Transcript Slide 1
Moving Palliative Care
Upstream
David E. Weissman, MD
Professor Emeritus
Medical College of Wisconsin
Consultant, Center to Advance Palliative Care
Objectives
• List three benefits of integrating palliative care principles
early into the course of chronic disease management.
• Describe three new models of palliative care service
delivery that seek to engage patients early in the disease
course.
• Characterize national efforts to impact health care policy
concordant with palliative care principles.
Historical Perspective
• Phase I Hospice
1970s-80s
• Phase 2 Palliative Care
1990s-2000s
• Phase 3 Spread
2010s-
The past 10 years
Not where we used to be…
St. John Providence Health System
Palliative Care
• Specialized medical care for people with
chronic and/or serious illness
• Focused on providing relief from the symptoms,
pain and stress of an illness with equal attention
to emotional and spiritual well-being
• Delivered by a multidisciplinary team to provide
an extra layer of support
• Care continues to be provided by PCP
• Can be provided at the same time as curative
treatment
The Palliative Care Intervention
• Interdisciplinary teams
– Patient-centered goals of care discussion
• Realistic prognostication
– Pain and symptom relief
– Disposition planning reflecting patient goals
– Patient/Family support
– Bereavement support
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Key Palliative Care Outcomes
– Reduced ICU length of stay
– Rapid symptom relief
– Earlier referral to hospice services-longer
– Greater patient/family satisfaction
– Lower hospital cost
– Prolonged survival (outpatient intervention)
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Program vs. Team
• Palliative Care Team
– Provides clinical services
• Palliative Care Program
– Clinical services
– Outcome/Value measurement
– Education
– Quality Improvement
– Systems integration
Standards and Certification
• Joint Commission Certification (2011)
• NQF Palliative Care Care Standards (2012)
• Commission on Cancer requirement, Cancer
Center Accreditation (2011)
• Board Certification, Hospice and Palliative
Medicine
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Physicians
Nurses: AP, RN, LPN
Social workers
Chaplains (pending)
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What is left to accomplish?
• In hospitals, at best, only 25-50% of palliative
care needs are being met.
– Variable penetration to areas of highest need:
• ICUs, ED, Oncology, Neurology, Renal
• Between hospitals and hospice there is a large
gap of palliative care needs across the
Continuum of health care.
– Outpatient services
– Long-term and Home care
– Home care
Hospitals
• Not all hospitals have consult services
• Those that do are typically overworked
– High rate of stress/burnout
– Many “martyrs”
– Adding more staff is problematic
• More staff leads to more consults
The Referral Conundrum
• Consults predominantly occur based on
clinician values, rather than patient needs
– Clinician values/attitudes inhibit provision of
excellent palliative care services
• My patient isn’t ready; my patient is not dying
• I’m not ready for palliative care
• I will not give up on my patient
• Education alone will not fix this problem.
Reality Check
• There will never be enough palliative care
specialists (all disciplines) to meet the
demand.
• Overall health care dollars will be
shrinking.
Solutions
1. Increase team efficiency: Accountability
and Value
2. New team models
3. Integrate palliative care principles into
high-risk locations
4. Identify unmet needs
5. Expand Generalist Palliative Care
6. Improve care across the continuum
1. Increase Team Efficiency
• Close examination of the process of care
delivery
– Staff time studies
– Determine cost/case
– Use metrics to determine efficiency and value
2. New Team Models
• “Counselor” Model
– Med Center Central Georgia/UMDNJ
• Staff
– Specially trained communication “counselors”
(Nursing, Mental health background)
• Intervention
– Manage most goal of care discussions
– Work in both parallel and series with PC team
3. Integration Projects
• Efforts to broaden the spread of palliative
care principles into locations of high unmet
needs, through …
– setting collaborative goals
– early patient identification (triggers)
– systems change to guide right care at right
time—routine family meetings
– quality improvement-data driven change
Models for Structuring
an ICU Palliative Care Initiative
Nelson, et al. CCM 2010; 38:1765.
