1. A Success Story Palliative Care in a Rural Community Dr. Thomas Putnam - Medical Director Renee Moulton - VP of Finance Lynn Austin - PC Director

2. Population =134,905 Aging population Young Adults Move for job opportunities Caregiving Vacuum

3. Connections Program 2007 to 2010 Mission: To address short LOS in Hospice People with Uncontrolled Symptoms called in to inquire People with no skilled need for a home RN agency fell in the cracks

4. Connections Interventions Many Supportive Calls Program helped with many Transportation Needs Social Work Needs Dominated Minimal Hospice Crossover (Why???)

5. 2011 in NYS Legislation Palliative Care Information Act (Tell ‘em) Palliative Care Access Act (Send ‘em) Hospice Modernization Act (Bill ‘em)

6. Start Up! (2012) Implementation Team formed from Multiple Agencies PC Leadership Center Training was helpful but… …there was nil experience at the Center in Home-Based PC “Making it up as we go.”

7. Advisory Committee Interested Physicians Community Stakeholders (Hospital Admin., Eldercare Attorney, Social worker) Met twice mostly to hear our plans Follow-up meeting now would be helpful

8. Home Hospice Model Full IDT (Nurse, SW, Chaplain, Doc) Initially using all Hospice staff Staying connected indefinitely (if loosely)

9. Inpatient Consult Model Very different from ours! Gentiva Vanderbilt Program (Feb. 2015) Starting from Inpatient Connection Craving home follow-up and continuity 2 to 5 NP visits then refer back to PCP and Pain Management if needed No other disciplines on the team

10. National Quality Forum Full IDT………but Who is paying? 24/7 Access Care Plan Team meetings to process goals Assess and Address Symptoms MOLST, HCP

11. Hospice Unique Strengths Vigorous Symptom Control Time-Intensive Transitional Conversations Inter-Disciplinary Collaboration Experienced EOL Guides

12. Hospice Strengths Extended Pre- HOSPICE - chemo >6 months HOSPICE Lite - Expensive Care or Valuable Home Agency prohibits Hospice Stealth HOSPICE- Patients in Denial or Hospicious

13. Early Patient Example, T.C. 41 y.o. woman, kids in school, lost income Cervical cancer with no more treatment options Referred to Hospice but unwilling Malignant Psoas syndrome Uncontrolled pain with q 6hr hydromorphone Home visits and addressing symptoms led to trust and acceptance

14. Early Referral Issues Chronic Pain patients excluded Prominent Social Work and HHA Needs Intake re-defined by insisting on Life- Limiting Illness with medical symptoms to manage Intake revised to allow difficult conversation/decision needs

15. PC is for Patients in Transition POCT—Philosophy of Care Transition LOCT---Location of Care Transition SOCT----Symptoms out of Control Transition

16. PC is for Patients in Transition (Buffalo PC Team visit) What are the goals and what are we doing? If goals are met, patient is discharged Insurance company (IH, Blues, Univera) oversight asked us “What are you accomplishing with our member?”

18. Vulture Resemblance Problem We had to Learn to Let Patients Go Off the PC Program (discharge them) This was not natural for Hospice staff Empathic listening and trust-building

19. “We are not a feeder program!” ……or are we? We do want longer LOS on Hospice About 1/3 PC patients went to Hospice We do want the most appropriate program for each patient

20. Boundary Struggles Hospice Staff doing PC have to re-think their role PC RN removed staples on a post-op patient with a home nursing agency PC SW filling out forms and making phone calls instead of empowering PC doctor prescribing without letting the agency nurse know the new orders

21. Hospice Biases We don’t do CPR in Hospice but in PC…? I was not used to thinking about routine drug monitoring and testing in Hospice patients

23. Development October 2011 started discussion and formation of implementation group March 2012 Training in Kentucky for Palliative Care Leadership Development of Mission, Vision, Strategic Plan, goals, teams

24. Palliative Care Program Implementation July 12, 2012 first referral Physician, Social worker, Spiritual Care, Registered Nurse Homegrown-Learning as we go along the way

25. Building Relationships Educate community Chautauqua Institution Home Health Agencies Educate PCP, Specialist

26. 2013 Live Program Intake process changed PC Coordinator RN –contact every 2-4 wks. & prn Social Work, Spiritual Care –prn

28. LESSONS LEARNED Fragmented Care---Constant Change Hospice staff unable to attend PC IDT meeting Education to on-call

29. Collaboration Weekly census Monthly telephone call Report to Insurance Case Manager

30. Staffing Increase for PC H & P certified NP to assist Dr. Putnam with initial visit. Full time Palliative Care RNCM. Part time SW from community. Half time Medical Director Pediatric team—Pediatric ELNEC trainer Palliative Care Director

