1. Cecilia L. May, MD October 28, 2015

2. You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but to live until you die. Dame Cicely Saunders

3. Vital U.S. Statistics  90 million Americans are living with serious illness, and this number is expected to more than double over the next twenty-five years. (Dartmouth Atlas)  By 2030, according to the Administration on Aging, 20% of the US population (72 million) will be over age sixty-five = > twice the number from 2000.

4. Target Population for Palliative Care Distribution of Total Medicare Beneficiaries and Spending, 2009 Total Number of FFS Beneficiaries: 37.5 million Total Medicare Spending: $265 billion Average per capita Medicare spending (FFS only): $7,064 Average per capita Medicare spending among top 10% (FFS only): $44,220 SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost & Use file, 2009.

5. 10% of Medicare patients with >/= 5 chronic problems utilize 66% of spending 1-2 chronic conditions 10% 3 chronic conditions 10% 4 chronic conditions 13% No chronic conditions 1 % 5+ chronic conditions 66% Source: J. Anderson & G. Horvath, Making the Case for Ongoing Care. Baltimore, MD. Partnership for Solutions, December 2002

6. What is Palliative Care? Care for patients (& families) with serious illnesses, regardless of prognosis, at ANY AGE/ANY STAGE  Aggressive Symptom Management  Emotional and Spiritual Support  Complex Medical Decision Making  Gift of Time for Referring Physicians  Goals of Care  Coordination of Care (e.g. home/outpt Palliative care, ECF, or transition to Hospice Care)

7. Palliative Care Services Inpatient Consultation Inpatient Unit ECF Consultation Outpatient Consultation Emergency Department Home Visits Advance Care Planning

8. “The Palliative Care Team will be coming to visit with you and your family. They often assist us with our patients and families who are facing serious illness and need symptom management and support.” How to Introduce Palliative Care

9. Is Palliative Care only EOL care?  NO, but it is an important part of palliative care.  Refers to the care of a person during the “last part” of life, from the point at which it has become clear that the person is in a progressive state of decline, may be from hours to months depending on the clinical situation.  In the hospital, may be equivalent to hospice care for those too ill to be discharged.

10. Palliative Care Curative Care Hospice

11.  “Home”: primary or family residence, nursing home, group home, assisted living facility; mandated to be >80% of delivered care of any hospice’s services  General Inpatient care: Short term, 3-5 days, active sx  Respite care, 5 day limit, no symptoms, caretaker care  Continuous care at home: Highly regulated, typically several to 24 hours  RARELY in hospice house care due to $$ What does Hospice care look like?

12. Hospice Care Life Prolonging Care Old Palliative Care Bereavement Hospice Care New DxDeath Palliative Care: A Paradigm Shift Life Prolonging Care

13.  2015 State-by-State Report Card on Access to Palliative Care reports data from the American Hospital Association fiscal year 2013  From 2008  2015, 66% of all US hospitals have PC programs, up from 53% in 2008  INDIANA has a B grade, as well as 36% of states  A = 34%, C = 18%, D = 14%, F = 0 (2011, F = 2%, D = 8%)  90% of hospitals with > 300 beds have PC programs  96% of Catholic hospitals have PC programs  Location matters as the South East/Central region has lowest #s  Nonprofit >> Public >> For Profit Center to Advance Palliative Care, www.capc.org/reportcard, 2015 Good News from CAPC

14.  Major barrier to expanding palliative care services is the lack of palliative medicine physicians. (1, 2)  1:71 Cardiologist for persons with CAD  1:141 Oncologist for every newly diagnosed cancer patient  1:1200 Palliative Medicine Physician for patients with serious illness  New PM fellowships need funding  Inpatient Palliative Care consultations can improve coordination of home care, increase safety and decrease readmissions for uncontrolled symptoms (reducing cost as a secondary effect) (3) 1. Center to Advance Palliative Care, www.capc.org/reportcard 2. Lupu. Estimate of Current Hospice and Palliative Medicine Physician Workforce Shortage. J Pall & Symptom Mgmt. December 2010; Vol. 40 (6): 899-911 3. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008 Sep 8; 168(16): 1783-90 Opportunities

