1. Reducing Avoidable Readmissions: The Business and Clinical Impact of Palliative Care Susan Enguidanos, PhD, MPH enguidan@usc.edu

2. Agenda Introduction to & Need for Palliative Care Evidence of Palliative Care Effectiveness Examples of Two Models of Palliative Care: Inpatient (Hospital-based) Home-based Palliative Care and 30-day Readmissions Getting Started

3. Introduction to Palliative Care

4. Rise in Aggressive Care? Teno et al., 2013

5. 65+ Medicare Beneficiaries ICU Use (Riley & Lubitz, 2010)

6. Background: Patient & Family Need Current dying experience is far from one that is desired by most Americans Majority of Americans prefer to die at home (Hays et al., 2001; Gallup, 2000) 33.5% die at home (2009; Teno et al., 2013) Patients continue to die in pain (Meier, 2006) 46% of Do Not Resuscitate orders written within 2 days of death

7. Palliative Care & Site of Death Studies show that most people prefer to die at home* Palliative Care patients more likely to die at home (Brumley, Enguidanos, Jamison et al., 2007) *(Townsend, Frank, Fermont, et al., 1990; Karlsen & Addington-Hall, 1998; Hays et al., 2001) P=.013 7

8. What is Palliative Care? Goal: “…to prevent and relieve suffering & to support the best possible quality of life for patients & their families, regardless of the stage of the disease or the need for other therapies.” What Palliative Care Does: “Expands traditional disease-model medical treatments to include the goals of enhancing quality of life for patient & family, optimizing function, helping with decision making, & providing opportunities for personal growth.” National Consensus Project for Quality Palliative Care, 2013

9. 9 Hospice Palliative care Curative / remissive therapy PresentationDeath Adapted from Lynn and Adamson, 2003

10. 10 Core Components of Palliative Care Interdisciplinary team: MD, RN, SW, Chaplain Physical, medical, psychological, social & spiritual support Patient & family education & training Develop plan of care Coordinated, patient-centered care

11. 11 Pain & symptom management comprehensive primary care to manage underlying conditions Aggressive treatment of acute exacerbation per patient and family request Facilitates transfer to hospice if appropriate Core Components of Palliative Care

12. 12 Palliative Care Models Hospital-based, Inpatient Palliative Care Programs Home-based Palliative Care

13. Inpatient Palliative Care (IPC) Consultative IPC service involves family meeting with patients/family Follow-up care as needed 13

14. Home-based Palliative Care Eligibility Diagnosis of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or cancer Life expectancy about 1 year Primary care physician “would not be surprised” if the patient died in the next year Palliative Care (PC) Multiple home visits provided by interdisciplinary palliative team Access to all usual medical care services

15. Palliative Care vs. Hospice Physicians not required to give a 6 month prognosis Patients do not have to forego curative care Palliative care physician coordinates care to prevent service fragmentation

16. National Use of Hospice Care (NHCPO, 2011, 2012)

17. Clinical and Economic Impact of Palliative Care

18. Inpatient Palliative Care Lower Costs of Care Lowered cost by $4855 (Gade, Venohr, Connor et al., 2008) More days in Hospice care (p=.04)

19. Fewer ICU Admissions at Readmission (IPC) (Gade, Venohr, Connor et al., 2008)

20. Other IPC Evidence (Morrison et al., 2008) Comparison Group Study IPC patients discharged had savings of $1696 in direct costs per admission (p=.004) $279 in direct costs per day (p<.001) IPC patients who died had savings of $4908 in direct costs per admission (p=.003) $374 in direct costs per day (p<.001)

21. The Economic and Clinical Impact of IPC Mean daily costs for IPC patients  33% (p<.01) pre- to post-intervention  14.5% compared to usual care (p<.01) LOS  30% Pain  by 86% Dyspnea  by 64% (Ciemins(Ciemins, Blum, Nunley, Lasher, Newman, 2007).BlumNunleyLasherNewman, 2007)

22. Home-based PC: Patient Satisfaction Brumley, Enguidanos, Jamison et al., 2007 p=.02

23. 23 Home-based Palliative Care: Total Service Costs Adjusted costs of care for PC patients 32.6% less than UC Saves $7,551 (Brumley, Enguidanos, Jamison et al., 2007) p<.001 n=292

24. Brumley, Enguidanos, Jamison et al., 2007 Home-based Palliative Care: Patient Acute Care Service Use (n=297) * P<.01

25. Home-based Palliative Care Patient Unadjusted Medical Service Use (n=297) * P<.01 Brumley, Enguidanos, Jamison et al., 2007

26. 30-Day Readmission among Seriously Ill Older Adults: Why Do They Come Back?

