. Weissman, MDProfessor EmeritusMedical College of WisconsinConsultant, Center to Advance Palliative Care
2 ObjectivesList 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-80sPhase 2 Palliative Care 1990s-2000sPhase 3 Spread s-
4 The Palliative Care Intervention Interdisciplinary teamsPatient-centered goals of care discussionRealistic prognosticationPain and symptom reliefDisposition planning reflecting patient goalsPatient/Family supportBereavement support
5 Key Palliative Care Outcomes Reduced ICU length of stayRapid symptom reliefEarlier referral to hospice services-longerGreater patient/family satisfactionLower hospital costProlonged 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 MedicinePhysiciansNurses: AP, RN, LPNSocial workersChaplains (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, RenalBetween hospitals and hospice there is a large gap of palliative care needs across the Continuum of health care.Outpatient servicesLong-term and Home careHome care
8 Hospitals Not all hospitals have consult services Those that do are typically overworkedHigh rate of stress/burnoutMany “martyrs”Adding more staff is problematicMore staff leads to more consults
9 The Referral Conundrum Consults predominantly occur based on clinician values, rather than patient needsClinician values/attitudes inhibit provision of excellent palliative care servicesMy patient isn’t ready; my patient is not dyingI’m not ready for palliative careI will not give up on my patientEducation alone will not fix this problem.
11 Reality CheckThere 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 modelsIntegrate palliative care principles into high-risk locationsIdentify unmet needsExpand Generalist Palliative CareImprove care across the continuum
13 1. Increase Team Efficiency Close examination of the process of care deliveryStaff time studiesDetermine cost/caseUse metrics to determine efficiency and value
14 2. New Team Models “Counselor” Model Staff Intervention Med Center Central Georgia/UMDNJStaffSpecially trained communication “counselors” (Nursing, Mental health background)InterventionManage most goal of care discussionsWork in both parallel and series with PC team
15 3. Integration ProjectsEfforts to broaden the spread of palliative care principles into locations of high unmet needs, through …setting collaborative goalsearly patient identification (triggers)systems change to guide right care at right time—routine family meetingsquality 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 treatmentsthey desire/are appropriate to their medicalcondition/prognosis.
18 Common trigger systems ICULength of stayMulti-organ failureMetastatic cancerProlonged unconsciousnessNursing home admissionEmergency departmentOncology clinicSpecial populationsLVAD/CHFNursing home admitsPEG or trach consideration
19 5. Generalist Pall. CareNeed to imbed Palliative Care principles into the system of health care deliveryCommitment: time/$Assessment: case finding—all patient screenResponsibility: QIEducation: all clinical staffStandards: who/what/when
20 Primary/Specialty Care Primary Pall Care: all cliniciansRoutine communication/symptom controlSpecialty Pall CareFamily meetings—esp. “difficult cases”Complex symptom managementTime managementSupport for difficult decisions
21 6. Move into the Continuum Outpatient Palliative CareFree-standingCo-management clinics: oncology, otherHome visitsIPAL-OPLong Term CareDedicated Pall Care staffGeriatric NP modelConsultative external team
25 Palliative Care is Central to the Success of Health Reform >95% of all health care spending is for the chronically ill64% of all Medicare spending goes to the 10% of beneficiaries with 5 or more chronic conditionsDespite high spending, evidence of poor quality of care25
26 Palliative Care, Health Reform and Chronic Disease Care Health reform initiativesReduce readmissionsReduce costImprove quality/Reduce variationShift chronic disease care out of the hospitalCare coordination/Bundling/ACOsPalliative Care services/outcomes are perfectly aligned with all these priorities!
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/impactMortality and readmission reductionCost control
29 What can you do? Push for collaborative initiatives ICU/ED/Cardiology/Cancer/HospitalistsFocus on improving generalist palliative care rather than striving for more consultsRemind everyone about the 50%!Seek opportunities identify patients with unmet needs