Transcript Kaiser Permanente Special Needs Program 2007 Talking Points

Home Based Palliative Care
Richard D. Brumley, MD
Gretchen Phillips, MSW
Kaiser Permanente
Downey, CA
Practice Change Fellows
January 24, 2008
Palliative Care Across the Continuum
Outpatient
Inpatient
Extended Care
Home-Based
Primary Care
Physician
Palliative Care
Consultation Team
Home Health
Palliative Care
Subspecialist
Physician
Hospitalist
Physicians
Extended Care
Facility
Hospice
Population
Care Manager
Discharge
Planners
Geriatric
Assessment
Clinic
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Challenges to Provide
End-of-Life Care
 Curative/Restorative
Care vs. Palliative Care
 Acute Care vs. Chronic Care
 Hospital Care vs. Home based Care
 Reduce care to Reduce cost vs. Improve care &
Reduce cost
 One percent of our members create over 30% of our
costs
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 53
years old
 COPD - 30 years
 Multiple Sclerosis - 20
years
 Chronic Stage III decub
 66 pounds
 Full Code
Used with written permission
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Usual Care
02/02 to 01/03


12 acute admissions
 63 days
 2 intubations
 22 different physicians
admitted/discharged
14 home health
admissions
 focus on decub care
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Core Components of
Palliative Care
 Patient
and family unit of care
 Interdisciplinary team directs/provides care
 Physician, Nurse, Social Worker
 Aide, Chaplain, Volunteer
 Home care emphasized
 all providers make home visits
 Plan of care - coordinated and supportive
services
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Core Components of
Palliative Care Cont.
 Physical,
medical, psychological, social and
spiritual needs
 Pain and symptom management
 comprehensive primary care to manage
underlying conditions
 aggressive treatment of acute exacerbation
per patient and family request
 24 hour phone support, visits if necessary
 Volunteer support & Bereavement services
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Palliative Care Admission Criteria
 CHF,
COPD, Cancer, or meet Hospice criteria for
disease and don’t want to be on hospice program
 Expected prognosis <12 months
 Deteriorating medical condition at risk for needing
symptom management
 Primary Care Provider when necessary
 Emphasis of care in the home setting
 1-2 or more ED or Inpatient admissions in the last
year
 Palliative Performance Scale < 5 (mainly sit or lie,
unable to do any work, extensive disease,
considerable assistance necessary with self-care)
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Palliative Care Case Load
 60-70
patients average daily census
 Staffing
 0.8 Physician
 4 Nurses
 2 Social Workers
 2 Home Health Aides
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Home Based PC Results
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298 patients, multi-site RCT
Pts home-bound w/ Cancer, COPD, CHF
ALOS 200 days
Compared to usual care:
 Pt/family satisfaction at 60 days and thereafter
PC patients more likely to die at home (51% UC vs. 71%
PC)
 Hospital admissions (36% vs. 59%)
 ER visits (20% vs. 32%)
Decreased (32.6%) utilization and costs
Total costs $20,221 usual care vs. $12,613 PC (p=.001)
Total cost avoidance = $7,552/patient
Average cost/day $213 UC vs. $133 PC
Patients transfer to Hospice when appropriate
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Home Health Referrals diverted to
Hospice and Palliative Care



Review of 70 referrals for 3 day period
20% possibly appropriate for H or PC
Age of Patients with Possible Referral
36 – 45 years old
46 – 55
56 – 65
66 – 75
76 – 85
86 – 95
1 referral
1
0
3
6
2
8%
8
0
23
46
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TriCentral, February, 2004
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Hospice & Palliative Care
Utilization
 12%
of H patients switched to PC
 7% of PC patients switched to H
 3% switched back and forth several times
 3% of patients who qualified for H wanted to
be on PC
Snapshot TriCentral May, 2005
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Hospice vs. Palliative Care
Patient Distribution
60
50
40
30
Hospice
Palliative Care
20
10
0
er
c
n
Ca
F
PD
H
C
O
C
TriCentral May, 2005
ia
er
t
h
uro
n
t
e
O
N
me
e
D
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Hospice and Palliative Care Deaths
vs. Usual Care Deaths
Bellflower Medical Center 2005
Deaths
400
H and PC
350
300
250
BF
Total
200
150
100
on
ar
y
D
33
em
%
en
tia
27
%
N
eu
ro
21
%
R
en
al
25
H
%
ep
at
ic
27
%
A
O
D
M
Pn
0%
eu
m
on
ia
0%
13
%
Pu
lm
ar
di
ac
C
C
an
ce
r
46
%
50
0
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Palliative Care
Replication Challenges
 Who
is the champion?
 Justify new program within constraints of current
budget climate
 Marketing
 What End-of-Life “infrastructure” is in place?
 Hospice, Bio Ethics Committee, Advance
Care Plans, Physician comfort/communication
with EOL care
 Late referrals
 Integration within the Continuum of Care
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Palliative Care References
Your Guide to Creating an Outpatient
Palliative Care Program
Open Society Institute
Project on Death in America
http://growthhouse.org/palliative/
Brumley, R., Enguidanos, S., et al, (2007)
“Increased Satisfaction with Care and Lower
Costs: Results of a Randomized Trial of In-Home
Palliative Care.” Journal of the American Geriatrics
Society, Volume 55, 2007, 993-1000
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Palliative Care
02/03 to 12/03
Usual Care
02/02 to 01/03


12 acute admissions
 63 days
 2 intubations
 22 different physicians
admitted/discharged
14 home health
admissions
 focus on decub care


No acute admissions
Palliative Care Team
 developed plan of care
for relief of dyspnea
 caregiver support
 consistent palliative
care team
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Life is a Journey
Live Long – Thrive – Die Well
 Engage
patients and
families in discussion
about goals of care
 Discuss likely course
of disease
 Honor patient
preferences
 Increase patient,
family, physician and
staff satisfaction with
care
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