Consultative Model
Integrative Model
Palliative Care Team
Palliative Care
Consultation
Palliative Care
Principles/Interventions
Embedded in
Usual ICU Care
Usual ICU Care
by Critical Care Team
Copyright 2010 Center to Advance Palliative Care. Reproduction by permission only.
www.capc.org/ipal
4. Find the Unmet Needs
A patient-centered approach would be to
design a system where palliative care
interventions are based on patient and/or
disease factors, rather than clinician
attitudes/values.
Patients are fully informed about treatment options.
Patients have equal access to all hospital resources.
Patients receive only the life-sustaining treatments
they desire/are appropriate to their medical
condition/prognosis.
Common trigger systems
• ICU
Length of stay
Multi-organ failure
Metastatic cancer
Prolonged unconsciousness
Nursing home admission
• Emergency department
• Oncology clinic
• Special populations
– LVAD/CHF
– Nursing home admits
– PEG or trach consideration
Primary Palliative Care Triggers
On Admission
A potentially life-limiting or life threatening
condition AND one of the following…
The ‘Surprise’ question
Frequent admissions
Difficult to manage symptoms
Complex care requirements
Decline in function or weight
Weissman DE and Meier DE. Identifying patients in need of a palliative care
assessment in the hospital setting: consensus recommendations. J Pall
Med 2011;14:1-7
Primary Palliative Care Triggers
Daily Checklist
The ‘Surprise’ question
Difficult to control symptoms
ICU LOS > 1 week
Lack of Goals of Care documentation
Disagreement/uncertainty re:
– Major medical decisions
– Resuscitation preferences
– Use of non-oral feeling/hydration
Weissman DE and Meier DE. Identifying patients in need of a palliative care
assessment in the hospital setting: consensus recommendations. J Pall Med
2011;14:1-7
5. Generalist Pall. Care
Need to imbed Palliative Care principles into
the system of health care delivery
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Commitment: time/$
Assessment: case finding—all patient screen
Responsibility: QI
Education: all clinical staff
Standards: who/what/when
Primary/Specialty Care
• Primary Pall Care: all clinicians
– Routine communication/symptom control
• Specialty Pall Care
– Family meetings—esp. “difficult cases”
– Complex symptom management
– Time management
– Support for difficult decisions
6. Move into the Continuum
• Outpatient Palliative Care
Free-standing
Co-management clinics: oncology, other
Home visits
IPAL-OP (2012)
• Long Term Care
Dedicated Pall Care staff
Geriatric NP model
Consultative external team
What else is new?
The Joint Commission
The Joint Commission:
Palliative Care Advanced Certification Program
http://www.jointcommission.org/certification/palliative
_care.aspx
HEALTH REFORM
Palliative Care is Central to the
Success of Health Reform
• >95% of all health care spending is for the
chronically ill
• 64% of all Medicare spending goes to the 10%
of beneficiaries with 5 or more chronic
conditions
• Despite high spending, evidence of poor quality
of care
Palliative Care, Health Reform
and Chronic Disease Care
• Health reform initiatives
– Reduce readmissions
– Reduce cost
– Improve quality/Reduce variation
– Shift chronic disease care out of the hospital
– Care coordination/Bundling/ACOs
Palliative Care services/outcomes are perfectly
aligned with all these priorities!
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Payers are getting into Palliative Care
What can you do?
1. Seek information:
– What health reform initiatives are your
administrators concerned about?
– What committees are working on health
reform topics?
2. Offer to participate; share information on
palliative care role/impact
– Mortality and readmission reduction
– Cost control
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What can you do?
3. Push for collaborative initiatives
– ICU/ED/Cardiology/Cancer/Hospitalists
– Focus on improving generalist palliative care
rather than striving for more consults
4. Remind everyone about the 50%!
– Seek opportunities identify patients with
unmet needs
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What can you do?
5. Push the professionalism of HPM
– Get yourself certified
– Get your hospital to be Joint Commission
certified
– Share the NQF Palliative Care Quality
Measures
– Submit your data to the National Palliative
Care Registry
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What can you do?
6. Take care of yourself and your program
– Recognize Palliative Care martyrdom
– Pay attention to team health/function
– Balance consults with other Program work
7. Share your successes
– CAPC Annual Seminar—Oral
presentation/poster
– Share your tools with others
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Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.
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• www.capc.org