27. Readmission Rates among IPC Patients Among IPC patients discharged, overall readmission rate = 10% Overall hospital readmission = 15% Reduced readmission by 1/3 Enguidanos, Vesper, & Lorenz (2012). 30 day readmissions among Seriously Ill Older Adults. Journal of Palliative Medicine, 1-6.

28. Type of Care at Discharge (n=408) (Enguidanos et al., 2012)

29. Readmission Rate by Post Discharge Service Use (Enguidanos et al., 2012)

30. Predictors of 30 Day Readmit No Advance Directive 2.7x’s more likely Nursing Facility 5x’s & Home (no care) 3.7x’s more likely As compared to discharge to Hospice & HBPC Enguidanos, Vesper, & Lorenz (2012). 30 day readmissions among Seriously Ill Older Adults. Journal of Palliative Medicine, 1-6. Examined age, gender, ethnicity, marital status, pain, diagnosis, # chronic conditions, anxiety, ADs, and their association with 30 day readmit Added discharge disposition to the model

31. Interviews with Seriously Ill 30-Day Readmits (n=10) CHF & Cancer Patients Three themes identified: 1. Lack of Support & Purpose 2. Rehospitalization as appropriate care 3. Lack of access to care/information

32. Theme: Lack of Support & Purpose Lack of support & purpose Living alone and lack of support “I wasn’t cooking for myself, I wasn’t doing anything…I just wasn’t eating” “It’s just a matter of me …motivating me” “If there was something I could look forward to…”

33. Theme: Appropriate Care Hospital care most appropriate for medical condition and treatment preferences “ I get to retaining the fluids again and then right back to where we were [hospital]” Preference for aggressive care “ I ain’t going nowhere, and I’m fighting”

34. Theme: Lack of access to care/information “I should be comfortable. I shouldn’t have to go, ‘Oh, I got pain I need pain meds.’ I shouldn’t be going after pain medication…I was told I should come back to the ER to get my pain medicine.” “Sometimes I have questions” “I could have REALLY used a hospital bed” Inability to physically transport spouse to specialist appt

35. Discussion Limited access to holistic care Enrollment in hospice and palliative care have clear benefits, but problems getting there Late referrals to hospice Limited number of home-based palliative care Most IPC referrals are late in the disease trajectory Too late to change the course of care or improve quality

36. Discussion Lack of continuity problematic: Quality of life Most people prefer to die at home. Late transfers increase odds of death in hospital (Gonzalo, 2011). Care may not be consistent with wishes.

37. Getting Started

38. Building a Palliative Care Program 1.Making the Case for Palliative Care 2.Designing a Palliative Care Program 3.Financing a Palliative Care Program 4.Implementing a Palliative Care Program 5.Measuring Quality & Impact of Palliative Care Programs Source: Center to Advance Palliative Care www.capc.org

39. Making the Case: Benefits to Hospitals Lower costs for hospitals and payers A systematic approach to caring for outlier patients Flexible programs support the primary care physician Meeting JCAHO Accreditation Standards Easing burdens on staff and increasing staff retention Meeting the needs of an aging population Source: Center to Advance Palliative Care

40. Components Needed for Success Strong Support from Administration Gather internal/external evidence Program Champion ID within or locate (eg, AAHPM Membership) Palliative Care Training and Mentoring CAPC, national leaders (eg, von Gunten) Clarity Clearly identified goals/mission Visibility Case finding, presentations, etc. Source: Davis, Jamison, Brumley, & Enguidanos, 2006