Palliative Care 2012: Matching Care to Patient’s Needs Diane E. Meier, MD Director Center to Advance Palliative Care diane.meier@mssm.edu www.capc.org www.getpalliativecare.org 1

Objectives How is palliative care important to improving value (quality and cost) in health care reform? Changing the delivery system to improve access to quality palliative care in and beyond the hospital

Core Principle “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 4 4

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.

Value of health care = Quality Cost The Value Equation-1 Value of health care = Quality Cost Numerator 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

Value of health care = quality cost The Value Equation- 2 Value of health care = quality cost Denominator 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 EFFICIENCY International Comparison of Spending on Health, 1980–2009 Average spending on health per capita ($US PPP*) Total expenditures on health as percent of GDP * PPP=Purchasing Power Parity. Data: OECD Health Data 2011 (database), version 6/2011. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 9 9

Sun Sentinel (Broward County edition) Tuesday, August 9, 2011

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, 2009 Adjusted for Cost of Living Dollars Source: OECD Health Data 2009 (June 2009).

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. 14

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Palliative Care is Central to Improving the Value Equation Because our patient population is driving most of the spending 16 16 16

Conceptual Shift for Palliative Care 17

Palliative Care Language Endorsed by the Public 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. This revised definition, based on the qualitative research, had a significant positive impact. 18 18

Exceptionally High Positives Once informed, consumers are extremely positive about palliative care and want access to this care if they need it: 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. 19 19

Palliative Care Hits the High Notes Better health. Better care Palliative Care Hits the High Notes Better 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 sees the person beyond the cancer treatment. It gives the patient control. It brings trained specialists together with doctors and nurses in a team-based approach to manage pain and other symptoms, explain treatment options, and improve quality of life during serious illness. 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. Support palliative care legislation (HR. XX & S. XX). Bring quality of life and care together for the millions facing cancer.

Palliative Care Teams Address 3 Domains Physical, emotional, and spiritual distress Patient-family-professional communication about achievable goals for care and the decision-making that follows 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 22

Palliative Care Across the Continuum Inpatient Consult Service Outpatient Specialty Clinics Cancer Center Outpatient PCP Clinics SNF Consult Service Provider Home Visits Inpatient Unit

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. 24

December 7, 2010 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

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 26

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 29 29

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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

Palliative Care Growth Source: Center to Advance Palliative Care, 2011 capc.org/reportcard 32 32

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 33 33

% “Great Deal” or “Some” Exposure to Palliative Care Hope for the Future: Younger physicians exposed to palliative care more than their predecessors. % “Great Deal” or “Some” Exposure to Palliative Care by Physician Age − 34 −

National Quality Forum: Palliative Care is One of Six National Priorities for Action http://www.nationalprioritiespartnership.org/Priorities 36

NQF-Endorsed Palliative Care Measures 02/14/2012 http://www 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 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

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 40

Strategic Partnerships 41

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 Threshold Effect: Unless you make an order-of-magnitude shift in intensity of time spent with a CCM patient - you’ll have diminishing return. FHI has defined factors in getting over the threshold. Demand Management DM/CM CCM-palliative care 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

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

2012 New ICU/ED/OPT Resources http://www.capc.org/ipal-icu

Metrics: The CAPC Registry Your data, local use Your data, compared Your data, compared and combined - Provides outside perspective & validation to plans Leverages data you collect for several purposes Builds consistency and critical mass for field & research

https://registry.capc.org

Uses of the Registry Registry Report 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. 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. Note: There are more operational features listed in the Registry than shown here. Other features are not shown due to PowerPoint size restraints.

New 2011 Tool to Help “Move Upstream” with Triggers & Checklists 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

The Challenge Most 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

Why Develop Triggers? Improve patient/family outcomes Reduce variation in care Make palliative care part of a systems-based approach to care Culture change

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

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.

Other Resources 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 www.capc.org

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

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

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/ )

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.

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 wheel