Aligning Patients and Clinicians on What Matters Most Diane E. Meier, MD Vice Chair and Professor, Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai Director, Center to Advance Palliative Care

No Disclosures

Objectives The case for integrated disease treatment and palliative care What works to improve quality? How to face outwards towards needs of: –Our patients, their families –Policy makers, payers, health system leadership

Concentration of Spending Distribution of Total Medicare Beneficiaries and Spending, 2011 Total Number of FFS Beneficiaries: 37.5 million Total Medicare Spending: $417 billion Average per capita Medicare spending (FFS only): $8,554 Average per capita Medicare spending among top 10% (FFS only): $48,220 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, 2011.

Value= Quality/Cost Because of the Concentration of Risk and Spending, and the Impact of Palliative Care on Quality and Cost, its Principles and Practices are Central to Improving Value

Mr.B An 88 year old man with mild dementia admitted via the ED for management of back pain due to spinal stenosis and arthritis. Pain is 8/10 on admission, for which he is taking 5 gm of acetaminophen/day. Admitted 3 times in 2 months for pain (2x), weight loss+falls, and altered mental status due to constipation. His family (83 year old wife) is overwhelmed.

Mr. B: Mr. B: “Don’t take me to the hospital! Please!” Mrs. B: “He hates being in the hospital, but what could I do? The pain was terrible and I couldn’t reach the doctor. I couldn’t even move him myself, so I called the ambulance. It was the only thing I could do.” Modified from and with thanks to Dave Casarett

Before and After Usual Care 4 calls to 911 in a 3 month period, leading to 4 ED visits and 3 hospitalizations, leading to Hospital acquired infection Functional decline Family distress Palliative Care Pain management 24/7 phone coverage Housecalls referral Support for caregiver Meals on Wheels Friendly visitor program No 911 calls, ED visits, or hospitalizations in last 18 months

The Modern Death Ritual: The Emergency Department Half of older Americans visited ED in last month of life and 75% did so in their last 6 months of life. Smith AK et al. Health Affairs 2012;31:

Mr. B and the Concentration of Risk Functional Limitation Frailty Dementia +/- Serious illness(es)

Most of Costliest 5% have Functional Limitations

Jones et al. JAGS 2004;52

Dementia Drives Utilization Prospective Cohort of community dwelling older adults Callahan et al. JAGS 2012;60: DementiaNo Dementia Medicare SNF use44.7%11.4% Medicaid NH use21%1.4% Hospital use76.2%51.2% Home health use55.7%27.3% Transitions

Dementia and Total Spend 2010: $215 billion/yr By comparison: heart disease $102 billion; cancer $77 billion 2040 estimates> $375 billion/yr Hurd MD et al. NEJM 2013;368:

Why? Low Ratio of Social to Health Service Expenditures in U.S. for Organization for Economic Co-operation and Development (OECD) countries, Bradley E H et al. BMJ Qual Saf 2011;20: Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.

Home and Community Based Services Improve Quality and Lead to Lower Costs Improves quality: Staying home is concordant with people’s goals. Reduces spending: Based on 25 State reports, costs of Home and Community Based LTC Services less than 1/3 rd the cost of Nursing Home care.

Study: Meals delivered to home reduces need for nursing home 10/14/2013 | HealthDay News A study published today in Health Affairs found if all 48 contiguous states increased by 1% the number of elderly who got meals delivered to their homes, it would prevent 1,722 people on Medicaid from needing nursing home care. The Brown University study found 26 states would save money because lower Medicaid costs would more than offset the cost of providing the meals.

What is Palliative Care? Specialized medical care for people with serious illness and their families Focused on improving quality of life as defined by patients and families. Provided by an interdisciplinary team that works with patients, families, and other healthcare professionals to provide an added layer of support. Appropriate at any age, for any diagnosis, at any stage in a serious illness, and provided together with curative and life-prolonging treatments. Definition from public opinion survey conducted by ACS CAN and CAPC research/2011-public-opinion-research-on-palliative-care.pdf

Conceptual Shift for Palliative Care Medicare Hospice Benefit Life Prolonging Care Not this Palliative Care Bereavement Hospice Care Life Prolonging Care But this DxDeath 19

New Model for Palliative Care

Palliative Care Models Improve Value Quality improves –Symptoms –Quality of life –Length of life –Family satisfaction –Family bereavement outcomes –MD satisfaction –Care matched to patient centered goals Costs reduced –Hospital costs decrease –Need for hospital, ICU, ED decreased –30 day readmissions decreased –Hospitality mortality decreased –Labs, imaging, pharmaceuticals reduced

