Moving Palliative Care Upstream David E. Weissman, MD Professor Emeritus Medical College of Wisconsin Consultant, Center to Advance Palliative Care

Objectives List three benefits of integrating palliative care principles early into the course of chronic disease management. Describe three new models of palliative care service delivery that seek to engage patients early in the disease course. Characterize national efforts to impact health care policy concordant with palliative care principles.

Historical Perspective Phase I Hospice 1970s-80s Phase 2 Palliative Care1990s-2000s Phase 3 Spread2010s-

The past 10 years

Not where we used to be…

St. John Providence Health System Palliative Care Specialized medical care for people with chronic and/or serious illness Focused on providing relief from the symptoms, pain and stress of an illness with equal attention to emotional and spiritual well-being Delivered by a multidisciplinary team to provide an extra layer of support Care continues to be provided by PCP Can be provided at the same time as curative treatment

The Palliative Care Intervention Interdisciplinary teams –Patient-centered goals of care discussion Realistic prognostication –Pain and symptom relief –Disposition planning reflecting patient goals –Patient/Family support –Bereavement support 7

Key Palliative Care Outcomes –Reduced ICU length of stay –Rapid symptom relief –Earlier referral to hospice services-longer –Greater patient/family satisfaction –Lower hospital cost –Prolonged survival (outpatient intervention) 8

Program vs. Team Palliative Care Team –Provides clinical services Palliative Care Program –Clinical services –Outcome/Value measurement –Education –Quality Improvement –Systems integration

Standards and Certification Joint Commission Certification (2011) NQF Palliative Care Care Standards (2012) Commission on Cancer requirement, Cancer Center Accreditation (2011) Board Certification, Hospice and Palliative Medicine –Physicians –Nurses: AP, RN, LPN –Social workers –Chaplains (pending) 10

What is left to accomplish? In hospitals, at best, only 25-50% of palliative care needs are being met. –Variable penetration to areas of highest need: ICUs, ED, Oncology, Neurology, Renal Between hospitals and hospice there is a large gap of palliative care needs across the Continuum of health care. –Outpatient services –Long-term and Home care –Home care

Hospitals Not all hospitals have consult services Those that do are typically overworked –High rate of stress/burnout –Many “martyrs” –Adding more staff is problematic More staff leads to more consults

The Referral Conundrum Consults predominantly occur based on clinician values, rather than patient needs –Clinician values/attitudes inhibit provision of excellent palliative care services My patient isn’t ready; my patient is not dying I’m not ready for palliative care I will not give up on my patient Education alone will not fix this problem.

Reality Check There will never be enough palliative care specialists (all disciplines) to meet the demand. Overall health care dollars will be shrinking.

Solutions 1.Increase team efficiency: Accountability and Value 2.New team models 3.Integrate palliative care principles into high-risk locations 4.Identify unmet needs 5.Expand Generalist Palliative Care 6.Improve care across the continuum

1. Increase Team Efficiency Close examination of the process of care delivery –Staff time studies –Determine cost/case –Use metrics to determine efficiency and value

2. New Team Models “Counselor” Model –Med Center Central Georgia/UMDNJ Staff –Specially trained communication “counselors” (Nursing, Mental health background) Intervention –Manage most goal of care discussions –Work in both parallel and series with PC team

3. Integration Projects Efforts to broaden the spread of palliative care principles into locations of high unmet needs, through … –setting collaborative goals –early patient identification (triggers) –systems change to guide right care at right time—routine family meetings –quality improvement-data driven change

Models for Structuring an ICU Palliative Care Initiative Nelson, et al. CCM 2010; 38:1765. Consultative Model Integrative Model Palliative Care Consultation Palliative Care Team Usual ICU Care by Critical Care Team Palliative Care Principles/Interventions Embedded in Usual ICU Care Copyright 2010 Center to Advance Palliative Care. Reproduction by permission only.

4. Find the Unmet Needs A patient-centered approach would be to design a system where palliative care interventions are based on patient and/or disease factors, rather than clinician attitudes/values. Patients are fully informed about treatment options. Patients have equal access to all hospital resources. Patients receive only the life-sustaining treatments they desire/are appropriate to their medical condition/prognosis.

Common trigger systems ICU Length of stay Multi-organ failure Metastatic cancer Prolonged unconsciousness Nursing home admission Emergency department Oncology clinic Special populations – LVAD/CHF – Nursing home admits – PEG or trach consideration

Primary Palliative Care Triggers On Admission A potentially life-limiting or life threatening condition AND one of the following… The ‘Surprise’ question Frequent admissions Difficult to manage symptoms Complex care requirements Decline in function or weight Weissman DE and Meier DE. Identifying patients in need of a palliative care assessment in the hospital setting: consensus recommendations. J Pall Med 2011;14:1-7

Primary Palliative Care Triggers Daily Checklist The ‘Surprise’ question Difficult to control symptoms ICU LOS > 1 week Lack of Goals of Care documentation Disagreement/uncertainty re: – Major medical decisions – Resuscitation preferences – Use of non-oral feeling/hydration Weissman DE and Meier DE. Identifying patients in need of a palliative care assessment in the hospital setting: consensus recommendations. J Pall Med 2011;14:1-7

5. Generalist Pall. Care Need to imbed Palliative Care principles into the system of health care delivery –Commitment: time/$ –Assessment: case finding—all patient screen –Responsibility: QI –Education: all clinical staff –Standards: who/what/when

Primary/Specialty Care Primary Pall Care: all clinicians –Routine communication/symptom control Specialty Pall Care –Family meetings—esp. “difficult cases” –Complex symptom management –Time management –Support for difficult decisions

6. Move into the Continuum Outpatient Palliative Care Free-standing Co-management clinics: oncology, other Home visits IPAL-OP (2012) Long Term Care Dedicated Pall Care staff Geriatric NP model Consultative external team

What else is new?

The Joint Commission The Joint Commission: Palliative Care Advanced Certification Program _care.aspx

HEALTH REFORM

Palliative Care is Central to the Success of Health Reform >95% of all health care spending is for the chronically ill 64% of all Medicare spending goes to the 10% of beneficiaries with 5 or more chronic conditions Despite high spending, evidence of poor quality of care

Palliative Care, Health Reform and Chronic Disease Care Health reform initiatives –Reduce readmissions –Reduce cost –Improve quality/Reduce variation –Shift chronic disease care out of the hospital –Care coordination/Bundling/ACOs Palliative Care services/outcomes are perfectly aligned with all these priorities! 36

Payers are getting into Palliative Care

What can you do? 1.Seek information: –What health reform initiatives are your administrators concerned about? –What committees are working on health reform topics? 2.Offer to participate; share information on palliative care role/impact –Mortality and readmission reduction –Cost control 38

What can you do? 3.Push for collaborative initiatives –ICU/ED/Cardiology/Cancer/Hospitalists –Focus on improving generalist palliative care rather than striving for more consults 4.Remind everyone about the 50%! –Seek opportunities identify patients with unmet needs 39

What can you do? 5.Push the professionalism of HPM –Get yourself certified –Get your hospital to be Joint Commission certified –Share the NQF Palliative Care Quality Measures –Submit your data to the National Palliative Care Registry 40

What can you do? 6.Take care of yourself and your program –Recognize Palliative Care martyrdom –Pay attention to team health/function –Balance consults with other Program work 7.Share your successes –CAPC Annual Seminar—Oral presentation/poster –Share your tools with others 41

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