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

2. 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 St. Charles Health System

3. Central Oregon

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

5. Centers of Care

6. 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 Triple Aim and Palliative Care

7. Centers of Care

8. 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 SCHS Advanced Illness Management Center of Care

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 familys goals and values

11. St. Charles AIM Palliative Care Consultations St. Charles Bend 2009 - 2009 - 222 consults - 2010 - 382 consults - 2011 - 436 consults - 2012 - 500+ consults St. Charles Cancer Center 2010 AIM Center of Care 2011 Outpatient Consultations Spring 2012 St. Charles Redmond Fall 2012 SCHS Advanced Illness Management Center of Care

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 BEFOREAFTER PAIN0.830.47 ANXIETY0.360.11 DYSPNEA0.590.28 N/V0.140.04

18. 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 SCHS Advanced Illness Management Center of Care

19. 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 ACCESS AIM Center of Care Initiatives: ACCESS

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

21. 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 ACCESS AIM Center of Care Initiatives: ACCESS

22. 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; 363:733-742 ACCESS AIM Center of Care Initiatives: ACCESS

23. 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- 15 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 3 - 1 consultation Quarter 4 - 11 consultations ACCESS AIM Center of Care Initiatives: ACCESS

24. 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 ACCESS AIM Center of Care Initiatives: ACCESS

25. 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 WORKFORCE AIM Center of Care Initiatives: WORKFORCE

26. 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 WORKFORCE AIM Center of Care Initiatives: WORKFORCE

27. 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 AWARENESS AIM Center of Care Initiatives: AWARENESS

28. 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 persons end- of- life wishes expressed and respected AWARENESS AIM Center of Care Initiatives: AWARENESS

29. 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 AWARENESS AIM Center of Care Initiatives: AWARENESS

30. 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 AWARENESS AIM Center of Care Initiatives: AWARENESS

31. 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 projects process. Model program: AWARENESS AIM Center of Care Initiatives: AWARENESS

32. 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 AWARENESS AIM Center of Care Initiatives: AWARENESS

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