31. 20142015 Q14478 Q244111 Q34190 Q42762 Palliative Nursing Visits

32. Palliative RN Visits

33. 20142015 Q19896 Q283191 Q391183 Q466153 Palliative Nursing Phone Calls

35. Unique Strengths Community program (98% home visits) MD/NP first to visit RN,SW, SC Pediatric to Adult Serve anyone; regardless of ability to pay

37. Payor Mixes

38. 2013 Live Program

39. 2014

40. 2015

41. Insurance Program Revenue vs. Visit Revenue

42. Things to Watch and Work For Patient insurance coverage changes from year to year Participation from Medicare and Medicaid Managed Care Plans with a (monthly) Program Reimbursement Model

43. So, where is the life preserver full of money for palliative care?

44. Financial Outcomes Still dependent on grants and donations Need more program participation by all payors Increased census in program patients Reimbursable role in ACO?

45. From Intake to Discharge (How our Palliative Care Program runs now)

46. Referrals All referrals from MD/NP are accepted as consult requests (may not proceed to full team involvement) Referrals come from many sources PCP’s Oncologists Home nurses Social Workers Family members

47. Intake Process “Either PC or Hospice; whatever you think” Anyone can make a referral Confirm with PCP Financial awareness for patient

48. MD/NP Visit Call to schedule Explain program on phone----DS/DC Medical Record review Patient signs consent to bill and allow information to go to loved ones. HIPAA Full medical Hx and limited Px Edmonton equivalent symptom scales Collaborate with PCP for any prescribing

49. MD/NP Visit Patient Goals PC Team goals Level assigned for follow up Some visits could be a one-time consult with no further team involvement Visit notes and Recommendations sent to the PCP, Specialists, Home Nursing Agency

50. Levels for Acuity and Visits Level 1 - active symptom management; follow-up 7 days or less Level 2 - family meetings and decisions to follow; visit in 2 weeks Level 3 - less urgent goals; 1 month visit or call Level 4 - Phone contact every 1 to 3 months; not on an insurance program

51. Inter-Disciplinary Team North County team and South County team meetings every fortnight New patients presented with assessments, goals of care All patients reviewed for goal progress, ER/hospital status, change in Level Discharges planned if goals are met and patient is stable

52. Alternate Week Meetings Director, MD/NP and nurses only Handoff for new acute patient issues Program and Policy Discussions

53. Statistics July 2012 - March 2016 Total patients411 Current Census57 Discharged169 Died34 Transfer to Hospice151

54. Re-certification Visits MD or NP Every 6 months or 3 months (Univera) per insurance program Consider Discharge or Continuation

55. PC Patient Discharge Invited to call and “re-up” if there are significant health changes Transfer to Hospice if appropriate

56. Quality Measures Documented 5 days or less to visit a new referral Symptom Scales (0 to 10) for pain, dyspnea, nausea, constipation Spiritual, Emotional, Social Sx Scales can be identified and rated 1 to 10 as well All disciplines evaluate by visit or phone HCP/DNR/MOLST DNR “flips” after education

57. MOLST Completion 2015 MOLST Completeness Before PC3 After PC40 Unknown7

58. QMD II Visits and phone calls in EMR and copies to PCP and to CHA if appropriate ER and Hospital avoidance events Insurance company case manager contacts Patient and referring doctor surveys PQRS measures

59. ER Avoidance Actual Numbers Cost ER Visits18$39,024 ER Avoidance59$127,912 (saved)

60. QMD III Controlled Medication Prescribing 1. Signed Med Consent/Agreement 2. Opioid Risk Tool to Stratify 3. Drug Testing and Monitoring

61. Rural Challenges Salaried MD Driving Time for home visits is financially draining (electronic work) Inheriting Home-bound Patients who have no other prescriber Controlled Drug Prescribing Handoffs are difficult to pull off in our area Internet Connectivity for e-MOLST

62. Hopes and Dreams Inpatient beds in SNF Increase Pediatric and Adult census Annual PC Fundraisers Full time NP Full time LCMSW (can bill mental health home visits) Volunteers Teaching Program for home-based PC

63. Conclusions - Palliative Care Wonderful opportunity to address Total Suffering in people with Hospice barriers Home visits are valuable; they build trust and credibility Using Hospice staff allowed flexibility in start-up but brought challenges Time allowed to listen well is a true gift! Outside funding is necessary