1. Palliative Care in MiPCT: Extending the Continuum of Care Phil Rodgers, MD FAAHPM Associate Professor, Department of Family Medicine Associate Director for Clinical Programs, Palliative Medicine Program University of Michigan Health System MiPCT 2013 Annual Summit October 2013

2. Colleen Tallen, MD Medical Director Pain and Palliative Care Cancer Survivorship Mercy Health Saint Mary’s Grand Rapids, MI I have no potential conflicts of interest or financial relationships to declare related to today’s presentation. No Potential Conflict of Interest to Declare

3. Objectives Understand the fundamentals of palliative care, and its value to securing the continuum of high quality primary care Identify specific opportunities to provide primary palliative care to your patients with advanced illness

4. Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice. 73 FR 32204, June 5, 2008 Medicare Hospice Conditions of Participation – Final Rule What is Palliative Care?

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6. Traditional Model of Care Curative Care Hospice Presentation/ Diagnosis Death

7. HOSPICE CARE HEALTH DiagnosisDeath Curative & Life Prolonging Care Prevention CURATIVE CARE ILLNESSDEATH Bereavement Palliative Care Symptom Management Life Closure EOL/ Dying New Model of Palliative Care

8. How is Palliative Care Different than Hospice? o Palliative care is appropriate at any point in a serious illness. It is provided at the same time as life-prolonging treatment. No prognostic requirement, no need to choose between treatment approaches. o Hospice is a medical benefit that supports care for those in the last weeks to few months of life. Patients must have a 2 MD-certified prognosis of <6 months, and often must give up insurance coverage for curative or life prolonging treatment in order to be eligible. (Medicare Hospice Benefit: 84% Medicare, 5% Medicaid, 3% uninsured)

9. Palliative care in the US Today 75% of US hospitals >50 beds have Palliative Care programs 85% of US medical schools have hospital-based palliative care programs Palliative Care now recognized by ACGME, ABMS, NQF, and CMS States in the US with higher hospital palliative care penetration have: Fewer Medicare hospital deaths Fewer intensive care unit / cardiac care unit (ICU / CCU) days Fewer admissions during the last 6 months of life Fewer ICU / CCU admissions during terminal hospitalizations Lower overall Medicare spending / enrollee Goldsmith BA, Dietrich J, et al. J Palliative Med 2008; 11(8):suppl 1-9 Teno JM, Clarridge BR, Casey V et al. JAMA 2004;291(1):88-93

10. Why Palliative Care Now? We’re living longer, with more illness Burdens of symptom management and care needs are increasing Treatment options and outcomes are more complex Family caregivers and supports systems are strained, eroded or absent Increasing emphasis on value in health care delivery

11. Target Population for Complex Care Coordination and Palliative Care Distribution of Total Medicare Beneficiaries and Spending Total Number of FFS Beneficiaries: 37.5 million Total Medicare Spending: $265 billion Average per capita Medicare spending (FFS only): $7,064 Average per capita Medicare spending among top 10% (FFS only): $44,220 NOTE: FFS is fee-for-service. Includes noninstitutionalized and institutionalized Medicare fee-for-service beneficiaries, excluding Medicare managed care enrollees. SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost & Use file, 2005.

12. 100 90 80 70 60 50 40 30 20 10 % Claimants Cost per Claimant Management ApproachPatient Type Care Management Targeted to Needs of Patients Worried well Self-resolving illness Low grade acute illness Demand Management Low Case Management Chronic diseases Moderate to severe acute illness Disease Management Medium High Complex Care Management Palliative Care Complex Patients Significant diagnosis Multiple co-morbidities Often terminal Several providers of care Psychological / social / financial upheaval

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14. Outcomes of Palliative Care Improved patient and family satisfaction Reduction in symptom burden Reduced costs Prolonged Survival

