PALLIATIVE CAREWhy?

Australian College of NursingVictorian Chapter

7 February 2013

Helen WalkerCabrini Palliative Care

•Current Scene•Clinical Outcomes•Economic Advantages•Role of Health Funds•Future Trends

PALLIATIVE CARE

• Aims to optimise quality of life of patients and their families facing a life limiting illness.

• It can be offered at anytime after a diagnosis and integrated into the overall treatment plan.

• The palliative approach needs to be practiced by all health care practitioners with assistance from specialist services as required.

CHANGING DEMOGRAPHICS

•Australia has an ageing population•Increased life expectancy•Decreasing fertility rates• % over 65s increasing•Over 85 aged group growing – increased health care needs•International trend •‘Sea change’ phenomena•Cultural diversity•Older age of carers

AGING POPULATION

Both the number of deaths and proportion of people aged 65 or over will dramatically increase in upcoming decades. They project:

• 1:4 of the population will be aged 65 or older as opposed to 1:8 in 2009.

• Pattern of disease changing - to include complex chronic illness in a higher proportion of the population.

• An increasing focus on palliative care service provision.

(AIHW 2011)

PROJECTED DEATHS

0–45–9

10–1415–1920–2425–2930–3435–3940–4445–4950–5455–5960–6465–6970–7475–7980–8485–8990–94

95+

450,000 300,000 150,000 0 150,000 300,000 450,000

Female Male

Insured Persons ('000)

Age

Cate

gory

Insured persons by age cohort

Current service issues

Australia is faced with an ageing population and therefore an increasing prevalence of age-related chronic conditions, such as cancer, organ failure, and dementia, which may require palliative care. (Australian Bureau of Statistics, 2009).

Current Service Levels

Each year in Australia, approximately 134,000 die and approximately half of these deaths are classified as expected, suggesting a large demand for palliative care services. (CareSearch-Palliative Care Knowledge Network, 2012; Gordon, Eager, Currow, & Green, 2009)

DEATH TRAJECTORIES

Understanding what happens at end of life, helps us to plan, involve patients and families, support and provide best care.

Time course to death

Sudden death vs Cancer vs Chronic Illness vs Frail Aged Sudden death

Time course to death

Sudden death vs Cancer vs Chronic Illness vs Frail Aged Sudden death

Cancer

Time course to death

Sudden death vs Cancer vs Chronic Illness vs Frail Aged Sudden death

Chronic illness

Time course to death

Sudden death vs Cancer vs Chronic Illness vs Frail Aged Sudden death

Models of Palliative Care in Australia

Palliative care is provided by public, non-government and private organisations, through a combination of delivery models, including:• Designated hospice services • Designated palliative care units in acute and sub acute hospitals• Non-designated inpatient palliative care services in acute or sub

acute hospitals• Ambulatory palliative care hospital services • Specialist palliative care community services• Primary care community-based services (Gordon, et al., 2009)

Models of Palliative Care in Australia

By international standards, Australia has been described as having impressive palliative care coverage of 85% of the population, delivered through flexible models of care across inpatient, outpatient and home settings. (Gomes, Harding, Foley, & Higginson, 2009)

Palliative Care Services in the Australian Private Sector

Privately insured patients: • Have an expectation their insurance will cover them

through all aspects of their illness journey and not cease when curative treatment is no longer appropriate.

• Are unable to access palliative care - therefore receiving more expensive, and at times, aggressive treatment in the final stages of life in a private acute hospital, which may not be the best place of care on many fronts.

Preferred place of death – need to invest

• Most people want to die at home• Many don't get this opportunity• Many reasons – many with a solution• Deaths in acute facilities are often problematic• We need to invest in community support to address

this problem – cheaper than ICU

Models of Palliative Care in Australia

However, more progress is required, with regard to the establishment of flexible funding and financing models to improve integration of care and encourage service substitution across settings. (Gordon, et al., 2009)

Australian Government and States and Territories have developed over arching strategic frameworks to guide the formation of palliative care policies, including funding arrangements and structures for service delivery (e.g. Strengthening palliative care: Policy and Strategic Directions 2011-2015, Victorian Department of Health, 2011).

Strategic Frameworks

CABRINI HEALTH APPROACH

Advance Care Planning

Green Sleeve Protocol

Mentorship of Professional

Bodies

NSAP

Education

Research

Quality

Integrated Model- Consult

- Case ManagementCabrini Hiealth

Integrated Services Model

6Providing quality

care supported by evidence

1Informing and

involving clients and carers

2Caring for carers

3Working together to ensure people die in their place of choice

4Providing specialist

care when and where it is needed

5Coordinating care

across settings

7Ensuring support

from communities

Client and carers

Boosting Community Services

Proposal for funds to support increased care packages for

carers

Website

New Patient Information

Brochure

MediaBuilding the

Narrative

Press Ganey

INTEGRATED PALLIATIVE CARE CABRINI HEALTH MODEL

Providing specialist services to ensure all patients/residents in a Cabrini Health Facility will receive end of life care – the right setting in the right way

Admission

Consult

Inpatient Consultancy Home

Care

Brighton

Prahran

Ashwood

Elsternwick/Hopetoun

Rehab

Malvern

CLINICAL OUTCOMESClinical Outcomes

Building Rigour in Palliative Care

The Australian Government has, as part of its palliative care strategy, a goal to build clinical evidence, quality and measurement in the sector. To this end, it has funded the Palliative Care Outcomes Collaboration (PCOC), Care Search and the National Standards Assessment Program.

