Palliative Care: What is it and why is it important? J. Randall Curtis, MD, MPH Director, Cambia Palliative Care Center of Excellence Harborview Medical Center, University of Washington

Outline: Five Questions What is palliative care and how does it help? Does palliative care reduce costs and is that important? How are we doing in the US today? What are we doing at UW Medicine? What can you do?

Definition of Palliative Care Specialized care for people with serious illnesses… focused on providing relief from the symptoms and stress of a serious illness - whatever the diagnosis Goal is to improve quality of life for both the patient and family… 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 Center to Advance Palliative Care 2011

Understanding the Words Palliative care: Improving quality of life for patients with serious illness End-of-life care: For those who are entering the last phase of life Hospice: A model for delivery of end-of-life care Palliative Care Hospice Care End-of-life Care

What do Americans really think? It is important patients and families be educated about palliative care options available to them How important is it that palliative care be a top priority for the health care system? Regence Foundation/National Journal: n=1000 US Adults Age 18+; 2/2011

Provision of Palliative Care Primary palliative care –Care provided by all clinicians caring for patients with serious illness Specialty palliative care –Care provided by palliative care specialists

Temel, N Engl J Med, 2010; 363:763

Early PC Improves Quality of Life 38 v 16%. p= v 4%. p=0.04 Temel, NEJM, 2010; 363:763 p=0.04

…Reduces Symptoms p=0.01 p=0.04 Temel, NEJM, :763

…Improves Survival Temel, N Engl J Med, 2010; 363:763 Standard care 8.9 months

Content analyses of palliative care clinical notes Randomly selected 20 patients from randomized trial Yoong, JAMA Intern Med, 2013; 174:283

Growth of PC Programs Nationally

Outline: Five Questions What is palliative care and how does it help? Does palliative care reduce costs and is that important? How are we doing in the US today? What are we doing at UW Medicine? What can you do?

Meta-review of 8 systematic reviews 10 good studies demonstrate a “clear pattern of cost savings” from inpatient palliative care consultation

UW and HMC inpatient palliative care: Analysis of patients with palliative care consult compared to similar patients without consult Costs reduced for patients seen by palliative care service, especially when PC involved early:  Days 1-7: Costs reduced 13% ($2141)  Days 8-30: Costs reduced 5% ($2870)  Days > 30: No cost reduct ion

NWH/HMC outpatient program: Patients seen by service had reduced ED visits by 29% and hospital admission by 20% compared to historical data

Is Reducing Costs Important? Saving money is not the goal!! Goal: improving the quality of care for patients and family; match care to patient’s informed goals Palliative care will only reduce costs if patients are getting more aggressive care than they want –This is the reality in the US in 2016

Outline: Five Questions What is palliative care and how does it help? Does palliative care reduce costs and is that important? How are we doing in the US today? What are we doing at UW Medicine? What can you do?

Changes in End-of-life Care for Medicare Beneficiaries Teno, JAMA, 2013, 309:470

Proportion of Deaths Preceded by CPR for Patients > 65 years old Ehlenbach, NEJM, 2009; 361:22

Who should bring up a discussion about palliative and end-of-life care? If you ask patients: –Doctors should bring it up If you ask doctors: –Patients should bring it up

Randomized Trial of Advance Care Planning Among 309 Elderly Hospitalized patients age >80 randomized to ACP by trained facilitator vs. usual care 81% received ACP; 56% completed AD –Facilitator used “Respecting Patient Choices” –ACP in collaboration with physician –Families present for 72% –Sessions took median 60 minutes Detering, Br Med J, 2010; 340:c1345

Randomized Trial of Advance Care Planning Among 309 Elderly Outcome (%) ACPControlp value Death in ICU PTSD in family Depression in family Anxiety in family Satisfied with death Satisfied with care Detering, Br Med J, 2010; 340:c1345

How are we doing in the US today? Our track record is not great There is much reason for hope and optimism –Palliative care helping to lead a transformation toward truly “patient-centered care”

Outline: Five Questions What is palliative care and how does it help? Does palliative care reduce costs and is that important? How are we doing in the US today? What are we doing at UW Medicine? What can you do?

 Launched by UW Medicine in 2012  Became Cambia PCCE in 2014  Mission: Improve palliative care received by patients with serious illness and their families and provide support to clinicians Develop new knowledge and educational and clinical resources to improve palliative care regionally as well as nationally and globally

Recruitments in 2015: Exciting Time of Program Building Tony Back, MD National leader in communication Moving to HMC to co-Direct Cambia PCCE Jim Fausto, MD Directed palliative care program at Montefiore Experience building palliative care into ACO Joan Teno, MD, MS National leader in health services Recruited from Brown to grow quality metrics programs at UW Rashmi Sharma, MD, MHS Emerging scientist with new award from American Cancer Society Focused on improving disparities in communication

Current Goals of Clinical Programs 1.Develop and implement standards for UW Medicine palliative care services 2.Develop and implement quality metrics and a quality dashboard Specialty palliative care Primary palliative care 3.Develop screening programs to identify patients with unmet palliative care needs 4.Achieve Joint Commission Advanced Certification for Palliative Care

Progress: Inpatient Palliative Care Achieved standards for palliative care in- and outpatient services at UW Medicine 24/7 coverage Interdisciplinary teams Achieve TJC certification UWMC: Joint Commission Advanced Certification in Palliative Care in 2014 HMC, Northwest, Valley: Target advanced certification for 2016 Developing quality metrics and dashboard Piloting screening programs at all sites

Key Achievements: Education Community of Educator Retreat – Annual event drawing across UW – Implementing developmental approach to palliative care education Annual Palliative Care Conference – 2 day conference with skills practice – Annual event drawing >200 interprofessional participants – Next one May 9-10,

Key Achievements: Education 2 Regional PC Training Center – Funded by Cambia Health Foundation – 9-month course for physicians, nurses, SW – Three 2½ day in-person sessions and weekly webinars – 2015: inaugural class of 24 (99 applications) Curriculum Renewal – School of Nursing and School of Medicine – Integrated palliative care across continuum Weekly palliative care grand rounds

Key Achievements: Research Focusing on making care better now T32 for palliative care research - Funded by NIH and started 3/15 - Four post-doctoral slots per year High profile publications - N Eng J Med, JAMA, Lancet, others Key recruitments of researchers – Joan Teno and Rashmi Sharma

Cambia PCCE Research Funding with Cambia PCCE Investigators as PI or Site PI

Cambia PCCE Targeting UW Medicine Pillar Goals Consistent availability of palliative care services will help us meet UW Medicine pillar goals: Serve all patients with serious illness and their families with compassion, respect, and excellence Provide high quality palliative care to every patient with serious illness, every time Provide support for clinicians caring for patients with serious illness to help recruit and retain the best clinicians Ensure financial viability by providing care that meets the goals of informed patients

The Frazier Family Foundation Funding Sources

Outline: Five Questions What is palliative care and how does it help? Does palliative care reduce costs and is that important? How are we doing in the US today? What are we doing at UW Medicine? What can you do?

How can you get involved? Interested in palliative care –Join as a Cambia PCCE member –Help develop and use resources Care for patients with serious illness –Education in palliative care –Resources for patients/families Community involvement –Community Advisory Board –Palliative Care Advancement Council

Summary Palliative care gaining momentum and communication is a central piece –Help to lead a transformation in medicine Quality of care for patients with serious illness is often inconsistent, but improving Education and resources for clinicians can clearly improve communication and care Steps you can take –Talk with your doctor and family –Join Cambia Palliative Care Center of Excellence