Presentation on theme: "Palliative Care 2012: Matching Care to Patient’s Needs"— Presentation transcript:
1 Palliative Care 2012: Matching Care to Patient’s Needs Diane E. Meier, MDDirectorCenter to Advance Palliative Care1
2 ObjectivesHow 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 AD44
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-1Value of health care = QualityCostNumerator problems100,000 deaths/year from medical errorsMillions more harmed by overuse, underuse, and misuseFragmentationMedical practice based on evidence <50% of the time50 million Americans (1/8th) without accessU.S. ranks 40th in quality worldwide
8 Value of health care = quality cost The Value Equation- 2Value of health care = qualitycostDenominator problemsInsurance premiums increased by 181% in the last 10 years.U.S. spending 17% GDP, >$8400 per capita/yrNearing 30% of total State spendingDespite high spending, 15% of our population has no insurance, and half are underinsured in any given year.Health care spending is the #1 threat to the American economy and way of life.
9 International Comparison of Spending on Health, 1980–2009 EFFICIENCYInternational Comparison of Spending on Health, 1980–2009Average spending on health per capita ($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, 2011.99
10 Sun Sentinel (Broward County edition) Tuesday, August 9, 2011
12 What is this money buying us? Organization for Economic Development and CooperationAmong 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 DollarsSource: 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 spendingMedicare Payment Policy: Report to Congress. Medpac 2009Health Affairs 2005;24:CBO May 2009 High Cost Medicare Beneficiariesnchc.org/facts/cost.shtmlCopyright 2008 Center to Advance Palliative Care. Reproduction by permission only.14
18 Palliative Care Language Endorsed by the PublicPalliative 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.1818
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.1919
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 trainedspecialists 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 treatingthe 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 distressPatient-family-professional communication about achievable goals for care and the decision-making that followsCoordinated, communicated, continuity of care and support for practical needs of both patients and families across settings
22 Palliative Care Improves Value Quality improvesSymptomsQuality of lifeLength of lifeFamily satisfactionFamily bereavement outcomesCare matched to patient centered goalsCosts reducedHospital costs decreaseNeed for hospitalization/ICU decreases22
23 Palliative Care Across the Continuum Inpatient Consult ServiceOutpatient Specialty ClinicsCancer CenterOutpatient PCP ClinicsSNF Consult ServiceProvider Home VisitsInpatient 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 lifeReduced major depressionReduced ‘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, 2010Palliative 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, 1999–2000KP 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+VTImproved 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 = 0.14Bakitas M et al. JAMA 2009;302(7):741-926
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; andCare in hospital associated with 8.8X family risk of prolonged grief disorderWright 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
31 How Palliative Care Reduces Cost Improved resource useReduced bottlenecks in high cost unitsImproved throughput and consistencyThe Conceptual Model:Dedicated medical team =Focus + Time =Decision Making / Clarity / Follow through
32 Palliative Care Growth Source: Center to Advance Palliative Care, capc.org/reportcard3232
33 America’s Care for Serious Illness A State-by-State Report Card onAccess to Palliative Care in Our Nation’s HospitalsSource: Center to Advance Palliative Care, capc.org/reportcard3333
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 Careby 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 lifeProportion in ED last week of lifeProportion >1 hospital stay in last 30 days of lifeProportion admitted to hospice <3 daysProportion not admitted to hospice before deathCARE: Consumer Assessments and Reports on End of Life CarePain ScreeningPain AssessmentDyspnea ScreeningDyspnea TreatmentTreatment PreferencesFor hospice only:Proportion with spiritual assessmentFamily 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 qualityThe Joint Commission: September 2011 release of a Palliative Care Advanced Certification Program.
42 Major Health Systems Get It Making multimillion dollar investments in palliative care integration across settings:Partners Health System/ Harvard Medical SchoolU. of Pittsburgh Health SystemDuke U. Health SystemNorth Shore-LIJ Health System
43 Payers Get ItExamples 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 careNEEDS
48 Emerging Initiatives Palliative care in the ICU, ED and OPT settings “Primary” palliative care, raise all boatsDevelopment of service standards & comparative data through Registry“Triggers” and ChecklistsCommunity based palliative careLong term careHome careOffice practicesCancer 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 prognosisOptions:“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:
51 Metrics: The CAPC Registry Your data, local useYour data, comparedYour data, compared and combined -Provides outside perspective & validation to plansLeverages data you collect for several purposesBuilds 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 ReportFocus 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 ComponentsCriteria for a Palliative Care Assessment at the Time of AdmissionCriteria for Palliative Care Assessment during Each Hospital Day
55 The ChallengeMost teams get late referrals or never see patients with …- Multiple co-morbid conditions and declining function- Difficult-to-control physical or psychological symptomsLong length-of-stay, especially in the ICUMultiple admissions, ED visits
56 Why Develop Triggers? Improve patient/family outcomes Reduce variation in careMake palliative care part of a systems-based approach to careCulture change
57 Approach to TriggersUse a risk assessment pathway to indentify patients who are most likely to have palliative care needs based on . . .Disease variablesPatient variablesMetastatic cancerAdvanced dementiaClass IV CHFMore than 2 hospitalizationswithin 3 monthsUnintentional loss of more than10% of body weightICU length of stay greater than X days
58 Principles Behind the Checklist Identify patients at greatest risk of unmetpalliative care needs on admit and daily duringstay.Standardize/improve assessment/documentationand basic palliative care management skills byprimary clinicians (nurse, social worker, chaplain,physician).Reserve specialist palliative care for complexproblems.
59 Other Resources www.capc.org Annual National Seminar The IPAL Project: Improving Palliative Care in the ICU/ED/OPTNational Palliative Care RegistryTMAudio-Conferences and WebinarsCAPCconnectTM Online Discussion ForumPalliative Care Leadership CentersTM Training and MentoringCAPC Campus OnlineTMTools, Toolkits and CrosswalksState-by-State Report Cardfor Patients and FamiliesAnd more
60 Recent Blog Post on How to Improve Access to Palliative Care
62 Getting started – Planning for a new program Use The Guide & CAPC Tools for orientationIdentify sponsors & clinical advocatesConduct a Needs Assessment, Systems AssessmentPrepare a draft plan to estimate patient volume & staffing needsIdentify skill development needs & IDT staffing needsStart a pilot in a focused areaPlan 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 workReview the IPAL materials & set goals with ICU, ED, ambulatory settingDo a needs assessment baseline using the criteria in the “Triggers” articleReview 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/ )
64 Actions to refresh an existing Palliative Care Program Apply for Advanced Certification in Palliative Care from The Joint CommissionAdopt the NQF ‘Preferred Priorities” / do a GAP analysis & a plan for QIIdentify 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 SummaryAlignment between patient needs, palliative care, and readiness for bundled payments or ICO/ACO systems integration modelsBrand palliative care separately from hospice and EOL, to improve access, quality, survival, efficiency (and EOL care)Tools exist; don’t recreate the wheel