Moving Palliative Care Upstream David E. Weissman, MD Professor Emeritus Medical College of Wisconsin Consultant, Center to Advance Palliative Care

Objectives List 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.

Historical Perspective Phase I Hospice 1970s-80s Phase 2 Palliative Care 1990s-2000s Phase 3 Spread 2010s-

The Palliative Care Intervention Interdisciplinary teams Patient-centered goals of care discussion Realistic prognostication Pain and symptom relief Disposition planning reflecting patient goals Patient/Family support Bereavement support

Key Palliative Care Outcomes Reduced ICU length of stay Rapid symptom relief Earlier referral to hospice services-longer Greater patient/family satisfaction Lower hospital cost Prolonged survival (outpatient intervention)

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 Medicine Physicians Nurses: AP, RN, LPN Social workers Chaplains (pending)

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, Renal Between hospitals and hospice there is a large gap of palliative care needs across the Continuum of health care. Outpatient services Long-term and Home care Home care

Hospitals Not all hospitals have consult services Those that do are typically overworked High rate of stress/burnout Many “martyrs” Adding more staff is problematic More staff leads to more consults

The Referral Conundrum Consults predominantly occur based on clinician values, rather than patient needs Clinician values/attitudes inhibit provision of excellent palliative care services My patient isn’t ready; my patient is not dying I’m not ready for palliative care I will not give up on my patient Education alone will not fix this problem.

Reality Check There will never be enough palliative care specialists (all disciplines) to meet the demand. Overall health care dollars will be shrinking.

Solutions Increase team efficiency: Accountability and Value New team models Integrate palliative care principles into high-risk locations Identify unmet needs Expand Generalist Palliative Care Improve care across the continuum

1. Increase Team Efficiency Close examination of the process of care delivery Staff time studies Determine cost/case Use metrics to determine efficiency and value

2. New Team Models “Counselor” Model Staff Intervention Med Center Central Georgia/UMDNJ Staff Specially trained communication “counselors” (Nursing, Mental health background) Intervention Manage most goal of care discussions Work in both parallel and series with PC team

3. Integration Projects Efforts to broaden the spread of palliative care principles into locations of high unmet needs, through … setting collaborative goals early patient identification (triggers) systems change to guide right care at right time—routine family meetings quality improvement-data driven change

www.capc.org/ipal

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 treatments they desire/are appropriate to their medical condition/prognosis.

Common trigger systems ICU Length of stay Multi-organ failure Metastatic cancer Prolonged unconsciousness Nursing home admission Emergency department Oncology clinic Special populations LVAD/CHF Nursing home admits PEG or trach consideration

5. Generalist Pall. Care Need to imbed Palliative Care principles into the system of health care delivery Commitment: time/$ Assessment: case finding—all patient screen Responsibility: QI Education: all clinical staff Standards: who/what/when

Primary/Specialty Care Primary Pall Care: all clinicians Routine communication/symptom control Specialty Pall Care Family meetings—esp. “difficult cases” Complex symptom management Time management Support for difficult decisions

6. Move into the Continuum Outpatient Palliative Care Free-standing Co-management clinics: oncology, other Home visits IPAL-OP www.capc.org/ipal Long Term Care Dedicated Pall Care staff Geriatric NP model Consultative external team

What else is new?

The Joint Commission The Joint Commission: Palliative Care Advanced Certification Program http://www.jointcommission.org/certification/palliative_care.aspx

HEALTH REFORM

Palliative Care is Central to the Success of Health Reform >95% of all health care spending is for the chronically ill 64% of all Medicare spending goes to the 10% of beneficiaries with 5 or more chronic conditions Despite high spending, evidence of poor quality of care 25

Palliative Care, Health Reform and Chronic Disease Care Health reform initiatives Reduce readmissions Reduce cost Improve quality/Reduce variation Shift chronic disease care out of the hospital Care coordination/Bundling/ACOs Palliative Care services/outcomes are perfectly aligned with all these priorities!

Payers are getting into Palliative Care

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/impact Mortality and readmission reduction Cost control

What can you do? Push for collaborative initiatives ICU/ED/Cardiology/Cancer/Hospitalists Focus on improving generalist palliative care rather than striving for more consults Remind everyone about the 50%! Seek opportunities identify patients with unmet needs

CONTACT ME dweissma@mcw.edu www.capc.org