1. Managing Advanced Illness to Advance Care Executive Briefing - AHA Annual Meeting Tuesday, April 30, 2013 10:45am – 12:15pm © 2012 American Hospital Association

2. Advanced Illness Management Strategies: Part I 2 The first CPI report framed AIM as a four-phase process to be addressed through three strategies—access, workforce and awareness The report also examined in depth how hospitals can increase access to AIM programs and change the way medi­cal services are utilized to improve outcomes and honor the wishes of patients and families.

3. Advanced Illness Management Strategies: Part II 3 This second and follow-up report: Expands and explains more precisely the three key strategies of AIM—access, workforce and awareness Provides health care systems strategies and case examples that focus on patient and community awareness and engagement and a ready, willing and able workforce.

4. Why Integrate AIM Programs? AIM programs allow hospitals to navigate the first-curve to second-curve transition and fill the gap. In the hospital setting, AIM programs are proven to: Provide patients with improved quality of life, reduced major depression and increased length of survival Lower utilization of clinical treatments and hospital admissions among enrolled patients Improve satisfaction scores for patients, family, caregivers and the multidisciplinary AIM-trained staff Reduce aggregate spending 4

5. Phases of AIM 5

6. Managing the Gap: Strategies to Developing a Successful AIM Program 6

7. Three Key AIM Strategies 7 Access Patient access to AIM services can be greatly increased when all hospitals and care systems are able to support and delivery high-quality AIM. Workforce Excellence in AIM depends upon the education and training of health care professionals that can deliver quality hospice, palliative and end-of-life care. Awareness Patient and family AIM awareness and understanding of the benefits of advanced illness planning and management can be significantly raised through communitywide strategies.

8. (1) Strategies to Increase Access to AIM Services Develop a multidisciplinary care team with leadership buy-in Identify qualifying patients through evidence-based protocols Think beyond the traditional four walls of the hospital to promote AIM collaboration throughout the surrounding community Use a performance improvement framework to measure, monitor, evaluate and adapt the program between disease states and throughout time 8

9. (2) Strategies to Expand Patient and Community Awareness and Engagement Increase patient accessibility to information about end-of-life care by developing awareness and “conversation-readiness” among health care professionals; work with stakeholders on the importance of conversations, advance directives and early decision making; provide effective language assistance services; and address low health literacy Launch community development strategies that spread awareness of cultural diversity and support partnerships with local leaders and organizations that cater to the patient population’s demographics, education levels, culture and language Develop a workforce that embraces diversity to address the needs of patients and families from a variety of backgrounds and is equipped with the skills and knowledge necessary to support and guide those facing end of life 9

10. (3) Strategies to Build a Ready, Willing and Able Workforce Develop educational programs that offer ongoing training for health care professionals to learn the necessary skills and competencies for engaging in sensitive conversations and that train health care providers on the role and impact of spirituality in end-of-life care Use a multicultural guide/spiritual toolkit to support understanding and meeting diverse patient needs Create a solid program infrastructure to sustain a successful palliative and end-of-life care program 10

11. Thank you! http://www.aha.org/about/org/ cpi.shtml 11

12. AHA Annual Meeting AIM Panel April 30, 2013 Laura Mavity, MD, Clinical DirectorKatie Hartley, BSN, CHPN, Administrative Director Centers of Care Advanced Illness Management

13. Sole Community Four Hospital System –Pioneer Memorial Hospital (CAH, 25 beds) –St. Charles Bend (261 beds) –St. Charles Madras (CAH, 25 beds) –St. Charles Redmond (48 beds) Primary Care and Subspecialty Practices Home Health and Hospice Services Behavioral Health Services St. Charles Health System

14. Central Oregon

15. WHAT: Our IDS is designed to achieve the Triple Aim HOW: Delivered through the Centers of Care model St. Charles Health System IDS

16. Centers of Care

17. To Improve the Health of Our Population (Better Health) –Complex planning and management of advanced illness patients eases stress for their loved ones –Intensive support for caregivers and families To Improve the Patient Experience (Better Care) –Improve pain and symptom control –Address emotional, psychosocial, and spiritual suffering in life-limiting illness –Clear and realistic patient-centered care goals –Seamless discharge planning to community resources –Improved patient and family satisfaction –Improved hospital staff and physician support and satisfaction To Reduce the Cost of Care (Better Value) –Streamline healthcare – avoid undesired or non-beneficial care –Reduce inappropriate resource utilization –Avoid hospital readmissions Triple Aim and Palliative Care

