palliative care 2012: matching care to patient’s needs diane e. meier, md director center to...
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Palliative Care 2012: Matching Care to Patient’s
Needs
Diane E. Meier, MDDirector
Center to Advance Palliative Care
www.getpalliativecare.org
Objectives
1. How is palliative care important to improving value (quality and cost) in health care reform?
2. Changing the delivery system to improve access to quality palliative care in and beyond the hospital
Core Principle
1. “The secret of the care of the patient is caring for the patient.” Francis Peabody, Harvard University, 1921
The Ends of Medicine: Our Professional Obligations
“I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients”
-Oath of Hippocrates, 400 BC
“May I never see in the patient anything but a fellow creature in pain.”
- Maimonides, 12th century AD
Health care in the U.S.
• What are the ends of medicine?– What are they in the U.S.?
• What should they be? “To cure sometimes, relieve often, comfort always.”
• The problem: “The nature of our healthcare system- specifically its reliance on unregulated fee-for-service and specialty care- …explains both increased spending and deterioration in survival.” Muenning PA, Glied SA. What changes in survival rates tell us about
U.S. health care. Health Affairs 2010;11:1-9.
The Value Equation-1
Value of health care = Quality CostNumerator problems
– 100,000 deaths/year from medical errors– Millions more harmed by overuse, underuse, and
misuse– Fragmentation– Medical practice based on evidence <50% of the time– 50 million Americans (1/8th) without access– U.S. ranks 40th in quality worldwide
The Value Equation- 2
Value of health care = quality costDenominator problems• Insurance premiums increased by 181% in the
last 10 years.• U.S. spending 17% GDP, >$8400 per capita/yr • Nearing 30% of total State spending• Despite high spending, 15% of our population
has no insurance, and half are underinsured in any given year.
• Health care spending is the #1 threat to the American economy and way of life.
International Comparison of Spending on Health, 1980–2009
* PPP=Purchasing Power Parity.Data: OECD Health Data 2011 (database), version 6/2011.
Average spending on healthper capita ($US PPP*)
Total expenditures on healthas percent of GDP
9Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
EFFICIENCY
9
Sun Sentinel (Broward County edition)Tuesday, August 9, 2011
Health Care vs Determinants of HealthGrowth in Massachusetts State Budget Spending FY2001 to FY2012
(Inflation adjusted)
Source: Massachusetts Budget & Policy Center Budget Browser
-60%
-40%
-20%
0%
20%
40%
60%
80%
100%
Health Care Primary-SecondaryEducation
Law andPublic Safety
Public Health Environmentand
Recreation
HigherEducation
Local Aid
%
What is this money buying us?
Organization for Economic Development and Cooperation
Among OECD member nations, the United States has the:
• Lowest life expectancy at birth.• Highest mortality preventable by health
care.
Cost: Hospital Spending per Discharge, 2009Adjusted for Cost of Living
17,206
12,163 11,988
9,398 9,131 9,026
7,312 7,312 7,295
4,667 4,527
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
US* CAN* NETH SWITZ NOR* SWE NZ OECDMedian
AUS* FR GER
Source: OECD Health Data 2009 (June 2009).
Dollars
Medical Spending in the U.S.$2.9 trillion in 2010
The costliest 5% account for 50% of all healthcare spending
Medicare Payment Policy: Report to Congress. Medpac 2009 www.medpac.gov
Health Affairs 2005;24:903-14.
CBO May 2009 High Cost Medicare Beneficiaries www.cbo.gov
nchc.org/facts/cost.shtml
Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.
Palliative Care is Central to Improving the Value Equation
• Because our patient population is driving most of the spending
Conceptual Shift for Palliative Care
Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis.
The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.
Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis.
The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.
Palliative Care Language Endorsed by the Public
95% of respondents agree that it is important that patients with serious illness and their families be educated about palliative care.
92% of respondents say they would be likely to consider palliative care for a loved one if they had a serious illness.
92% of respondents say it is important that palliative care services be made available at all hospitals for patients with serious illness and their families.
Once informed, consumers are extremely positive about palliative care and want access to this care if they need it:
Exceptionally High Positives
Palliative Care Hits the High NotesBetter health. Better care. Lower cost.
Key Messages:Palliative care sees the person beyond the cancer treatment.
Palliative care is all about treating the patient as well as the disease.
It’s a big shift in focus for health care delivery—and it works.
