1. Home Based Palliative Care Richard D. Brumley, MD Gretchen Phillips, MSW Kaiser Permanente Downey, CA Practice Change Fellows January 24, 2008

2. 2 Palliative Care Across the Continuum Primary Care Physician Subspecialist Physician Population Care Manager Geriatric Assessment Clinic Palliative Care Consultation Team Hospitalist Physicians Discharge Planners Home Health Extended Care Facility Palliative Care Hospice OutpatientInpatientExtended CareHome-Based

3. 3 Challenges to Provide End-of-Life Care  Curative/Restorative Care vs. Palliative Care  Acute Care vs. Chronic Care  Hospital Care vs. Home based Care  Reduce care to Reduce cost vs. Improve care & Reduce cost  One percent of our members create over 30% of our costs

4. 4  53 years old  COPD - 30 years  Multiple Sclerosis - 20 years  Chronic Stage III decub  66 pounds  Full Code Used with written permission

5. 5 Usual Care 02/02 to 01/03  12 acute admissions  63 days  2 intubations  22 different physicians admitted/discharged  14 home health admissions  focus on decub care

6. 6 Core Components of Palliative Care  Patient and family unit of care  Interdisciplinary team directs/provides care  Physician, Nurse, Social Worker  Aide, Chaplain, Volunteer  Home care emphasized  all providers make home visits  Plan of care - coordinated and supportive services

7. 7 Core Components of Palliative Care Cont.  Physical, medical, psychological, social and spiritual needs  Pain and symptom management  comprehensive primary care to manage underlying conditions  aggressive treatment of acute exacerbation per patient and family request  24 hour phone support, visits if necessary  Volunteer support & Bereavement services

8. 8 Palliative Care Admission Criteria  CHF, COPD, Cancer, or meet Hospice criteria for disease and don’t want to be on hospice program  Expected prognosis <12 months  Deteriorating medical condition at risk for needing symptom management  Primary Care Provider when necessary  Emphasis of care in the home setting  1-2 or more ED or Inpatient admissions in the last year  Palliative Performance Scale < 5 (mainly sit or lie, unable to do any work, extensive disease, considerable assistance necessary with self-care)

9. 9 Palliative Care Case Load  60-70 patients average daily census  Staffing  0.8 Physician  4 Nurses  2 Social Workers  2 Home Health Aides

10. 10 Home Based PC Results  298 patients, multi-site RCT  Pts home-bound w/ Cancer, COPD, CHF  ALOS 200 days  Compared to usual care:   Pt/family satisfaction at 60 days and thereafter  PC patients more likely to die at home (51% UC vs. 71% PC)   Hospital admissions (36% vs. 59%)   ER visits (20% vs. 32%)  Decreased (32.6%) utilization and costs  Total costs $20,221 usual care vs. $12,613 PC (p=.001)  Total cost avoidance = $7,552/patient  Average cost/day $213 UC vs. $133 PC  Patients transfer to Hospice when appropriate

11. 11 Home Health Referrals diverted to Hospice and Palliative Care  Review of 70 referrals for 3 day period  20% possibly appropriate for H or PC  Age of Patients with Possible Referral 36 – 45 years old1 referral 8% 46 – 551 8 56 – 650 0 66 – 75323 76 – 85646 86 – 95215 TriCentral, February, 2004

12. 12 Hospice & Palliative Care Utilization  12% of H patients switched to PC  7% of PC patients switched to H  3% switched back and forth several times  3% of patients who qualified for H wanted to be on PC Snapshot TriCentral May, 2005

13. 13 Hospice vs. Palliative Care Patient Distribution Percent of Patients TriCentral May, 2005

14. 14 Hospice and Palliative Care Deaths vs. Usual Care Deaths Bellflower Medical Center 2005

15. 15 Palliative Care Replication Challenges  Who is the champion?  Justify new program within constraints of current budget climate  Marketing  What End-of-Life “infrastructure” is in place?  Hospice, Bio Ethics Committee, Advance Care Plans, Physician comfort/communication with EOL care  Late referrals  Integration within the Continuum of Care

16. 16 Palliative Care References Your Guide to Creating an Outpatient Palliative Care Program Open Society Institute Project on Death in America http://growthhouse.org/palliative/ Brumley, R., Enguidanos, S., et al, (2007) “Increased Satisfaction with Care and Lower Costs: Results of a Randomized Trial of In-Home Palliative Care.” Journal of the American Geriatrics Society, Volume 55, 2007, 993-1000

17. 17 Usual Care 02/02 to 01/03  12 acute admissions  63 days  2 intubations  22 different physicians admitted/discharged  14 home health admissions  focus on decub care Palliative Care 02/03 to 12/03  No acute admissions  Palliative Care Team  developed plan of care for relief of dyspnea  caregiver support  consistent palliative care team

18. 18 Life is a Journey Live Long – Thrive – Die Well  Engage patients and families in discussion about goals of care  Discuss likely course of disease  Honor patient preferences  Increase patient, family, physician and staff satisfaction with care