18. Centers of Care

19. Realistic patient and family-centered care goals –Re-evaluated throughout the duration of illness –Empowering patients and families about healthcare choices –Facilitate referrals to appropriate community programs –Advanced care planning Expert symptom and comfort management –Whether pursuing aggressive life prolonging care or comfort measures only –Independent of prognosis Focus on patients with progressive life limiting illness with prognosis of two years or less SCHS Advanced Illness Management Center of Care

20. Palliative Care Delivery The Clinical Approach: -Basis is family conference -Time intensive assessment of patient and family values, symptoms and their understanding of disease and prognosis to develop patient-centered care goals -Ongoing intensive communication and support for patients and families with accessibility for questions or concerns The Conceptual Model: Dedicated team Focus + Time Decision Making + Clarity + Follow through

21. Foundations of Palliative Care Dying is normal Advance care planning is important Coordination of care and services is imperative Medical care provided should be based on the patient and his or her family’s goals and values

22. St. Charles AIM Palliative Care Consultations St. Charles Bend 2009 - 2009 - 222 consults - 2010 - 382 consults - 2011 - 436 consults - 2012 - 500+ consults St. Charles Cancer Center 2010 AIM Center of Care 2011 Outpatient Consultations Spring 2012 St. Charles Redmond Fall 2012 SCHS Advanced Illness Management Center of Care

23. AIM Consultation Requests by Specialty *OTHER: CT SURGERY, NEUROLOGY, GEN SURG, ORTHO, GI, REHAB, INTERNAL MED, VASCULAR SURGERY

24. Disposition after AIM Consultation

25. Diagnosis Classes for AIM Consultation

26. AIM Payer Classification

27. SCHS Advanced Illness Management Center of Care 2012 Data Highlights: $4,000 average direct variable cost avoidance per inpatient AIM consultation AIM patient 30 day readmission rate 4.86% (expected 10.4%), overall readmission rate 8.74% Average time from admission until AIM consultation: 4.1 days Average LOS after AIM consult: 2.7 days Most common reason for consultation: Goals of Care Discussion/Advance Care Planning

28. SCHS Advanced Illness Management Center of Care 2012 Data Highlight Average symptom burden (ESAS) before and after consultation BEFOREAFTER PAIN0.830.47 ANXIETY0.360.11 DYSPNEA0.590.28 N/V0.140.04

29. Develop seamless care flows for patients with advanced illnesses throughout our regional health care system Collaboration/Partnerships –St. Charles AIM Program: Inpatient consultations all four hospitals Outpatient consultations all four sites including St. Charles Cancer Center Bend and Redmond –Regional hospice and Transitions programs –Regional physicians, practices, and community programs SCHS Advanced Illness Management Center of Care

30. Outpatient Consultation Service Development Justification = most patients spend most of their time outside of hospitals Opportunity –Improves quality patient care –Potentially decreases in-hospital mortality –Increases efficiency in health care systems and accountable care organizations ACCESS AIM Center of Care Initiatives: ACCESS

31. Needs Assessment Why are you considering outpatient services? Staffing Patient Focus Stakeholders ACCESS AIM Center of Care Initiatives: ACCESS

32. Model: Embedded Clinic Collaborative relationship between a host clinic and palliative care staff All costs of the clinic operations are born by the host clinic Patients referred predominately from the host clinic Defined clinical pathways or protocols may exist defining patient flow between the host and palliative care staff ACCESS AIM Center of Care Initiatives: ACCESS

33. Finances: Support and alignment Most outpatient palliative care practices operate at loss Primary cost is labor – Billing = <50% of expenses NEJM Temel Study showed mean cost savings per outpatient consult $2,282 –Decreased inpatient visits-mean $3,110 per patient –Less chemotherapy-mean $640 per patient –Longer lengths of hospice stays Temel et al. Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer. NEJM 2010; 363:733-742 ACCESS AIM Center of Care Initiatives: ACCESS

34. Outpatient AIM Consultation Service Cancer Center Advanced Stage Lung Cancer initiative 2011 Inpatient - 7 consultations 2012 Inpatient - 35 consultations Disposition: - 9 died in the hospital- 15 left the hospital with hospice - 5 discharged with home health- 1 discharged to SNF - 1 discharged to inpatient rehab- 1 discharged home without services Outpatient: Quarters 1, 2, and 3 - 1 consultation Quarter 4 - 11 consultations ACCESS AIM Center of Care Initiatives: ACCESS

35. System standardization of processes and procedures AIM consultation availability at all four hospitals - St. Charles Bend, Cancer Center, Outpatient -St. Charles Redmond, Cancer Center, Outpatient -Pioneer Memorial Hospital and St. Charles Hospice Prineville -Expand hospice staff role to include palliative care consultations -St. Charles Madras and Hospice -Expand hospice staff role to include palliative care consultations Coordination with multiple regional hospices, other service organizations Quality/Performance Improvement Program ACCESS AIM Center of Care Initiatives: ACCESS