Palliative Care Teams Address 3 Domains
1. Physical, emotional, and spiritual distress2. Patient-family-professional
communication about achievable goals for care and the decision-making that follows
3. Coordinated, communicated, continuity of care and support for practical needs of both patients and families across settings
Palliative Care Improves Value
Quality improves– Symptoms– Quality of life– Length of life– Family satisfaction– Family bereavement
outcomes– Care matched to
patient centered goals
Costs reduced– Hospital costs
decrease– Need for
hospitalization/ICU decreases
Palliative Care Across the Continuum
Inpatient Consult Service
Outpatient Specialty Clinics
Cancer Center
Outpatient PCP Clinics
SNF Consult Service
Provider Home Visits
Inpatient Unit
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Palliative Care Improves Quality in Office Setting
Randomized trial simultaneous standard cancer care with palliative care co-management from diagnosis versus control group receiving standard cancer care only:
– Improved quality of life – Reduced major depression – Reduced ‘aggressiveness’ (less chemo <
14d before death, more likely to get hospice, less likely to be hospitalized in last month)
– Improved survival (11.6 mos. vs 8.9 mos., p<0.02)
Temel et al. Early palliative care for patients with non-small-cell lung cancer NEJM2010;363:733-42.
Palliative Care at Home for the Chronically Ill Improves Quality, Markedly Reduces Cost
RCT of Service Use Among Heart Failure, Chronic Obstructive Pulmonary Disease, or Cancer Patients While Enrolled in a Home Palliative Care Intervention or Receiving Usual Home Care, 1999–2000
13.211.1
2.3
9.4
4.6
35.0
5.3
0.92.4
0.90
10
20
30
40
Home healthvisits
Physicianoffice visits
ER visits Hospital days SNF days
Usual Medicare home care Palliative care intervention
KP Study Brumley, R.D. et al. JAGS 2007
RCT of Nurse-Led Telephonic Palliative Care Intervention
• N= 322 advanced cancer patients in rural NH+VT• Improved quality of life and less depression
(p=0.02)• Trend towards reduced symptom intensity
(p=0.06)• No difference in utilization, (but v. low in both
groups)• Median survival: intervention group 14 months,
control group 8.5 months, p = 0.14
Bakitas M et al. JAMA 2009;302(7):741-9
Consequences of Late Referral to Palliative Care
Serious Adverse Outcomes for Bereaved Caregivers:
Compared to care at home with hospice, • Care in ICU associated with 5X family risk
of Post Traumatic Stress Disorder; and • Care in hospital associated with 8.8X
family risk of prolonged grief disorder
Wright A et al. Place of death: Correlation with quality of life of patients with cancer and predictors of bereaved caregivers mental health. JCO 2010; Sept 13 epub ahead of print
Effect of Palliative Care on Hospital Costs
How Palliative Care Reduces Cost
• Improved resource use• Reduced bottlenecks in high cost units• Improved throughput and consistency
The Conceptual Model: Dedicated medical team =
Focus + Time = Decision Making / Clarity / Follow
through
Source: Center to Advance Palliative Care, 2011 capc.org/reportcard
Palliative Care Growth
America’s Care for Serious Illness
A State-by-State Report Card on
Access to Palliative Care in Our Nation’s Hospitals
Source: Center to Advance Palliative Care, 2011 capc.org/reportcard
Hope for the Future: Younger physicians exposed to palliative care more than their predecessors.
− 34 −
% “Great Deal” or “Some” Exposure to Palliative Care by Physician Age
National Quality Forum: Palliative Care is One of Six National Priorities for Action
http://www.nationalprioritiespartnership.org/Priorities
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NQF-Endorsed Palliative Care Measures 02/14/2012
http://www.qualityforum.org/Measures_List.aspx#e=1&s=n&so=a&p=1&cs=148
• CARE: Consumer Assessments and Reports on End of Life Care
• Pain Screening• Pain Assessment• Dyspnea Screening• Dyspnea Treatment• Treatment Preferences
For hospice only:• Proportion with spiritual
assessment• Family Evaluation of Hospice
Care
For cancer only:• Proportion getting chemo last
14 days of life• Proportion in ED last week of
life• Proportion >1 hospital stay in
last 30 days of life• Proportion admitted to hospice
<3 days• Proportion not admitted to
hospice before death
National Recognition of Importance of Palliative Care to
Healthcare Value
MedPAC: Called a meeting of national experts in palliative care in May 2011 to understand what Medicare payment policies might advance access and quality
The Joint Commission: September 2011 release of a Palliative Care Advanced Certification Program.
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Palliative Care: “on the map” with IHI
http://www.ihi.org/IHI/Programs/ImprovementMap
Strategic Partnerships
Major Health Systems Get It
Making multimillion dollar investments in palliative care integration across settings:• Partners Health System/ Harvard Medical
School• U. of Pittsburgh Health System• Duke U. Health System• North Shore-LIJ Health System
Payers Get It
Examples of private sector approaches to community-based
palliative care
Matching (Payer) Resources to Needs
Demand Management DM/CM CCM-palliative care
RE
SO
UR
CE
S
NEEDS
Payer Models
Although the world is full of suffering, it is full also of the
overcoming of it.
