1. Improving oncology care with more integration of palliative care Thomas J. Smith, MD FACP Harry J. Duffey Family Professor of Palliative Medicine Director of Palliative Medicine Johns Hopkins Medical Institutions Professor of Oncology Sidney Kimmel Comprehensive Cancer Center tsmit136@jhmi.edi

2. Objectives 1.Reasons why. 2.Smaller fixes within reach. a)More use of palliative care consultation services. b)More primary palliative care in oncology practices c)More and earlier use of hospice (live better and longer) 3.Big fixes. a)Insurance: Aetnas Compassionate Care Program b)Sutter Health Advanced Illness Model

3. Medical care costs 2-fold more in the US than any other country OECD Health Data 2011 $4500 $8100

4. Cancer care costs are rising exponentially - $173 billion at 2% growth rate Mariotto AB, et al. Projections of the cost of cancer care in the United States: 2010- 2020. J Natl Cancer Inst. 2011 Jan 19;103(2):117-28. Claxton G, et al. Health Aff (Millwood). 2010 Oct;29(10):1942-50.

5. Care patterns for cancer patients who died at a major medical center, Summer 2011 (see Dy S et al, JPM 2011; *Dow and Smith, JCO 2010) Process measureN (%)Targets Seriously ill61 Use of ventilator16 (26)10% Deceased35 (57) Any goals of care discussion26 (43)95% Advance directives on file4 (7)90% Oncologist brought up Ads*2/75 (1%)100% Death in hospital21 (34)10% Discharged with hospice14 (23)60% Chemo with 2 weeks of death, solid tumor patients 28-35%<10% Quality of care is not optimal

6. We are still hospital oriented and not hospice oriented near the very predictable end of life. Medicare Patients, Unadjusted Cancer Care Measures, By Hospital Characteristics, Morden, Health Affairs 2011 MeasureAll NCCN cancer centers Academic hospitals Community hospitals Death in hospital (%)30.232.633.829.7 Hospice use, last month of life (%) 53.853.450.354.2 Days in hospice, last month of life (per decedent) 8.48.67.68.5 Hospitalized, last month of life (%) 64.960.264.465.1 ICU use, last month of life (%) 24.723.32624.6

7. QOL concerns are not raised or discussed in cancer clinical settings. 2010 ACS CAN National Poll on Facing Cancer in the Health Care System (www.acscan.org) Q: After diagnosis and before starting treatment, did anyone on care team ask what is important to you/family in terms of QOL?

8. 3/4s of patients with lung and colon cancer think they could be cured with chemo (Weeks J, et al. NEJM 2012) Half of all lung cancer patients have had NO discussion with any of their doctors about hospice 2 months before they die. Huskamp HA, et al. Arch Intern Med. 2009 Only 37% of patients have any conversation about dying. (Wright AA, JAMA 2008) 60% of us prefer not to have hard conversations (DNR, AMDs, hospice) until there are no more treatment options left. Keating NL, et al. Cancer. 2010 Telling some one they are incurable is not enough – people want information about prognosis, what will happen to them, and their options.

9. Definition of palliative care 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. – Diane Meier, MD, Director, Center to Advance Palliative Care, July 1, 2011

10. Palliative care in addition to usual oncology care allowed lung cancer patients to live almost 3 months longer than those who got usual oncology care. Temel J, et al. NEJM 2010; Temel J, et al, JCO 2011 Longer and better survival Better understanding of prognosis Less IV chemo in last 60 days Less aggressive end of life care More and longer use of hospice $2000 per person savings to insurers and society

11. The American Society of Clinical Oncology now recommends …combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden. -Now 5 randomized trials showing the same results. -No trials showing harm or increased costs.