36. St. Charles AIM Team/Center of Care expansion 2009: 1 part-time palliative care MD 2013: 3 palliative care MDs (2.35 FTE) and 2 hospice medical directors, dedicated AIM team SW, AIM RN case manager, AIM chaplain pending (shared position with Cancer Center) Cambia Health Foundation Sojourns Pathway Grants $237,000 CAPC Palliative Care Leadership Center training and mentorship UCSF palliative care program financial data analysis pilot project WORKFORCE AIM Center of Care Initiatives: WORKFORCE

37. AIM Team members and Center of Care provide caregiver education 3 grand rounds delivered by AIM Team Dr. Diane Meier 9/12 Dr. Ira Byock pending 11/13 Palliative Care education for caregivers by AIM Team (palliative care, symptom management, hospice benefit, end of life process, care goal discussions, advance care planning) Over 30 presentations delivered annually WORKFORCE AIM Center of Care Initiatives: WORKFORCE

38. AIM Team members provide regular community education Heart Failure University Pulmonary Rehabilitation “Better Breathers” group Kiwanis, Rotary Club presentations Wholeness Seminars at a local hospice agency System board presentations AWARENESS AIM Center of Care Initiatives: AWARENESS

39. The Conversation Project Co-founded by Pulitzer Prize-winner Ellen Goodman and developed in collaboration with IHI A public engagement campaign with the transformative goal to have every person’s end- of- life wishes expressed and respected AWARENESS AIM Center of Care Initiatives: AWARENESS

40. The Conversation Project Pioneer Sponsor Program An IHI-sponsored Initiative Purpose is to better prepare health care delivery systems to receive and respect patients’ wishes about end-of-life care 12 Pioneer Sponsors committed to ensuring health systems are “Conversation Ready” by developing and piloting processes to create these systems within health care AWARENESS AIM Center of Care Initiatives: AWARENESS

41. The Conversation Project “Pioneer Sponsor” Program St. Charles Health System is the only West coast “Pioneer Sponsor” with hospitals holding a rural designation within the system Reframe the provider-patient relationship around the question, “What matters most to you?” Ultimate objective is to package proven methods and provide programs with new tools and strategies to achieve these goals AWARENESS AIM Center of Care Initiatives: AWARENESS

42. St. Charles “Pioneer Sponsor” Projects Pilot at Heart Failure University A program attended by newly diagnosed patients with heart failure as well as those with disease exacerbations Pilot of St. Charles Health System Caregiver Engagement Personally engage our own caregivers in the conversation project’s process. Model program: AWARENESS AIM Center of Care Initiatives: AWARENESS

43. AIM Center of Care Newsletter –Distributed to community partners three times per year, relays educational opportunities, resources Bloom Project Comfort Care Program and Cart Integrative Therapies - partnership with Cancer Center Creation of Mosaic art piece with AIM Center of Care Partners AWARENESS AIM Center of Care Initiatives: AWARENESS

44. SCHS Advanced Illness Management Center of Care Mosaic Art Piece

46. Sharp HospiceCare’s Transitions Program A New Model for Late Stage Disease Management Daniel R. Hoefer, MD CMO, Outpatient Palliative Care and Hospice Suzi K. Johnson, MPH, RN Vice President Sharp HealthCare Hospice and Palliative Care

47. First generation outpatient palliative care Second generation outpatient palliative care 1.UCSF 2.Kaiser 3.Sutter (AIM) 4.VA 5.Care More 6.Health Care Partners 7.Partners Medical Group (Boston) 8.University of Pittsburgh 9.Long Island Jewish 10.Hospice of the Valley 11.Sharp HealthCare

48. CMS Goals: 1.Better individual patient care 2.Better population care 3.Lower growth in health care expenditures 4.Prevent readmissions Sharp Transitions Goals: 1.Better individual patient care 2.Better population care 3.Reverse the growth in heath care expenditures 4.Better professional caregiver support 5.Better professional family support and conflict resolution 6.Prevent any admissions including primary admissions Goals

49. Principles of Transitions Proactive In home Disease Management Proactive Psychosocial Management Accurate description of what the health care industry can and cannot provide

50. “The continued application of traditional treatment strategies which are valuable to the patient at an earlier time in their health experience has the opposite effect on patients at end of life resulting in inferior outcomes.” Daniel Hoefer, MD CMO, Outpatient Palliative Care and Hospice Sharp HospiceCare Cultural Mind Shift

51. Issues Important in the Management of a Pre-terminal Aging Population:  Mobility Deficit  Transportation Deficit  Financial Restraint  Social Support/Family Deficit  Cognitive Deficit  Compliance Deficit  Change in Goals of Care It is better to bring healthcare to patients at this time, than to bring patients to healthcare.

