1. FATE: Family Assessment of Treatment at End-of-life David J Casarett MD MA CHERP, Philadelphia VAMC Division of Geriatrics University of Pennsylvania

2. VA Mission: To Honor Veterans’ Preferences for Care at the End of Life "VA must offer to provide or purchase hospice & palliative care that VA determines an enrolled veteran needs." 38 CFR 17.36 and 17.38

3. How well are we doing?  Data are needed: »To identify problems »To distinguish high- vs. low-performing facilities »To guide improvement efforts »To shape policy related to: Funding Workforce Health care systems organization

4. Quality measurement opportunities in VHA  Opportunity to translate data into policy  Opportunity for a public health approach/population -based  Data-rich health care system and Electronic Medical Record

5. Data availability sets the VA apart: Potential for nationwide quality measurement  Structures of care »Consult services »HVPs »Inpatient units  Processes of care »Consults »Referrals to hospice  Outcomes (provide answers to key policy- relevant questions) »Do palliative care consults improve care? »Does home hospice improve care?

6. Background  HSRD-funded instrument development project  Multisite »5 sites in initial phase (current) »15 sites in feasibility test  Preliminary version approved by Office of Management and Budget as a quality tool (10/06)  Planned for review as a Type III (mandatory) Directors performance measure

7. Approach  Afterdeath telephone interview of families »Enrolled veterans who had at least one healthcare contact with the VA in the last month of life »Inpatient, outpatient, and NHCU deaths  Eligibility »National death bulletin notifications »Chart review »Letter to families »Telephone call (approximately 2 months after death)

8. Epidemiology of the veteran population (2005)  ~24,000,000 living veterans »~687,000 projected veteran deaths (2005- 2006)  ~100,000 enrolled deaths  ~29,000 inpatient deaths http://www.va.gov/vetdata/demographics/index.htm VA is responsible Only the VA is accountable VA is accountable

9. Sites (Phase I)  Philadelphia  Birmingham  West Los Angeles  Louisville  Lebanon

10. Domains  Well-being and dignity (5 items)  Communication (4 items)  Care consistent with preferences (2 items)  Symptom management (4 items)  Care around the time of death (5 items)  Emotional/spiritual support (4 items)  VA services (3 items)  VA death benefits (3 items)  Admitted to facility of choice (1 item)

11. Reporting  Anonymous (self-identified only)  Domain scores and rankings  Future: case-mix adjusted  www.caringforveterans.org www.caringforveterans.org

12. Site-specific feedback: www.caringforveterans.org

15. Value to the VA: Examples of 3 policy-relevant questions  Do palliative care consults improve care?  Does home hospice improve care?  Is home hospice better than inpatient palliative care?

16. Value to the VA: Do PC consults improve care? (FATE score, n=309)  Yes: 86% vs. 64% (p<0.001)* *Adjusted for age ethnicity, income, diagnosis (cancer vs. non-cancer), and site.

17. Value to the VA: Does hospice improve care for deaths at home? (FATE score, n=143)  Maybe: 89% vs. 85% (not significant)*  BUT: Significant interaction by site (e.g. hospices in some cities have a greater effect than in others). *Adjusted for age, ethnicity, income, diagnosis (cancer vs. non-cancer) and LOS.

18. All hospices are not equal  Died at home with hospice: »Range across sites (means): 43-78 (P=0.010) »Small variation in VA service scores »Larger variation in VA death benefits »Large variation in communication, care around the time of death, and symptoms

19. No place like home?  Died at home with hospice: »FATE score mean 67 (IQ range 45-76)  Died in a VA hospital with palliative care: »FATE score mean 76 (IQ range 64-82) (P=0.014)

20. Preliminary results: summary  Inpatient PC improves care  Home hospice probably improves care  There is substantial variation among hospice programs  Inpatient PC may be as good as home hospice care

21. Next steps  Approval for QI use  Approval as a national quality measure  Rollout nationally »Central administration? »Central data collection »Routine reporting and integration into VISN quality initiatives

22. Collaborators Support  FATE collaborators and supporters: »Ken Rosenfeld MD »Christine Ritchie MD MPH »Scott Shreve MD »Christian Furman MD »Amos Bailey MD »Tom Edes MD »Diane Jones MSW  VA RCD 00008-01 and ARCDA  VA HSRD IIR 03-128-2  VA CPP #217  VA CSP #476  Center for Health Equity Research and Promotion  R01 CA109540-01  Paul Beeson Physician Scholars Award  NIH K01 AI 01739-01  Hartford Foundation  VistaCare Foundation  Commonwealth Fund  Greenwall Foundation

23. Questions:  How to integrate with FEHC?  How could these data be useful to hospices?  How could hospice partner with VA facilities to help them improve their FATE scores?