12. Hospice in the United States Hospice is defined as a Medical Benefit Truly managed care: – $150 a day outpatient, $500 a day inpatient – Everything must be paid from that Must have a 50/50 chance of death in the next 6 months if the disease runs its natural course Hospice eligibility: Hospice in a Minute

13. How do we better integrate palliative care into our care? Primary PC: every oncologist should be able to do. – Communication (ask, tell, ask) – Symptom Assessment and management (ESAS, MSAS) – Spiritual assessment (FICA, SNAP, AMEN) – Hospice referrals Secondary PC: referral, just like referral to cardiologist. Tertiary PC: specialized inpatient and research programs. Need more PC people – Fellowships – Advanced training (EPEC-O, ELNEC, OncoTalk)

14. How to do palliative care in the office. Cheng J, King L, Alesi ER, Smith TJ. J Oncol Practice, 2013 Table 1: Components of Office-based Primary Oncology Palliative Care 1.Ask, Tell, Ask. Always ask people how much they want to know, and what they do know. Then tell them, in understandable words. Ask What is your understanding of your situation? 2. At each transition point (when changing treatments or prognosis) ask, tell, ask. What are you hoping for? and What is your understanding of your situation? 3. Always do a symptom assessment. 4. At least some of the time, do a spiritual assessment. 5. Make a hospice information referral when the patient still has 3-6 months left to live. 6. Audit hospice referrals, like QOPI does. 7. Set up best practices for seriously ill patients who have less than a year to live. 8. Take advantage of decision aids to help those patients who want to know their prognosis. Use www.Eprognosis.orgwww.Eprognosis.org 9. Use some palliative care pearls in your practice, such as olanzapine for nausea, ginger for nausea, ginseng or dexamethasone for fatigue and better quality of life. 10. Use chart prompts in your EMR. Advance Directive __Yes __ No __ Not discussed Code status __Full ___DNR Other _______________ DPMA ___________________________________

15. There are opportunities to improve our practice on hospice referrals

16. How do we better integrate hospice into our care? Have a hospice information visit when we think the person has 3-12 months to live. Cant hurt. OK to predict wrongly. Can dramatically help – Makes us address difficult issues like code status – Informs family that the situation is serious and their loved one is dying – MOLST – Will, Living Will, DPMA, Life Review, Dignity therapy Smith TJ, Longo DL. Talking with patients about dying. N Engl J Med. 2012 Oct 25;367(17):1651-2. doi: 10.1056/NEJMe1211160.

17. Hospice eligibility is straightforward The SURPRISE QUESTION: Would you be surprised if this person were to die in the next 6 months? Failure to thrive: BMI < 22, involuntary weight loss CHF NYHA Class IV, EF < 20% COPD: hypoxemia at rest, FEV1 < 30% Dementia < 6 words Liver disease: INR > 1.5, albumin < 2.5 Cancer – much easier. Salpeter et al. J Palliat Med. 2012 Feb;15(2):175-85J Palliat Med. – Hypercalcemia, any malignant effusion, spinal cord compression, ECOG PS 2 or higher

18. The benefits are straightforward…better care, and people who use hospice for even one day live longer. Connor SR, et al. J Pain Symptom Manage. 2007 Mar;33(3):238-46.

19. We miss opportunities to recognize hospice-eligible patients, they are readmitted, and cost more. U of Iowa Hospitals. 688 in-hospital deaths 209 decedents had preceding admission 60% of decedents were eligible for hospice on the penultimate admission, based on NHPCO, National Hospice and Palliative Care Organization worksheets. -Only 14% had any discussion of hospice, despite being eligible; 14 of 17 enrolled, all from ONE service - Hopkins among the lowest of UHC Hospitals for hospice discharges from Cardiology, some other services Freund K, et al. J Hosp Med. 2012 Mar;7(3):218-23. doi: 10.1002/jhm.975. Epub 2011 Nov 15.

20. We miss opportunities to recognize hospice-eligible patients, they are readmitted, and cost more. Table: Comparison of Cost and Length of Stay Between Patients Enrolled and Not Enrolled in Hospice During a Terminal Hospital Admission Enrolled in hospice before last admission n = 7/14 Not enrolled in hospice, all diagnoses, n = 202/209 Cost Mean$4963$52 219 Median$3690$23 322 Standard deviation $3250$85 101 Standard deviation 4.4725.05 Palliative Care ConsultationYES, $41,859 NO, $58,386 P<0.04 Freund K, et al. J Hosp Med. 2012 Mar;7(3):218-23. doi: 10.1002/jhm.975. Epub 2011 Nov 15. Weckmann MT, et al. Am J Hosp Palliat Care. 2012 Sep 5.

