1. SC Coalition for the Care of the Seriously Ill ( SC CSI) August 27, 2011 SCMA Board Retreat John C. Ropp, III, MD, Chairman, SC CSI

2. Outline Overview SC CSI Membership, Mission, Aims, and Activities ‘Mainstreaming’ Palliative Care Consider legislative strategy for 2012 (POLST) Feedback from SCMA Board October 12 Summit on Care of the Seriously Ill

3. SC Coalition for the Care of the Seriously Ill ( SC CSI) Founding Members: SCMA, SCHA, TCC, SC Healthcare Ethics Network, LifePoint, AARP, SC Nurses Association Mission: All persons in SC with serious, chronic, or terminal illnesses will have an active voice in the care decision process

4. 4 Almost 50% of U.S. population has at least one chronic medical condition, consuming 80% of healthcare resources – Hypertension is the most common chronic condition, with 50M+ people in the U.S. needing treatment for high blood pressure – 23M people have asthma, with economic costs projected at $20B in 2010 – 24M people have diabetes; one-fourth are unaware they have it Between 2005 and 2030, the number of Americans with chronic conditions will increase by almost 30% – 20% to 30% of all Americans are projected to have diabetes by 2050 Sources: Partnership for Solutions, John Hopkins University; Health Affairs, 26, no. 1 (2007): 142-153 Large and Growing Problem: People with Chronic Medical Conditions Number of People With Chronic Medical Conditions (in millions)

5. Source: G. Anderson and J. Horvath, Chronic Conditions: Making the Case for Ongoing Care. Baltimore, MD: Partnership for Solutions, December 2002. Medicare Beneficiaries - Chronic Conditions & Spending

6. Cancer vs. Non-Cancer Illness Trajectories to Death Cancer vs. Non-Cancer Illness Trajectories to Death Health Status Time Crises Death Decline Field & Cassel, 1997 Cancer End-organ disease 30 MONTHS

7. 4 Aims 1.Education/tools for healthcare professionals Toolkit with sample policies developed by physicians: C-ROS; Communication, Consent, Decision-making Process for Seriously Ill Inpatients Improve communication as patients transition across the continuum of care Identification of patient values, beliefs, and wishes regarding their own healthcare Best practices for honoring advance directives regardless of setting

8. 4 Aims 2. Education/tools for patients and communities Advance Directives Healthcare decision making Understanding their diagnosis and what they can do 3. Appropriate relationship-centered care in all settings Establish palliative care in all SC hospitals; expand palliative care training County-level mapping of resources for chronic, serious, terminal illnesses and make information accessible

9. 4 Aims 4. Policy/Advocacy-Legal & Regulatory Advocate for the alignment of requirements and policies related to the care and decision-making processes for the care of seriously, chronically, or terminally ill persons Consider feasibility of ‘durable DNR orders’ Consider POLST for SC (Physician Orders for Life- Sustaining Treatment Paradigm)

10. 10 ‘Mainstreaming’ Palliative Care Definition of Palliative Care: Interdisciplinary care that aims to relieve suffering and improve quality of life for patients with advanced illness, and their families. It is provided simultaneously with all other appropriate medical treatment. www.capc.org

11. Palliative care means patient and family- centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice. 73 FR 32204 - Medicare Hospice Conditions of Participation –Final Rule June 5, 2008

12. Palliative Care Primary palliative care: refers to the basic skills and competencies required of all physicians and other health care professionals. Secondary palliative care: refers to specialist clinicians that provide consultation and specialty care.

13. POLST: Physician Orders for Life- Sustaining Treatment Paradigm The national POLST Paradigm program is designed to improve the quality of care people receive at the end of life. It is based on “effective communication of patient wishes, documentation of medical orders and a promise by health care professionals to honor these wishes. “

14. When is POLST Appropriate? Terminal illness Advanced disease Prognoses is death within a year Debilitating chronic progressive illness

15. In the Emergency Department “Why is this patient here?” “What does this patient want?” “How aggressive should we be?” “Do I intubate the patient?” “Who is involved in this patient’s care?” “Who has authority to speak for this patient?” “What is the appropriate disposition?”

16. Developing Programs *As of January 2011 Endorsed Programs No Program (Contacts) Designation of POLST Paradigm Program status based on information available by the program to the Task Force. National POLST Paradigm Programs*

17. POLST History 1991 - Patient Self Determination Act 1991 - POLST form developed in Oregon 2002 - POST in West Virginia 2007 - MOST in North Carolina 2011-Chairperson of SC CSI becomes POLST contact for SC

18. How Advance Directives and POLST Work Together Adapted with permission from California POLST Education Program © January 2010 Coalition for Compassionate Care of California

19. An outcomes continuum: POLST Better informed consent + Patient’s documented wishes + Family consensus Patients’ wishes known & honored = + Portable MD orders = Satisfaction & communication Risk & Costs = = Hospice LOS = Hospital LOS = Pain management = Hospice & Palliative Care Utilization

20. POLST: Steps in the process  Needs assessment  Core working group  Task Force with reps from all stakeholders  Pilot Project  Legal Issues  Education/Training  Program Coordination  Distribution of form  Review Program Components and apply for endorsement  Media  Available Resources

21. POLST: Making it happen Legislation Policy Procedure Protocol Algorithm Education Application Process Improvement Data Collection

22. POLST ISSUES FOR SC Access to POLST forms (24/7 access to a registry would be ideal) Legislation needed if POLST to be used as a physician order Messaging important—honoring patient wishes not cost containment Roper to start demonstration project next month

23. Discussion/feedback Reminder: Join us on October 12 in the SCMA Board Room for the Summit on the Care of the Seriously Ill