Why are Health Funds concerned about Palliative Care?Senate Enquiry into Palliative Care, October 2012 Committeecommented as follows:

“The committee acknowledges that in the future, demand for palliative care services will increase as the population ages. As more Australians invest in private health insurance, the committee calls on the private health sector to contemplate the role they might play in helping meet the growing demand for comprehensive palliative care.

The committee considers that further research into the potential role of the private health sector, including private health insurers, in providing palliative care services is required and suggests that the federal government initiate such a review.”

PCOC

A 15% improvement in clinical outcomes has been demonstrated nationally since 2009 - with all but 5 specialist units in Australia participating in this robust program.

PCOC

By standardising palliative care assessments, PCOC has: • Led to the development of a common language in

palliative care• Allowed for clinical outcomes to be measured and

compared• Facilitated the development of benchmarking in

the palliative care sector.

PALLIATIVE CARE EXTENDS LIFEMean Survival for Lung

Cancer Patients

Usual Patients

Mean Survival for Pancreatic Cancer Patients

Hospice Patients

Daysp=0.0001

n=700. n=586

Daysp=0.0102

n=493 n=386

240

279

189

210

Average hospice length of stay was 38 days

Average hospice length of stay was 47 days

Study in Brief: Comparing Hospice and Non-hospice Patient Survival

• Retrospective review of 4,493 patients using Medicare claims data

• Included patients with six terminal diagnoses: congestive heart failure, breast cancer, colon

cancer, lung cancer, pancreatic cancer, prostate cancer.

• Patients were assigned to hospice group if they had at least one hospice claim within three years

of their diagnosis

• Average hospice length of stay was 43 days

• Survival difference was not statistically significant for breast and prostate cancer patients

FACT-L1 Symptom Management Scores

Usual Care

p=0.03n=74. n=77

92

98

Higher scores indicate fewer symptoms, better quality of life

Palliative Care

Usual Care

19

21

Palliative Care

Usual Care

53

59

Palliative Care

LCS2 Symptom Management Scores

p=0.04n=74. n=77

TOI3 Symptom Management Scores

p=0.009n=74. n=77

VALUE OF PALLIATIVE CAREA service complementing curative therapies

Palliative Care Services

Symptom and pain management

Emotional and spiritual support

Family conferences

Conversations about goals of care

End of life planning

Care coordination

Educating and supporting clinicians in other care settings

Curative Treatment

Palliative Care Spec PC Bereavement

Economic Benefits

Private Health Insurance and Palliative Care

In 2008/2009: - 77% of palliative care was provided for public patients- 16% of this cohort were funded by private health funds, and- 7% by the Department of Veterans Affairs

(AIHW, 2011)

Why are Health Funds concerned about Palliative Care?• Palliative care is seen as a “bottomless pit” and not a

“prudent investment”, by some health insurers.

• Concern that there is no legislative barrier to funds placing palliative care in their schedules.

Private Health Insurance and Palliative Care

Home based palliative care services are premised on the fact the needs of most palliative care patients can be met through the primary health care system including the GP.

Benefits are generally structured based around an initial visit, usually by a nurse and paid on a daily basis, irrespective of the number of visits per day.

Allied Health is not funded in the payment, nor is medical support, personal care or equipment and medical supplies.

Bereavement services are provided in most cases.

Private Health Insurance and Palliative Care

Potential benefits of health insurance funds covering out of hospital home based palliative care services include:

• Decreased re-admission rates. • Increased savings from lower readmission rates to hospital and shorter

duration of hospital stay. • Decreased waiting periods for accessing publicly funded home based

palliative care services (which can result in adverse patient episodes and prolonged hospital admission).

• Immediate access to these services in the home upon discharge -significantly improving outcomes.

Future Trends

Influences?

• Equity of Access – from Rolls Royce for some to Mercedes Benz for all

• Role of the Private sector• Population aging• National Standards • Euthanasia debate• Person centred care movement• Education/Research

In the future:• Have built capacity and capability across the health system to

manage terminal illness and death• The quality of the way we die won’t be determined by lottery• Will be patient and family choice• Will be quality community services• %futile treatment would have decreased• Symptom burden at end of life decreased• Bereavement programs in place• More even service distribution in 3rd world• More people comfortable to discuss death and dying in the

community

Health Promotion

• http://www.compassionatecommunities.ie/about#bills-story-video

HALLMARKS OF SUCCESSPalliative Care Models

1 Embedded Specialist RN2 Inpatient Consult Service3 Dedicated Inpatient Unit4 Outpatient Clinic5 Home Based Care6 Community Comfort

Hallmarks of an Integrated Program

1 Clinicians trust the palliative care team

2 Palliative care team scrupulous about care coordination

3 Advance care planning routine for all patients at end of life

4 Palliative care team highly visible 5 Clinicians share responsibility for

initiating palliative care6 Clinicians trained to provide

palliative care