Helen Keller
Optimism 1903
Appendices
• Practical steps and resources
Emerging Initiatives
• Palliative care in the ICU, ED and OPT settings• “Primary” palliative care, raise all boats• Development of service standards & comparative
data through Registry• “Triggers” and Checklists• Community based palliative care
– Long term care– Home care– Office practices– Cancer Centers
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Palliative Care in the ICU
Principle:
Integration of palliative care should be part of comprehensive critical care for all patients beginning at ICU admission- regardless of prognosis
Options:
“Consultative Model”: Increase involvement of palliative care consultants in ICU, particularly for patients/families at highest risk
“Integrative Model”: Embed palliative care principles and interventions in daily ICU practice for all ICU patients
-> depending on institutional and ICU resources, a combined model is usually preferred.
- Nelson, J.E. et al Critical Care Medicine 2010, 38: 1765-72
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Metrics: The CAPC Registry
Your data, local use
Your data,
compared
Your data, compared
and combined -
Provides outside perspective & validation to plans
Builds consistency and critical mass for field & research
Leverages data you collect for several purposes
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https://registry.capc.org
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Uses of the Registry
NQF Operational Features as adapted by CAPC. Reference: Weissman DE, Meier DE: Operational features for hospital palliative care programs: consensus recommendations. J Palliat Med 2008;11:1189–1194.
Note: There are more operational features listed in the Registry than shown here. Other features are not shown due to PowerPoint size restraints.
Registry Report
Focus on operational features that palliative care programs have in place.
Will provide data on total of programs that have a feature in place to allow for comparative analyses.
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Tables include:
• Primary Palliative Care Assessment Components
• Criteria for a Palliative Care Assessment at the Time of Admission
• Criteria for Palliative Care Assessment during Each Hospital Day
New 2011 Tool to Help “Move Upstream” with Triggers & Checklists
The ChallengeMost teams get late referrals or never see patients with …
- Multiple co-morbid conditions and declining
function
- Difficult-to-control physical or psychological
symptoms
- Long length-of-stay, especially in the ICU
- Multiple admissions, ED visits
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Why Develop Triggers?
Improve patient/family outcomes
Reduce variation in care
Make palliative care part of a systems-based approach to care
Culture change
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Approach to Triggers
Use a risk assessment pathway to indentify patients who are most likely to have palliative care needs based on . . .
Disease variables Patient variables
• Metastatic cancer
• Advanced dementia
• Class IV CHF
• More than 2 hospitalizations within 3 months• Unintentional loss of more than 10% of body weight
• ICU length of stay greater than
X days
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Principles Behind the Checklist
Identify patients at greatest risk of unmet palliative care needs on admit and daily during stay. Standardize/improve assessment/documentation and basic palliative care management skills by primary clinicians (nurse, social worker, chaplain, physician). Reserve specialist palliative care for complex problems.
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www.capc.org
• Annual National Seminar• The IPAL Project: Improving Palliative Care in the ICU/ED/OPT• National Palliative Care RegistryTM
• Audio-Conferences and Webinars• CAPCconnectTM Online Discussion Forum• Palliative Care Leadership CentersTM Training and Mentoring• CAPC Campus OnlineTM
• Tools, Toolkits and Crosswalks• State-by-State Report Card• www.getpalliativecare.org for Patients and Families• And more
Other Resources
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Recent Blog Post on How to Improve Access to Palliative Care
• http://healthaffairs.org/blog/2012/04/30/learning-from-amy-berman-barriers-to-palliative-care-and-how-we-might-overcome-them/
Suggestions for Action
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Getting started – Planning for a new program
• Use The Guide & CAPC Tools for orientation• Identify sponsors & clinical advocates• Conduct a Needs Assessment, Systems Assessment• Prepare a draft plan to estimate patient volume & staffing
needs• Identify skill development needs & IDT staffing needs• Start a pilot in a focused area• Plan for growth; establish metrics; define funding criteria
& sources
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Actions to Align Palliative Care with Mission & Organizational Goals
• Include palliative care specialists on QI workgroups /ACO, ICO, IHI projects / redesign work
• Review the IPAL materials & set goals with ICU, ED, ambulatory setting
• Do a needs assessment baseline using the criteria in the “Triggers” article
• Review all patients discharged with “mortality risk score of 4” (APR DRG) - find actionable outreach & follow up (tie to Re-Admissions & Transitions projects)
• Initiate POLST style community initiatives & connect to inpatient initiatives –include community providers, consumers, and health system (http://www.ohsu.edu/polst/ )
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Actions to refresh an existing Palliative Care Program
• Apply for Advanced Certification in Palliative Care from The Joint Commission
• Adopt the NQF ‘Preferred Priorities” / do a GAP analysis & a plan for QI
• Identify unmet patient needs & launch a pilot – Examples: CHF patients, LVAD patients, Dialysis, or Dementia.
• Review activity data & educational & collaboration efforts that integrate skills vs. promote referrals (to create capacity for new initiatives); utilize EPERC, EPEC, and ELNEC. Set goals for team that are not tied to patient consult volume.
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Summary
• Alignment between patient needs, palliative care, and readiness for bundled payments or ICO/ACO systems integration models
• Brand palliative care separately from hospice and EOL, to improve access, quality, survival, efficiency (and EOL care)
• Tools exist; don’t recreate the wheel65