PALLIATIVE CARE Why? Australian College of Nursing Victorian Chapter 7 February 2013 Helen Walker Cabrini 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 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

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 , 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 Management Cabrini Hiealth Integrated Services Model 6 Providing quality care supported by evidence 1 Informing and involving clients and carers 2 Caring for carers 3 Working together to ensure people die in their place of choice 4 Providing specialist care when and where it is needed 5 Coordinating care across settings 7 Ensuring support from communities Client and carers Boosting Community Services Proposal for funds to support increased care packages for carers Website New Patient Information Brochure Media Building the Narrative Press Ganey

INTEGRATED PALLIATIVE CARE CABRINI HEALTH MODEL

CLINICAL OUTCOMES Clinical 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 Committee commented 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 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 LIFE Mean Survival for Lung Cancer Patients Usual Patients Mean Survival for Pancreatic Cancer Patients Hospice Patients Days p= n=700. n=586 Days p= n=493 n= 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-L 1 Symptom Management Scores Usual Care p=0.03 n=74. n= Higher scores indicate fewer symptoms, better quality of life Palliative Care Usual Care Palliative Care Usual Care Palliative Care LCS 2 Symptom Management Scores p=0.04 n=74. n=77 TOI 3 Symptom Management Scores p=0.009 n=74. n=77

VALUE OF PALLIATIVE CARE A 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 CareSpec 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 3 rd world More people comfortable to discuss death and dying in the community

Health Promotion lls-story-video

HALLMARKS OF SUCCESS Palliative Care Models 1 Embedded Specialist RN 2 Inpatient Consult Service 3 Dedicated Inpatient Unit 4 Outpatient Clinic 5 Home Based Care 6 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 care 6 Clinicians trained to provide palliative care