1. Palliative and Geriatric Medicine: Matching Care to Our Patient’s Needs
Diane E. Meier, MD
Department of Geriatrics and Palliative Medicine
Icahn School of Medicine at Mount Sinai
Director, Center to Advance Palliative Care 1

2. No Disclosures

3. Objectives The case for integrated geriatrics and palliative medicine
What works to improve quality and reduce costs for vulnerable old people?
Limitations of our taxonomy and tribalism
How to face outwards towards needs of:
Our patients, their families
Policy makers, payers, health system leadership

4. Thanks and Attribution

5. Concentration of Spending Distribution of Total Medicare Beneficiaries and Spending, 2011
Average per capita Medicare spending (FFS only): $8,554
Average per capita Medicare spending among top 10% (FFS only): $48,220
Total Number of FFS Beneficiaries: million
Total Medicare Spending: $417 billion
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. 5

6. Because of the Concentration of Risk and Spending, Geriatrics and Palliative Care Principles and Practices are Central to Improving Quality and Reducing Cost

7. 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 a lot of acetaminophen.
Admitted 4 times in 6 months for pain (2x), weight loss+falls, and altered mental status due to constipation.
His family (83 year old wife) is overwhelmed.

8. Mr. B:
Mr. B: “I told the Dr. that I never wanted to go back to the hospital again. It’s torture—you have no control and can’t do anything for yourself. And you get weaker and sicker. Every time I’m in the hospital it feels like I’ll never get out.”
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

9. Functional Limitation Dementia Frailty Serious illness(es)
Concentration of Risk
Functional Limitation
Dementia
Frailty
Serious illness(es)

10. Most of Costliest 5% have Functional Limitations

11. 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:

12. Dementia Drives Utilization
Prospective
Cohort of community dwelling older adults
Callahan et al. JAGS 2012;60:
Dementia
No Dementia
Medicare SNF use
44.7%
11.4%
Medicaid NH use
21%
1.4%
Hospital use
76.2%
51.2%
Home health use
55.7%
27.3%
Transitions
11.2
3.8

13. 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:

14. In case you are not already worried… The Future of Dementia Hospitalizations and Long Term Services+Supports
10 fold growth in dementia related hospitalizations projected between 2000 and 2050 to >7 million.
Zilberberg and Tija. Arch Int Med 2011;171:1850.
3 fold increase in need for formal LTSS between now and 2050, from 9 to 27 million.
Lynn and Satyarthi. Arch Int Med 2011;171:1852.

15. Why? Low Ratio of Social to Health Service Expenditures in U.S.
for Organization for Economic Co-operation and Development (OECD) countries, 2005.
Ratio of social to health service expenditures for Organization for Economic Co-operation and Development (OECD) countries, The ratio is calculated by dividing total expenditures on social services by total expenditures on health services. *The ratio for Portugal is from 2004, owing to missing data for Source: OECD Health Data 2009 (accessed June 2009); OECD Social Expenditure Dataset (accessed December 2009); authors' calculations.
Bradley E H et al. BMJ Qual Saf 2011;20:
Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.

16. Surprise! Home and Community Based Services are High Value
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 1/3rd the cost of Nursing Home care.

17. This is Our Expertise
Highest risk, highest cost population is ours: functional limitation, frailty, cognitive impairment +/- serious illness(es)
What are the roles of the the geriatrics and palliative care disciplines in improving care of this population?

18. 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

19. Conceptual Shift for Palliative Care Goals
Medicare Hospice Benefit
Life Prolonging Care Dx
Death
Old
Palliative Care
Bereavement
Hospice Care
Life Prolonging
Care
New 19

20. What is Geriatrics?
Geriatrics focuses on the health care of elderly people and aims to promote health by preventing and treating disease and disability in older adults. (Wikipedia)
Geriatrics aims to improve health, independence, and quality of life in all older people. (AGS)

21. Geriatrics and Palliative Care: Leaning In Morrison RS. JPM 2013
AIDS
Cancer (<65)
Gait Disorders
Cancer
Genetic/ Developmental Disorders
Well Older Adults
Advanced Organ Failure
Geriatrics
Palliative Care
Stable chronic disease
Stroke/Neuromuscular Disease
Pediatric Oncology
Chronic Critical Illness
Geriatric syndromes
Dementia
Peri-operative care
Traumatic Brain Injury
Frailty

22. Palliative and Geriatric 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

23. Key Characteristics of Effective Models 1: Targeting
RESOURCES
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

24. Jones et al. JAGS 2004;52

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

26. Targeting on the Front Lines
Ask yourself:
Does this patient have an advanced long term condition or a new dx of a serious illness or both?
Would you be surprised if this patient died in the next 12 months?
Does this patient have decreased function, progressive weight loss, >= 2 unplanned admissions in last 12 months, live in a NH or AL, or need more personal care at home?
Does this patient have advanced cancer or heart, lung, kidney, liver, or cognitive failure?