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:

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 KP Study Brumley, R.D. et al. JAGS 2007

Palliative Care in NHs

Person-Directed Approach to Care –Promotes personal comfort at all times –Incorporates each person’s life story into the care plan –Creates a personalized homelike environment –Anticipates needs rather than waiting for agitation or distress –Empowers staff to do whatever is needed to make each person comfortable

Comfort Matters Care care/jewish-home-lifecare-adopts-comfort-first- model-of-palliative-care-for-elders-with-dementiahttp:// care/jewish-home-lifecare-adopts-comfort-first- model-of-palliative-care-for-elders-with-dementia fa_fact_meadhttp:// fa_fact_mead Supported by NY+Chicago Alzheimer’s Association, Samuels Foundation in NYC

Key Characteristics of Effective Models 1: Targeting Demand Management DM/CM CCM-palliative care RESOURCES NEEDS

Gómez-Batiste X, et al. BMJ Supportive & Palliative Care 2012;0:1–9. doi: /bmjspcare

Ask yourself: Would you be surprised if this patient died in the next 12 months? Does this patient have decreased function, cognitive impairment, progressive weight loss, unplanned admissions in last year, live in a NH or AL, or need help at home? Does this patient have advanced cancer or heart, lung, kidney, liver, or cognitive failure? Targeting on the Front Lines

Key Characteristic 2: Goal Setting “Don’t ask what’s the matter with me; ask what matters to me!” Ask the person and family, “What is most important to you?”

Priorities for Care Survey of Senior Center and AL subjects, n=357, dementia excluded, no data on function Asked to rank order what’s most important: Overall, independence ranked highest (76% rank it most important) followed by pain and symptom relief, with staying alive last. Fried et al. Arch Int Med 2011;171:1854

Key Characteristic 3: Families are Home Alone 40 billion hours unpaid care/yr by 42 million caregivers worth $450 billion/yr Providing “skilled” care Increased morbidity/mortality/ban kruptcy aarp.org/ppi

Families Need Help if We Are to Honor People’s Goals Mobilizing long term services and supports in the community is key to helping people stay home and out of hospitals. Predictors of success: 24/7 meaningful phone access; high-touch consistent and personalized care relationships; focus on social and behavioral health; integration of social supports with medical services.

Payers Are Already Bringing the Care Home

MA Full Risk PMPM contract with HealthCare Partners/DaVita 15%+margin. >700K patients “Now instead of patients/day, Dr. Dougher sees 6- 8.” “Now instead of patients/day, Dr. Dougher sees 6- 8.”

Key Characteristic 4: Pain and Symptoms – Disabling pain and other symptoms reduce independence and quality of life. HRS- representative sample of 4703 community dwelling older adults Pain of moderate or greater severity that is ”often troubling” is reported by 46% of older adults in their last 4 months of life and is worst among those with arthritis. Smith AK et al. Ann Intern Med 2010;153:

It’s Not Only Pain: Symptom Burden of Community Dwelling Older Adults with Serious Illness Walke L et al, JPSM, 2006 * * * * * * * * 75% or more reported symptom as bothersome

Key Characteristic 5: Dose Flexibility Early advance care planning + communication on what to expect + treatment options + access. As illness progresses, ability to titrate dose intensity of services. Morrison and Meier. N Engl J Med 2004;350(25):

What do we have to do to realize this vision? 1. Workforce Training Not even close to enough clinicians with specialty training to meet the needs Therefore, we need to: –Train every clinician and help community providers to step up –Provide subspecialty consultation for the most complex –Improve evidence base through research

What do we need to do to realize this vision? 2. Public awareness: We need a positive vision of the good to drive demand and access and to help leaders to know about and implement models.

Treating the person beyond the disease.

Transforming 21 st Century Care of Serious Illness Gomez- Batiste et al.2012 Change from:Change to: Terminal ……………………………………Advanced Chronic Prognosis weeks-month…………………..Prognosis months to years Cancer……………………………………..All chronic progressive diseases Disease……………………………………..Condition (frailty, fn’l dep, MCC) Mortality…………………………………….Prevalence Cure vs. Care………………………………Synchronous shared care Disease OR palliation……………………..Disease AND palliation Prognosis as criterion……………………..Need as criterion Reactive…………………………………….Screening, Preventive Specialist……………………………………Palliative/Geriatric Care Everywhere Institutional………………………………….Community No regional planning……………………….Public health approach Fragmented care……………………………Integrated care

(Present) and Future “The future is here now. It’s just not very evenly distributed.” William Gibson The Economist, 2003