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

2. St. Charles Health System
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

3. Central Oregon

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

5. Centers of Care

6. Triple Aim and Palliative Care
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

7. Centers of Care

8. SCHS Advanced Illness Management Center of Care
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

9. 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

10. 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

11. SCHS Advanced Illness Management Center of Care
St. Charles AIM Palliative Care Consultations
St. Charles Bend 2009
consults
consults
consults
consults
St. Charles Cancer Center 2010
AIM Center of Care 2011
Outpatient Consultations Spring 2012
St. Charles Redmond Fall 2012

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

13. Disposition after AIM Consultation

14. Diagnosis Classes for AIM Consultation

15. AIM Payer Classification

16. 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

17. SCHS Advanced Illness Management Center of Care
2012 Data Highlight
Average symptom burden (ESAS) before and after consultation
BEFORE AFTER
PAIN
ANXIETY
DYSPNEA
N/V

18. SCHS Advanced Illness Management Center of Care
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

19. AIM Center of Care Initiatives: ACCESS
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

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

21. AIM Center of Care Initiatives: ACCESS
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

22. AIM Center of Care Initiatives: ACCESS
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:

23. AIM Center of Care Initiatives: ACCESS
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 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 consultation
Quarter consultations

24. AIM Center of Care Initiatives: ACCESS
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

25. AIM Center of Care Initiatives: WORKFORCE
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

26. AIM Center of Care Initiatives: WORKFORCE
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

27. AIM Center of Care Initiatives: AWARENESS
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

28. AIM Center of Care Initiatives: AWARENESS
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

29. AIM Center of Care Initiatives: AWARENESS
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

30. AIM Center of Care Initiatives: AWARENESS
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

31. AIM Center of Care Initiatives: AWARENESS
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:

32. AIM Center of Care Initiatives: AWARENESS
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

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

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