27. 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?”
“Ultimately, good medicine is about doing right for the patient. For patients with MCC, severe disability, or limited life expectancy, any accounting of how well we’re succeeding in providing care must above all consider patients’ preferred outcomes.” Reuben and Tinetti NEJM 2012;366:777-9.

28. Goals 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

29. 29 29

30. Impact of Goal Setting through Advance Care Planning
Prospective data on >3000 Medicare beneficiaries (linked HRS, claims, and NDI)
Advance directives associated with lower Medicare spending, lower hospital death rate, and higher hospice use in medium-high Medicare spending regions of the U.S.
Nicholas et al. JAMA 2011;306:

31. Key Characteristic 3: LTSS Can We Deliver on People’s Goals When Families are Home Alone?
40 billion hours unpaid care/yr by 42 million caregivers worth $450 billion/yr
Providing “skilled” care
Increased morbidity/mortality/bankruptcy
aarp.org/ppi

32. Optimistic Baby Boomers say “Get Ready, Kids!”
70% of those who have never received long term care say they can rely on family in time of need as they age, (compared to 55% of those who have received it).
The Scan Foundation/NORC/AP April 2013
To.pbs.org/15TQh2B

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

34. Payers Are Already Bringing the Care Home

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

36. 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:

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

38. Key Characteristic 5: The Dynamic Nature of Risk
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):

39. Taxonomies and Their Discontents
Balkanized health system: Hospital, office, NH, AL, home, PACE, LTACH, hospice…
Balkanized disciplines: GIM, FM, geriatrics, palliative care, cardiology, oncology, hospitalists, SNFists…
Zillions of evidence-based “best practices” based on small scale programs.
Competitive, struggling, isolated, ineffective at meeting population needs.

44. We Are Confusing Our Audiences
Policy makers and payers and hospitals and health systems: Who has the best impact on LOS? On 30 day readmissions? On hospital mortality? On HCAHPS? On total (payer) spend? For which patient population? In which settings? Does anyone pay for this? How can I believe your cost avoidance arguments? How do I choose?
Patients and families: HELP!!

45. What to Do? Implement, Scale
Our challenge is broad implementation of what’s been shown to work in small scale programs.
Scaling and diffusion of innovation via technical assistance, training, and social marketing.
Be at the table or be on the menu: Drive policy change

46. Clear, Simple Technical Assistance for
What do systems, payers, colleagues and people and their families need?
Clear, Simple Technical Assistance for
System integration design
Model(s) selection
Implementation, quality, and standardization
Risk stratification and targeting
Evaluation

48. Care Management www.med-ic.org ACE/HELP NICHE Palliative Care
Move Inpatients Through the System Safely and Efficiently:
ACE/HELP
NICHE
Palliative Care
Keep some patients with acute illness out of the hospital: Hospital at Home
Prevent Readmission:
Care Transitions Programs
Care Management
Provide patient-centered, coordinated care: PCMH (GRACE, Guided Care), Medical house calls, ACOs

49. What do systems, payers, colleagues and people and their families need?
2. Workforce Training
Not even close to enough clinicians with specialty training to meet the needs
Therefore, our role is to:
Train generalists and help communities to step up
Provide subspecialty consultation for the most complex
Improve evidence base through research

51. What do systems, payers, colleagues and people and their families need?
3. Public and constituency awareness through social marketing and PR: We need to create a positive public vision of the good to drive demand and access and to help leaders to know about, and then implement models.

52. Public Awareness
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.

54. Transforming 21st Century Care of Serious Illness Gomez-Batiste et al
Change from: Change to: Prognosis weeks-month…………………..Prognosis months to years Disease……………………………………..Condition (frailty, fn’l dep, MCC) 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

55. Working Together: Why is it So Tricky
Perception of zero sum game
Same pot of money
Competition for attention, curricular time, media, grants, policy, patients, and model dissemination

56. Examples of Joint Activities
Joint geriatrics-palliative medicine fellowship training at MSSM
AGS-AAHPM collaboration workgroup
JAGS 2012;60:583-7.
GeriPal: 60,000 page views/m, high media uptake
Choosing Wisely- Common priorities
Geriatrics Entrustable Professional Activities call for core competencies in palliative medicine/goal setting

57. AGS-AAHPM Work Group
Focus groups: “Pooling of political, funding, and research influence was repeatedly seen as a strategy that needed to be fully used, taking advantage…of greater strength with greater numbers.”
A joint proposal for collaboration was submitted to and approved by the Boards of Directors of both organizations.
Next steps?
JAGS 2012;60:583-7.

58. The Way Forward
“…most important is establishing a culture of collaboration and trust…”