1. Meeting the Needs of Those with Serious Illness: National Trends in Palliative Care Tom Gualtieri-Reed, MBA Spragens & Associates, LLC Chicago Regional Leadership Summit for Supportive Care Chicago, Illinois May 1, 2015

2. Agenda  What is Palliative Care?  The Impact of Palliative Care on Value  National Trends & Challenges  Q&A 2

3. 3 What is Palliative Care?

4. 4  Palliative care is an approach to medical care for people with serious illness.  It focuses on providing patients and their families with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis or stage of the disease.  The goal is to improve quality of life for both the patient and the family.  It is provided by a team of palliative care doctors, nurses and other specialists who work together with a patient’s other doctors to provide an extra layer of support.  It is appropriate at any age and at any stage in a serious illness and is provided along with regular disease treatment.

5. Palliative Care is Delivered Concurrent with Disease Treatment Source: Morrison and Meier. N Engl J Med 2004;350(25):2582-90. 5

6. 6 An 88 year old man with 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), falls, and altered mental status due to constipation. His family (83 year old wife) is overwhelmed. Case Example: Mr. B Source: Diane E. Meier, MD, FACP, Director of the Center to Advance Palliative Care (CAPC). Used with permission

7. 7 Case Example: 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.”

8. 8 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 House calls referral Pain management 24/7 phone coverage Support for caregiver Meals on Wheels Friendly visitor program No 911 calls, ED visits, or hospitalizations in last 18 months Before and After

9. Clinical Skills: Pain and symptom management Goal setting Caregiver support Social & spiritual support Structural Elements: Targeting of those with serious illness Interdisciplinary team-based care Flexible levels of care delivery “dose” Care across settings and 24/7 access to care team Delivered concurrently or independently of disease treatment Characteristics of Quality Palliative Care Note: Derived from the National Quality Forum’s framework and preferred practices for quality palliative care and the National Consensus Project for Quality Palliative Care guidelines 9

10. Understanding the Need: Sickest 5% Account for 50% of Expenses Source: Agency for Healthcare Research and Quality analysis of 2009 Medical Expenditure Panel Survey. Distribution of health expenditures for the U.S. population, by magnitude of expenditure, 2009 1% 5% 10% 50% 65% 22% 50% 97% $90,061 $40,682 $26,767 $7,978 Annual mean expenditure 10

11. Source: IOM Dying in America Appendix E http://www.iom.edu/Reports/2014/Dying-In-America-Improving-Quality-and-Honoring- Individual-Preferences-Near-the-End-of-Life.aspx Who Are the Costliest 5% of Patients? 11

12. Who are the 5%? Risk is concentrated among those with: Functional Limitation Dementia Frailty Serious illness(es) 12

13. 13 The Impact of Palliative Care on Value

14. The Value Equation Value = Quality Cost 14

15. Crisis prevention What is the Impact of Palliative Care? Quality: ► Relieves pain and symptoms ► Patients live longer ► Better family support Cost: ► Setting & treatment aligned with patient goals ► Reduces 911 calls, ED visits, and hospitalizations ► Reduces unnecessary tests, procedures 15

16. Palliative Care Improves Outcomes For Patients 151 lung cancer patients randomized to usual care versus usual + palliative care consultation Compared to usual care only patients, palliative care patients were observed to have: – Significantly improved quality of life – Less depression – Fewer burdensome treatments – Improved survival: + 11 weeks Temel et al, NEJM 2010 16

17. Palliative Care Improves Outcomes for Families Caregivers of patients receiving palliative care have: – Better quality of life, experience less regret, and show improvements in physical and mental health Compared to dying at home with hospice: – Dying in hospital associated with: 9 fold increased risk of prolonged grief disorder in caregivers – Dying in an ICU associated with: 5 fold increased risk of posttraumatic stress disorder (PTSD) in caregivers Wright AA et al, JAMA, 2008; JCO, 2010, 17

18. Live DischargesHospital Deaths Costs ($)Usual Care (n=18,2347) Palliative Care (n=2,630) Δ Usual Care (N= 2,124) Palliative Care (2,278) Δ Per Admission $11,140$ 9,445$1,696* * $22,674$17,765$4,908** ICU$7,096$1,917$5,178*$14,542$7,929$7,776* Died in ICU18%4%14%* *P<.001**P<.01 18

19. Palliative Care Reduces Readmissions Hospital palliative care reduces readmissions by 50%. Discharge with hospice or palliative care associated with a 4-6 fold reduction in readmissions as compared to discharge to: – home (home health or no home care) – nursing home (without hospice) Nelson et al, Perm J, 2011; Enguidanos, JPM 2012, Adelson et al, ASCO 2013 19

20. Palliative Care at Home for the Chronically Ill KP Study Brumley, R.D. et al. JAGS 2007 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. 20