21. People who use hospice are re-admitted less often, use less medical resources, and get better care. Enguidanos S, Vesper E, Lorenz K. 30-Day Readmissions among Seriously Ill Older Adults. J Palliat Med. 2012 Dec;15(12):1356-61. doi: 10.1089/jpm.2012.0259. Epub 2012 Oct 9. Table 2. Readmission Rate by Post-discharge Medical Service Use Post-discharge medical services Ratio of readmissions Percent Hospice 11/240 4.6 Home-based palliative care 5/60 8.3 Home health 2/15 13.3 Nursing facility 14/58 24.1 Home no care 9/35 25.7 Hospice saves Medicare $2309 per decedent, and the longer the hospice Length of stay, the bigger the savings. Taylor DH Jr, Ostermann J, Van Houtven CH, Tulsky JA, Steinhauser K. What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Soc Sci Med. 2007 Oct;65(7):1466-78. Epub 2007 Jun 27. Better care, consistent with what people would choose. Smith TJ, Schnipper LJ. The American Society of Clinical Oncology program to improve end-of- life care. J Palliat Med. 1998 Fall;1(3):221-30.

22. Identifying hospice eligible patients makes a difference PC program

23. Change our standards of care to incorporate national guidelines and best practices about palliative care.

24. 7. Set guidelines like the U S Oncology pathways that preserve survival, reduce cost by 35% in lung and colon cancer For NSCLC and colon cancer, equal results, less toxicity, less cost. Neubauer M, et al. J Oncol Pract. 2010 Jan;6(1):12-8. Hoverman JR, et al. J Oncol Pract. 2011 May;7(3 Suppl):52s-9s Equal survival With no 3, 4, 5 th Line chemo Generics Limit to 3 lines Of chemo Less chemo Less hospital More hospice 2x LOS, use Someone in the office -AMDs -DPMA -Hospice info visit

25. Advanced Care: How choice, comfort and dignity can drive cost reduction in a shared risk/shared savings world Brad Stuart MD stuartb@sutterhealth.org Bending the Cost Curve for Seriously Ill Patients Annual Assembly of AAHPM & HPNA March 8, 2012

26. Moving Care Out of the Hospital HOSPITALS Emergency Dept. Hospitalists Inpatient palliative care Case managers Discharge planners MEDICAL OFFICES Physicians Office staff HOME-BASED SERVICES Home health Hospice New Advanced Care staff & services EHR Patient Registry 911 Care Liaisons Care managers Telesupport Transitions Team CRITICAL EVENTS Acute exacerbation Pain crisis Family anxiety CRITICAL EVENTS Acute exacerbation Pain crisis Family anxiety

27. Tracking the Process of Personal Choice HOSPITALS PHYSICIAN OFFICES HOME-BASED SERVICES TELESUPPORT EHR Shared decisions made over time at the patients own pace Start the conversation Inpatient PC Inpatient PC Hospitalist Hospitalist PCP PCP Handoff Trained team linked across all settings Continuity at high or low acuity

28. Advanced Illness Management (AIM ) 90 Days Pre/Post Enrollment – Hospital 54% reduction in admissions 80% reduction in ICU days 26% reduction in inpatient LOS (2 days/case) – Physicians – Home 52% reduction in MD visits 60% increase in hospice enrollment 49% increase in home health enrollment

29. Net System, Payer Savings Payer Mix = 71% Medicare Per Beneficiary Per Month: 312 millionx 10% = $ 14.2 billion Potential Medicare Savings: – System savings $1125 – AIM rollout expense ($ 912) – Net system gain $ 213 PBPM Total payer savings $ 760 PBPM x 5%x $760/mo.x 12 mo/yr.

30. Lessons Learned in Advanced Care Re-engineer, re-brand, integrate – Add services people, clinicians want & need – Integrate MDs, AC, PC & Hospice Personal goals drive cost savings – Person-centered trumps patient-centered – Seriously ill people dont want to be patients Turn the business model upside down – Get the heads out of the beds – Invest in home and community

31. Conclusions