1. Program Development for Safety Net Institutions Catherine Deamant, MD Director, Palliative Care Services Cook County Health and Hospitals System Coleman Fellowship Workshop September 7, 2013 We Bring HealthCARE to Your Community

2. Definition of Safety Net Institution Provides significant level of care to low-income, uninsured, and vulnerable populations. – Not dependent upon public vs. non-profit – Core safety net providers: mission to have “open door” to all regardless of ability to pay (high uninsured, Medicaid, vulnerable) High risk for fragmented care, inadequate community support & high symptom burden

3. Palliative Care in Safety Net Setting Goals of palliative care are same as all hospitals: – Provide high quality interdisciplinary care to improve quality of life for patients with serious illness throughout the continuum of care with respect and dignity. Justifications for palliative care are same for all hospitals: – Cost savings – Patient/family satisfaction – Quality metrics

4. Palliative Care in Safety Net Setting Know who you serve Demonstrate credibility Identify unique opportunities

5. Know who you serve: Patients & Families Lack of access to care means late diagnosis – 40% diagnosed with advanced illness within 3 months of hospitalization (20% on the index admission) Culturally diverse: – 30% Limited English proficiency 60% uninsured at time of admission – Fear of financial burden 8% advanced liver disease (national-2%) – Limited social support Young population – Average age-58 years

6. Demonstrate credibility with patients Address the barriers to quality end of life care through palliative care interventions – Develop relationship with interpreter services – Educate on advance directive as form of empowerment – Address misconceptions of hospice care – Respect wishes for site of death-home is not always a goal Trust: – PC consult for hospice referral – Build relationship; avoid abandonment Facilitate goal of return to home country – Must be patient’s goal, not institution’s

7. Impact on Disparities: End of Life Decisions Outcome VariableOverallPCCPrimary team Completed a Durable Power of Attorney for Health Care 126/141 (89%) 118 (94%) 8 (6%) DNR Status153/173 (88%) 101 (66%) 52 (34%) Hospice Enrollment134/147 (91%) 37% died inpatient hospice 173 African-American patients with Cancer seen by PC

8. Know who you serve: Providers Emotionally challenging to care for very young patients who are dying with limited resources – Support primary team – Strategies to reduce burnout (especially for PC team) Majority of consultations for goals of care Develop hospital-hospice relationship who will share the mission (unless hospital has own hospice) – Be comprehensive in your PC role (address issues of prognosis and resuscitation before referral) – Serve as attending physician – Provide medications for transfer home

9. Hospital Deaths seen by PC Measurement20092012Nat’l % of deaths with PC consult (any LOS) 71/190 (37%)166/327 (51%)13% % of deaths with PC consult (LOS <2 days) 6/62 (10%)14/83 (17%) % of deaths with PC consult (LOS >2 days) 65/128 (51%)149/244 (61%)

10. Know who you serve: Administration Palliative care can facilitate more effective utilization of scarce hospital resources – Assist in care planning for chronic, complex patients – Long Stay Committee; Case Management Rounds; Ethics – Identify options for right setting of care Healthcare Reform – Patient-Centered Medical Home-Priority for ambulatory palliative care – High hospital occupancy rate (challenge for inpatient unit) Educational Mission – Fellowship; Resident Rotation; Medical Student Rotation

11. CCHHS Palliative Care Impact JSHRushUICMercyU of CSinai % of Deaths with ICU Admission 102625202428 % of Deaths in Hospital 293533253444 Hospice Enrollment 4540 514523 Hospice Days (per decedent) 201114 157 http://www.dartmouthatlas.org, 2003-2007 Lowest death rates associated with ICU admission Second lowest hospital deaths Second highest hospice enrollment Highest length of stay in hospice care Among Medicare Decedents:

12. 2012 Statistics: Ambulatory PC Cost savings-$840,000-1.2 million Cost AnalysisFactorsCost savings/revenue Hospital CostsTotal per day$3,426 Total inpt cost$7637-11,063 Potential Cost- avoidance Total cost savings (110 pts)$840,070-1,216,930 Potential Revenue generation Revenue in outpatient$48,290 2012: Total number of paracentesis performed-110 home or clinic Assumptions: Hospitalization for paracentesis is 2-3 days with admit thru ED Charge code-49082 at $439