21. 21 National Trends & Challenges  Increased access to quality palliative care in hospitals  Growth in need in the office, home and post-acute settings  Our ability to meet the need through workforce development  Payer and payment trends  National attention on palliative care and serious illness  Increased access to quality palliative care in hospitals  Growth in need in the office, home and post-acute settings  Our ability to meet the need through workforce development  Payer and payment trends  National attention on palliative care and serious illness

22. ► In 2012, hospital programs were serving over 6MM patients each year. ► Palliative care prevalence and # of patients served has nearly tripled since 2000. Palliative Care Growth: U.S. ► 100% of the U.S. News 2014 – 2015 Honor Roll Hospitals Have a Palliative Care Team. ► 100% of the U.S. News 2014 – 2015 Honor Roll Children’s Hospitals Have Palliative Care Teams. Source: CAPC analysis of 2012 National Palliative Care Registry™ Annual Survey 22

23. This chart shows the mean palliative care service penetration for palliative care teams, from the lowest to highest quartiles in terms of staffing. Higher staffing levels are a key determinant of higher penetration rates (serving more patients in need). Insufficient staffing continues to present a barrier to reaching patients in need. Source: CAPC analysis of 2012 National Palliative Care Registry™ Annual Survey 23 Higher Staffing Results in Palliative Care Serving More Patients in 2012

24. 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. Source: Smith AK et al. Health Affairs 2012;31:1277-85. 24

25. The Family Burden 65 million caregivers deliver care at home to a seriously ill relative – Average 20 hours/week – 87% state they need more help – 33% in poor health themselves Stressed caregivers are at significantly increased risk of death, major depression, reduced quality of life, and loss of work Emanuel et al. Ann Intern Med 2000, Levine C. N Engl J Med1999, Schulz et al. JAMA 1999; Schulz et al. JAMA 1999;282:2215., Kuhlthau et al, Matern Child Health 2010, Natl Fam Caregivers Assoc, 2010 25

26. 26 Source: Center to Advance Palliative Care

27. Where are the Gaps? Smaller hospitals (<100 beds) Home Nursing home and assisted living Office practices Cancer centers 27

28. Meeting the Growing Need Example: Over 65 Trends 1950 2000 2050 Proj* In 2050, the number of Americans aged 65 and older is projected to be 88.5 million, more than double its population of 40.3 million in 2010. In 2050, those aged 65 and over are projected to account for 20% of the population in the U.S., up from 13% in 2010. *Source: U.S. Census Bureau. U.S. Department of Commerce. 28

29. Examples: Interdisciplinary team – leverage all skills Train all clinicians serving seriously ill Redesign payment models to support the care that is needed Examples: Interdisciplinary team – leverage all skills Train all clinicians serving seriously ill Redesign payment models to support the care that is needed How do we Meet the Need? 29 Source: Center to Advance Palliative Care On-line Training. www.capc.orgwww.capc.org 29

30. 30 With funding support from the California HealthCare Foundation Sponsored by: www.capc.org/payertoolkit Opportunities for Payer-Provider Partnerships

31. Payer Case Examples Demonstrate Options for Impact Better Quality of Life Better Quality of Care Community Collaboration & Awareness Provider Training and Recognition Member Engagement & Care Management Medical Policies & Coverage Payment Innovations 31

32. 32 Payer Results… For the 1% of all Medicare Advantage members enrolled in the Compassionate Care program, there is an:  82% hospice election rate;  81% ↓ in acute days;  86% ↓ in ICU days;  High member and family satisfaction  Total cost reduction of over $12,000 per member For those members enrolled in the Highmark Advanced Illness Services program: Satisfaction: 95% would refer Friends/Family Metrics: Hospice election: 79% Average/median LOS in hospice: 85/29 days Acute care last six/one months of life: 14% ↓ / 33% ↓ ICU last six/one months of life: 30% ↓ / 48% ↓ ER visits in last 1 month of life: 39% ↓ Increased health care proxy completion rates: 42% of persons 18 years of age and older across 39 counties; 47% in Rochester Region (2008) vs. 20% national completion rate Nearly 60% of Excellus BCBS employees have completed health care proxies. Was founding force behind NY’s eMOLST: the first electronic form and process documentation system in the nation that also serves as the state registry. 32 Source: Center to Advance Palliative Care Payer Toolkit. www.capc.orgwww.capc.org

33. 33 Growing National Attention and Resources to Expand Access Tools, Training & Technical Assistance Advanced Certification in Palliative Care 2014 IOM Report & Recommendations Requires Palliative Care for Cancer Center Accreditation Palliative Care Training for Nurses Sponsoring Planning Grants for Payer-Provider Partnerships

34. 34 Q&A