1. The Evolving Role of Palliative Care in the Health Care Continuum October 12, 2011 John E. Barkley, MD, FCCP Chief Medical Officer Post-Acute Care Services Carolinas HealthCare System

2. 2 Outline  Review the Current “Curative Model” of Care & Associated Outcomes  Learn Definitions of Palliative Care, Palliative Medicine & Hospice  Review clinical, economic, demographic data that serve as the basis for need of Palliative Care across the continuum  Learn current national standards for quality Palliative Care  Review impact of Palliative Care in select patient populations

3. Current State 3

4. 4 Diagnosis of Life Threatening Illness Death Cure/Control/Restore/Rehabilitate Hospice “Curative” Model Palliative care begins

5. Slide 5 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 6 30 MONTHS

6. 6 Patients are Suffering  The SUPPORT Principal Investigators. JAMA 1995; 274: 1591-1598.  Desbiens NA et al. Crit Care Med 1996; 24:1953-1961.  Singer et al. JAMA 1999;281(2):163-168.  Somogyi-Zalud E et al. JAGS 2000; 48:S140-145.  Nelson & Danis. Crit Care Med 2001; 29(2): N2-N9.  Nelson JE et al. Crit Care Med 2004; 32:1527-1534.  Nelson JE et al. Arch Intern Med 2006; 166:1993-1999.

7. 7 Caregivers are Suffering  Tolle et al. Oregon report card. 1999 www.ohsu.edu/ethics  Emanuel et al. Ann Intern Med 2000;132:451.  Steinhauser et al. JAMA 2000;284:2476-82.  Lee et al. Am J Prev Med 2003;24:113.  Teno et al. JAMA 2004;291:88-93.  Wright et al. J Clin Oncol 2010;28:4457-64. DEATH: RR 1.8 if care giving >9 hrs/wk for ill spouse RR 1.6 among caregivers reporting emotional strain

8. Definitions 8

9. 9 Definitions 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

10. 10 …Definitions 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

11. 11 …Definitions  Palliative Medicine Practitioners Recognized by American Board of Medical Specialties – 2006 Major or sole clinical focus is the study and care of patients with: –Complex medical illness –Uncontrolled symptoms –Limited prognosis

12. 12 Definitions - Palliative Care vs. Hospice  Non-hospice palliative care Appropriate at any point in a serious illness Provided at the same time as life-prolonging treatment No prognostic requirement  Hospice Palliative care for the terminally ill Two physicians certify prognosis ≤ 6 months Medicare Part A “carve out”…give up traditional Medicare A & B coverage Must forgo “curative” treatments 12

13.  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 …Definitions

14. Imperatives for Palliative Care 14

15. 15 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) 7000 people age 65 per day

16. International Comparison of Spending on Health, 1980–2006 Average spending on health per capita ($US PPP) Total expenditures on health as percent of GDP Data: OECD Health Data June 2008

17. 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

18. Distribution of Total Medicare Beneficiaries and Spending, 2005 Total Number of FFS Beneficiaries: 37.5 million Total Medicare Spending: $265 billion Average per capita Medicare spending (FFS only): $7,064 Average per capita Medicare spending among top 10% (FFS only): $44,220 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, 2005.

19. Health Care Reform 19 Health Care Reform = Clinical Integration Clinical Integration = Care Coordination Across the Continuum

20. New “Rules of the Game”  Less $$$ not more  Value vs. Volume  “Zero Sum Game” Top quartile rewarded Bottom quartile pays the bill  Bundled/Grouped/Episode-specific payments

21. 21 Patient-Centered Care Continuum

22. National Recommendations for Quality Palliative Care 22

23. National Consensus Project & National Quality Forum  Foundational elements National definition & description of high quality comprehensive palliative care Resource for practitioners addressing palliative care needs of patients & families Educational framework & blueprint for structure and provision of palliative care

24. Eight Domains with 38 Preferred Practices 1.Structure and Process of Care 2.Physical Aspects of Care 3.Psychological and Psychiatric Aspects of Care 4.Social Aspects of Care 5.Spiritual, Religious and Existential Aspects of Care 6.Cultural Aspects of Care 7.Care of the Imminently Dying Patient 8.Ethical and Legal Aspects of Care

25. CAPC Consensus Panel Papers  Operational Features for Hospital Palliative Care Programs (2008)  Operational Metrics for Hospital Palliative Care Programs (2008)  Palliative Care Inpatient Unit Operational Metrics (2009)  Clinical Care & Customer Service Metrics (2010)  Identifying Patients in Need of a Palliative Care Assessment in the Hospital Setting (2011) Practical Road Maps to Follow