15. Improved Family Satisfaction Mortality follow back survey palliative care vs. usual care Casarett et al. J Am Geriatr Soc 2008;56:593-99. N=524 family survivors Overall satisfaction markedly superior in palliative care group, p<.001 Palliative care superior for:  Emotional and spiritual support  Information and communication  Care at time of death  Access to services in community  Well-being and dignity  Care type and setting concordant with patient preference  Pain and symptom control

16. Improved Symptom Control Bakitas M et al. JAMA 2009;302(7):741-9 N= 322 advanced cancer patients in rural NH+VT Improved quality of life and less depression (p=.02) Trend towards reduced symptom intensity (p=.06) No difference in utilization, very low in both groups Median survival: intervention group 14 months, control group 8.5 months, p=.14

17. How Palliative Care Reduces Length of Stay and Cost Palliative care: Clarifies goals of care with patients and families Helps families to select medical treatments and care settings that meet their goals Assists with decisions to leave the hospital, or to withhold or withdraw death-prolonging treatments that don’t help to meet their goals capc.org/research-and-references-for-palliative-care/citations Lilly et al, Am J Med, 2000; Dowdy et al, Crit Care Med, 1998; Carlson et al, JAMA, 1988; Campbell et al, Heart Lung, 1991; Campbell et al, Crit Care Med, 1997; Bruera et al, J Pall Med, 2000; Finn et al, ASCO, 2002; Goldstein et al, Sup Care Cancer, 1996; Advisory Board 2002; Davis et al J Support Oncol 2005; Smeenk et al Pat Educ Couns 2000; Von Gunten JAMA 2002; Schneiderman et al JAMA 2003; Campbell and Guzman, Chest 2003; Smith et al. JPM 2003; Smith, Hillner JCO 2002; www.capc.org; Gilmer et al. Health Affairs 2005. Campbell et al. Ann Int Med.2004; Health Care Advisory Board. The New Medical Enterprise 2004. Elsayem et al, JPM 2006; Fromme et al, JPM 2006; Penrod et al, JPM 2006; Gozalo and Miller, HSR 2006; White et al, JHCM 2006; Morrison RS et al Arch Int Med 2008www.capc.org

18. Palliative Care Shifts Care Out of Hospital to Home Service Use Among Patients Who Died from CHF, COPD, or Cancer Palliative Home Care versus Usual Care, 1999–2000 Brumley, R.D. et al. 2007. J Am Geriatr Soc.

19. Hospital Palliative Care Reduces Costs Cost and ICU Outcomes Associated with Palliative Care Consultation in 8 U.S. Hospitals Live DischargesHospital Deaths CostsUsual Care Palliative Care Δ Usual Care Palliative Care Δ Per Day$867$684$183*$1,515$1,069$446* Per Admission$11,498$9,992$1,506* $23,521 $16,831$6,690* Laboratory$1,160$833$327*$2,805$1,772$1,033* ICU$6,974$1,726$5,248*$15,531$7,755$7,776*** Pharmacy$2,223$2,037$186$6,063$3,622$2,441** Imaging$851$1,060-$208***$1,656$1,475$181 Died in ICUXXX18%4%14%* *p<.001 **p<.01 ***p<.05 Morrison, RS et al. Archives Intern Med 2008;

20. Palliative Care Can Improve Survival Randomized controlled-trial, 151 patients with metastatic NSCLC Palliative care plus cancer treatment vs. usual cancer care Intervention group showed: Better QOL and symptom scores Less ‘aggressive care’ at end-of-life Prolonged survival (~2 months)

21. Temel J, et al. New Engl J Med 2010; 363(8): 733-42

22. What does Palliative Care Do? Pain and physical symptom management Clear communication Difficult or complex treatment decisions Managing care transitions Detailed and practical help at all stages of care Emotional and spiritual support “Right Care, Right Place, Right Time”

23. Palliative Care Delivery Tertiary Palliative Care Delivered by subspecialty Palliative Care Teams Secondary Palliative Care Delivered by clinicians frequently caring for seriously ill patients Primary Palliative Care Delivered by all interdisciplinary clinicians to patients with serious illness, and their families