52. Current Culture of Health Care Reactive versus Proactive Paternalistic Dependent

53. 27% of patients with incurable terminal disease believed they could have been cured Unresectionable non-small-cell lung cancer54% AIDS32% CHF22% ALS16% COPD12% Daniel P Sulamsy, OFM, MD, PhD, et al, The Accuracy of Substituted Judgment in Patients with Terminal Diagnoses, April 1998, Annals of Internal Medicine, Vol 128(8), PP 621-29 The Traditional Medical Model “This Disease Can Be Cured”

54. Hospitalizations last year of life - CHF Acceptable or Not? Historical average hospitalizations for CHF during the last year of life 3.5

55. Where Patients with CHF Die Acceptable or Not? Historically 63% of CHF patients died in the hospital (2005)

57. Expanding the Care Continuum Home Setting Focus on high risk late stage chronic illnesses Skilled Clinicians Flexible Models Cost efficient

58. Four Pillars of Transitions Comprehensive in-home patient and family education about their disease process; proactive medical management Evidence-based Prognostication Professional Proactive Management of the Caregiver Advance Health Care Planning Extending the evidence based benefits of Hospice Care to patients at an earlier point in their healthcare.

59. Pillar One In Home Proactive Disease Management Registered Nurse Medical Social Worker Spiritual Care Primary Care MD Palliative Care MD

60. Improved Compliance Decrease Primary Admissions & Re-admissions Improved Symptom Management Improved Disease Management The best medication reconciliation occurs in the home

61. Pillar Two Evidenced-Based Medical Prognostication British Medical Journal; Extent and Determinants of Error in Doctors Prognoses in Terminally Ill patients; Prospective Cohort Study; Vol 320(7233), 19 Feb 2000 pp.469-473 1.343 doctors 2.Estimates on 468 terminally ill patients 3.Mean patient survival – 24 days 4.Considered accurate if estimate within 33% for any give patient 5.20% of the time accurate a.80% of the time inaccurate b.63% over-optimistic

62. The Clinical Consequences of Institutionalized Over-optimism (Pillar Two Continued) 6. The average over-optimistic estimate was off by 530% a.Increases the risk that treatment decisions by patients, families and healthcare providers are NOT consistent with reality b.Leaves patients and families emotionally unready for inevitable outcomes c.Increase risk that providers will lose credibility British Medical Journal; Extent and Determinants of Error in Doctors Prognoses in Terminally Ill patients; Prospective Cohort Study; Vol 320(7233), 19 Feb 2000 pp.469-473

63. Diagnosis and Treatment vs. Diagnosis, Treatment and Prognosis

64. Biometric models + functional decline patterns + specific biological data + general biological data + adjusting for your personal tendencies = accurate, effective, professional and compassionate information.

65. Event Prognostication – Prognostication which guides the patient in an expected series of events.

66. Anticipatory Guidance

67. CHF 82 Year old male Co-managed with specialist Functional Decline Progressive decline SOB Slow rise in ADL decline

70. Pillar Three Professional Evidence-Based Care for the Caregiver Evidence based medicine - Hospice care is associated with an absolute reduction in death rates in the caregiver at 18 months post death of the patient of 0.5% (1 in 200) Nicholas Christakis, et al, The Health Impact of Health care on families: a Matched Cohort Study of Hospice Use by Decedents and Mortality Outcomes in Surviving, Widowed Spouses, Social Science and Medicine 2003, vol57 pp.465-475

71. Pillar Four Advance Health Care Planning Evidence based medicine shows that AHCDs (which would include POLST) do not consistently match the health care desired by the patient with the care received by the patient

72. Problems with Advance Health Care Directives  They are not disease specific  They are too vague or contradictory to be interpreted in the context of the care which is being provided Resolve Morale Conflict Proactively Create Disease Specific Directives

73. Transitions Case Management Design Active Phase Maintenance Phase Role of Hospice –24 hour call availability –Full integration and hand offs between programs

74. Transitions Active Phase RN Case Manager  4-6 visits in 6 week time frame MSW  1-2 visits for goals of Care discussion; completion of POLST

75. Transitions Maintenance Phase RN Case Manager  Telephonic case management – every 2-4 weeks until transferred to hospice  Home visits as needed for assessment  Coordinate care with MD ongoing  Transfer to hospice when appropriate

76. Hospitalization ER Utilization: All cause During Transitions 94% reduction in primary CHF admissions

78. Synergy Transitions to Hospice ….The impact of change…

81. Cost of Care

82. Thank You