1. Evolution & Maturation of the Practice of Hospice and Palliative Medicine Charles F. von Gunten, MD, PhD May 16, 2013 Vice President, Medical Affairs Hospice & Palliative Care

2. Value Equation Value Quality Cost =

3. ‘Excellent’ Quality of Care Teno et al JAMA 2004;291:88-93 percent

4. Outcomes in Last Place of Care Teno et al JAMA 2004;291:88-93 n = 1578 percent

5. Cost Significant Savings with Hospice Care as compared with no hospice care. – 1-7 days; $2,650 – 8-14 days: $5,040 – 15-30 days: $6,340 – 53-105 days: $2,561 Kelley AS et al Health Affairs 2013;552:561.

6. Inescapable conclusion Referral for hospice care is expected outcome when death is expected. Quality measure End of ‘choice’ for hospice care Analogy of hand-washing

7. 90% of Americans die of Diseases of ‘chronic illness’ Heart Failure Cancer Emphysema / COPD Stroke Dementia Diabetes mellitus

8. England vs US Convergent Evolution Inpatient Unit Inpatient Unit Home care teams Home care teams Consultation Services Consultation ServicesHospitalAmbulatory Formal training & recognition Formal training & recognition Health System Standards Health System Standards Home Care Teams Home Care Teams Inpatient Units Inpatient Units Consultation Services Consultation ServicesHospitalAmbulatory Formal training & recognition Formal training & recognition Health System Standards Health System Standards

9. Conventional Care PresentationPresentationDeathDeath Anti-disease Therapy Bereavement Care 6m6m Hospice Care

10. Conventional Care PresentationPresentationDeathDeath Anti-disease Therapy Bereavement Care 6m6m Palliative Care

11. Therapies to modify disease Hospice Medicare Benefit Presentation Therapies to relieve suffering and/or improve quality of life Bereavement Care 6mDeath

12. Palliative Care

13. Std + Palliative Care = 3 Prolonged life 3 months 2010

14. Benefits of Early Palliative Cancer Care Survival Longer Better Understanding prognosis Goals of care Less IV chemo in last 60 days  Quality of Life Improved mood

15. ASCO Recommends… Concurrent palliative care for seriously ill cancer patients – from the beginning 2012

16. Clinical Palliative Care ConsultationServicesConsultationServices InpatientCareInpatientCare HospiceHospice Ambulatory & Home Health Ambulatory SNFSNF

17. Not-for-profit, faith-based health system West Ohio Conference of United Methodist Church 18,000 staff 2,800 physicians 3,000 volunteers 10 hospitals (member and managed) +30+ sites +124,000+ effective occupancy cases (inpatient admissions and observation stays) +393,000 ED visits +1.8 million outpatient visits (excluding Emergency Department) +$2.4B in net revenue OhioHealth © OhioHealth Inc. April 2013. All rights reserved. CONFIDENTIAL.

18. OhioHealth Locations Coverage 40 county market area serving 3.5M people © OhioHealth Inc. April 2013. All rights reserved. CONFIDENTIAL.

19. 19 Barriers Hospices Palliative Care Clinicians Religious (Magical) Thinking Consumerism Current Reward System

20. 20 Take Home Messages Palliative Medicine delivers on the value equation: improved quality; reduced cost. Hospice care is an expected part of comprehensive care – No more talk of ‘choice’ Specialist Palliative care teams bring innovations into rest of health care. – Generalist care changes