24. Primary Palliative Care Many patients die in the care of their PCP Effective palliative care is high-quality primary care through the end of life Primary care providers are uniquely situated to provide comprehensive care to patients and families facing life-limiting illness Our growing challenge is to provide this care in a coordinated, sustainable way

25. Primary Palliative Care ‘Tasks’ Prognosis – help communicate prognosis to inform patient/family decision-making Planning – establish goals of care consistent with patient/family desires and values Palliation – carefully assess and address physical, emotional, interpersonal and spiritual symptoms Prescribe Hospice – discuss when/if hospice care is an appropriate option Smucker D. Clin Fam Prac; Elsevier, June 2004

26. Prognosis: Consider and communicate Palliation: Integrate Palliative and Disease- Oriented Measures Planning: Clarify Patient’s Values and Goals of Care Prescribing Hospice: Understand eligibility criteria and explain options for care Tasks of Primary Palliative Care Smucker D. Clin Fam Prac, June 2004

27. Why is Prognosis Assessment Important? Important to medical teams Assist clinicians in their decision making Avoid costly interventions that may cause suffering Guides recommendations for interventions likely to be beneficial Optimization of resource allocation and utilization of support services

28. Why is Prognosis Assessment Important? Important to patients and their families: Information helps patients and families in choosing therapeutic options Planning for emotional and financial management through advancing illness and end-of-life Not receiving a prognosis is the most common reason families say they are dissatisfied with end-of-life care

29. Karnofsky Performance Scale 100% Normal, no complaints, no evidence of disease 90 Able to carry on normal activity: minor symptoms of disease 80 Normal activity with effort: some symptoms of disease 70 Cares for self: unable to carry on normal activity or active work 60 Requires occasional assistance but is able to care for needs 50 Requires considerable assistance and frequent medical care 40 Disabled: requires special care and assistance 30 Severely disabled: hospitalization indicated, death not imminent 20 Very sick, hospitalization necessary: active treatment necessary 10 Moribund, fatal processes progressing rapidly 0 Death DA Karnofsky, JS Burchenal, 1949

30. Predictions of survival Time predictions: “How long do you expect this person to live”? Outcome predictions: “ What is the probability you think this person will be alive in 6-12 months”? or “Would I be surprised if this patient died within the next 12 months”? Outcome predictions more accurate than time predictions Br J Cancer 1990;62:685-689

31. Planning: Outcomes Advanced Directives Living Wills Durable Power of Attorney for Health Care (DPOA-HC) “Do-not-resuscitate orders” Prolonged mechanical ventilation Artificial nutrition (tube feeding)

32. Starting the Conversation “What are you hoping for?” “What are you afraid of?” “What is most important to you in your life?” “Have you thought about what it might be like if we can’t help you live the way you want to live?” “Have you thought about dying? Have you talked to anyone about it?”

33. When to Start: Clinician Cues At time of serious diagnosis Advanced CHF, cancer, dementia, etc. At time of functional change At time of crisis or disease progression Hospitalizations, ICU stays Initiation of advanced therapies Artificial nutrition/hydration Dialysis, LVAD, tracheostomy, etc.

34. ...Patient and Family Cues “I don’t know if I can do this much longer” “I don’t want to come back to the hospital again” “We can’t stand to see Mom like this” “What happens if this (procedure/ medicine/treatment) doesn’t work?” “I’m so tired, I just want to die”

35. Shared Decision-Making Patient/Family Goals Values Hopes Resources Medical Providers Clear information Prognosis Recommend plans to meet goals, be consistent w/values Commitment to always provide care

36. Words that Work “We want to help you live as well as you can, for as long as you can”. “You’re sick and it’s serious, but we’ll be with you no matter what happens”. “What can I do for you now?” “We will do all we can to get you the best care possible”.

37. Resources Hospice Finder (www.mihospice.org)www.mihospice.org Palliative Care Programs and Resources (www.capc.org)www.capc.org Educational Tools (www.eperc.mcw.edu)www.eperc.mcw.edu Patient and Family Resources www.theconversationproject.org www.fivewishes.org