26. 26

27. 27

28. 28 = Primary Palliative Care = Secondary Palliative Care

29. Slide 29 Early integration of palliative care with intensive care for all ICU patients, regardless of prognosis, and their families, is a clinical practice guideline. –Selecky PA et al. Chest 2005;128:3599-610. (American College of Chest Physicians) –Lanken PN et al. Am J Respir Crit Care Med 2008;177:912-27. (American Thoracic Society) –Truog RD et al. Crit Care Med 2008;36:953-63. (American College of Critical Care Medicine). Critical Care

30. Slide 30 Outcomes of Palliative Care

31. 31 How Does Palliative Care Work?  Interdisciplinary team (MD, NP, RN, MSW, Pastoral Care, others) with patient-centered, family focused care approach Addresses physical symptoms and emotional suffering Clarifies goals of care with patients and families Helps patients & families select medical treatments and care settings that match their goals Improves patient-physician-family communication and decision-making Provides practical and emotional support for exhausted family caregivers Enhances transitions and continuity of care across settings 31 “Right Care, Right Time, Right Place”

32. 32 Temel JS et al. NEJM 2010; 363(8): 733-742.

33. Early PC + Oncology vs. Oncology  FACT-L 98.0 vs. 91.5 (p=.03)  Depression 16% vs. 38% (p=.01)  Resuscitation preferences documented 53% vs. 28% (p =.05)  “Aggressive Care” 33% vs. 54% (p =.05) 33 Temel JS et al. NEJM 2010; 363(8): 733-742.

34. 34 P =.02; HR 1.7 Median Survival 11.6 vs. 8.9

35. “Coping with Cancer” “Do you recall having a discussion with your treating MD about care preferences at EOL”  NCI funded study  7 outpatient sites from 2002-2008  638 patients with Advanced/Metastatic Cancer  37% reported having EOL discussions before baseline Wright, A.A. et al. JAMA, 2008; 300(14): 1665-1673. Zhang, B. et al. Arch Intern Med 2009; 169(5): 480-488. Mack, J.W. et al. J Clin Oncol 2010; 28(7): 1203-1208. Wright, A.A. et al. J Clin Oncol 2010; 28(29): 4457-4463.

36. “Coping with Cancer” Patient Impact  EOL discussions ≠ higher rates of major depressive disorder or more worry  68% received EOL care that was consistent with baseline preferences  Less likely to receive “aggressive care” Mechanical ventilation Attempted resuscitation ICU admission  QOL lowest and physical distress highest with more “aggressive care”  More enrolled in hospice & had longer LOS  No survival differences  “Aggressive care” resulted in 36% higher costs

37. “Coping With Cancer” Caregiver Impact  ICU or hospital deaths = psychiatric illness in bereaved caregivers  Worse QOL  More regret  Higher risk of a major depressive disorder 37

38. Live DischargesHospital Deaths CostsUsual Care Palliative Care Δ Usual Care Palliative Care Δ Per Day$830$666$174*$1,484$1,110$374* Per Admission$11,140$9,445$1,696**$22,674$17,765$4,908** Laboratory$1,227$803$424*$2,765$1,838$926* ICU$7,096$1,917$5,178*$14,542$7,929$7,776* Pharmacy$2,190$2,001$190$5,625$4,081$1,544*** Imaging$890$949($58)***$1,673$1,540$133 Died in ICUXXX18%4%14%* *P<.001**P<.01***P<.05 Arch Intern Med 2008; 168(16):1783-1790

39. 39 Health Affairs 2011; 30(3): 454-563

40. 40 Health Affairs 2011; 30(3): 454-563

41. 41 Health Affairs 2011; 30(3): 454-563

42. Hospital “X”  Consult Volume – 765  Length of Stay Mean Day of Consult – 7.4 Mean Days to Discharge- 6.3 Mean LOS – 13.7  Direct Variable Cost Savings - $1,865,146.00  Clinical Revenue - $110,847.00  HPCCR Invoices - $271,089.00  Net Cost Savings for Hospital “X” – $1,704,904.00  Net Savings/Case - $2229.00 ($354/day)

43. 43 Conceptual Shift from “Curative Model” Medicare Hospice Benefit Life Prolonging Care Old Palliative Care Bereavement Hospice Care Life Prolonging Care New DiagnosisDeath

44. How to Proceed?  System-based approach “Top down & bottom up” Development & full integration of Primary & Secondary PC into all care including chronic disease management programs 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. 44

45. Summary  Patient & Caregivers are suffering under current model  Many imperatives for Palliative Care making it an essential strategy going forward  National recommendations exist  Positive impact of Palliative Care well documented  Complete integration across the continuum requires: Top down + bottom up approach Development of Primary & Secondary Palliative Care Evidence-based practices QA/PI 45