15.  Standards defining QUALITY Palliative Care help field progress  JCAHO Advanced Certification for Palliative Care started in Sept, 2011  American College of Surgeons requires PC program for ACoS CA Cert  HFAP is creating standards for PC certification  Institute of Medicine Report, 2014, Dying In America  National Quality Forum Standards  American Association of Hospice and Palliative Medicine (AAHPM)  Center to Advance Palliative Care (CAPC)  ABMS Physician Certification (ABIM, multiple other disciplines)  HPNA Nursing Certification Quality and Certification

16.  2006 -- Named PC to top 6 priorities for healthcare  2011 -- 14 new PC measures released www.qualityforum.org, Pain Management Measures  Hospice and Palliative Care — Pain Screening  Hospice and Palliative Care — Pain Assessment  Patients treated with an Opioid who are given a bowel regimen  Patients with advanced cancer assessed for pain at outpatient visits Dyspnea Management Measures  Hospice and Palliative Care — Dyspnea Treatment  Hospice and Palliative Care — Dyspnea Screening Care Preference Measures  Patients admitted to the ICU who have care preferences documented  Hospice and Palliative Care — Treatment Preferences  Percentage of hospice patients with documentation in the clinical record of a discussion of 345 spiritual/religious concerns or documentation that the patient/caregiver did not want to discuss  Comfortable dying  Hospitalized patients who die an expected death with an ICD that has been deactivated Quality of Care at the End of Life Measures  Family Evaluation of Hospice Care  CARE — Consumer Assessments and Reports of End of Life  Bereaved Family Survey National Quality Forum Palliative Care Measure Report

17. CAPC – Registry 1. Operational data (e.g. volume and type of referrals, date of admission/consultation) 2. Clinical data (e.g. pain and symptom control) 3. Customer data (e.g. patient, family, and health care provider satisfaction surveys) 4. Financial data (e.g. billing revenues, cost per day, length of stay)

18. AAHPM HPNA MWM 10 Quality Measures 1. Hospice and Palliative Care -- Comprehensive Assessment 2. Screening for Physical Symptoms 3. Pain Treatment within 24 hours 4. Dyspnea Screening and Management 5. Discussion of Emotional or Psychological Needs 6. Discussion of Spiritual/Religious Concerns 7. Documentation of Surrogate 8. Treatment Preferences 9. Care Consistency with Documented Care Preferences 10. Measures of Quality of Care (Patient or Family)

19.  2010 Study: Mass General Hospital RCT of 151 patients newly diagnosed metastatic NSCLC to receive either early palliative care (EPC) with standard oncologic care or SOC alone.  27 died by 12 weeks and 107 (86% of the remaining patients) completed assessments  EPC group had:  better quality of life than did SOC patients  > 50% less depression than SOC patients  Less “aggressive” end-of-life care (33% vs. 54%, P = 0.05)  Increased Median survival (11.6 mos vs. 8.9 mos, P = 0.02) Temel, M. et al. “Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer.” New England Journal of Medicine. 2010. 363:733-742. The Changing Face of Palliative Medicine

20.  2009 -- Aetna piloted the use of “open access” hospice = cancer patients were able to get home hospice services CONCURRENT with “aggressive” chemotherapy and radiotherapy.  Results = access to hospice (31%  72%), mean hospice days 2x avg, and inpatient hospital stays.  Costs  CMS took note and is now beginning a pilot program, Medicare Care Choices Model, to allow some MC pts to receive palliative care services with concurrent curative care starting 2016.  Hospice and Palliative Care lines are becoming blurred as a result Spettell et al. (2009). “A comprehensive case management program to improve palliative care.” Journal of Palliative Medicine 12 (9): 827–832 http://innovation.cms.gov/initiatives/Medicare-Care-Choices / The Changing Face of Palliative Medicine

21. Curative Care Palliative Care Hospice Evolving Hospice/PC Paradigm

22.  Care aimed at relieving suffering and providing the best quality of life for patients and their families, at any age and any stage of serious illness.  Focus on intensive symptom management, communication and coordination of care.  Provided along with curative treatment.  Currently, not equal to hospice.  Not limited to end-of-life care.  Not dependent on prognosis. The Answer to “What is Palliative Care?”

23. More Palliative Care is the Answer Established, evidence-based specialty Initiate care plans to satisfy patient goals Increase satisfaction; measurable results Collaborative care model Decrease cost and readmissions Integrate care across multiple service lines

25. Thank you ! Questions?? Call us anytime, Palliative Care Team : 502-4949 office 420-1602 ans. svc. 418-4033 Dr. May