Transcript Palliative Care in the Nursing Home

Transformational Palliative
Care:
Matching What We Do To Our
Patient’s Needs
Diane E. Meier, MD
Department of Geriatrics and Palliative Medicine
Icahn School of Medicine at Mount Sinai
Director, Center to Advance Palliative Care
[email protected]
www.capc.org
www.getpalliativecare.org
No Disclosures
Objectives
• The case for palliative medicine
• What works to improve quality and reduce
costs for vulnerable populations?
• Limitations of our taxonomy and
professional tribalism
• How to face outwards towards needs of:
– Our patients, their families
– Policy makers, payers, health system
leadership
Concentration of Spending
Distribution of Total Medicare Beneficiaries and Spending, 2011
37%
90%
63%
Average per capita
Medicare spending
(FFS only): $8,554
Average per capita
Medicare spending
among top 10%
(FFS only): $48,220
10%
Total Number of FFS Beneficiaries:
37.5 million
Total Medicare Spending:
$417 billion
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, 2011.
Because of the Concentration
of Risk and Spending,
Palliative Care Principles and
Practices are Central to
Improving Quality and
Reducing Cost
Mr.B
•
•
•
•
An 88 year old man with mild
dementia admitted via the ED for
management of back pain due
to spinal stenosis and arthritis.
Pain is 8/10 on admission, for
which he is taking 5 gm of
acetaminophen/day.
Admitted 3 times in 2 months
for pain (2x), weight loss+falls,
and altered mental status due
to constipation.
His family (83 year old wife) is
overwhelmed.
Mr. B:
•
•
Mr. B: “Don’t take me to the
hospital! Please!”
Mrs. B: “He hates being in the
hospital, but what could I do?
The pain was terrible and I
couldn’t reach the doctor. I
couldn’t even move him myself,
so I called the ambulance. It
was the only thing I could do.”
Modified from and with thanks to Dave Casarett
Concentration of Risk
• Functional Limitation
• Dementia
• Frailty
• Serious illness(es)
Most of Costliest 5% have
Functional Limitations
http://www.cahpf.org/docuserfiles/georgetown_trnsfrming_care.pdf
The Modern Death Ritual:
The Emergency Department
Half of older Americans visited
ED in last month of life and 75%
did so in their last 6 months of
life.
Smith AK et al. Health Affairs 2012;31:1277-85.
Dementia Drives
Utilization
Prospective
Cohort of
community
dwelling older
adults
Dementia
No Dementia
Medicare SNF use
44.7%
11.4%
Medicaid NH use
21%
1.4%
Hospital use
76.2%
51.2%
Home health use
55.7%
27.3%
Transitions
11.2
3.8
Callahan et al. JAGS 2012;60:81320.
Dementia and Total Spend
• 2010: $215 billion/yr
• By comparison: heart disease
$102 billion; cancer $77 billion
• 2040 estimates> $375 billion/yr
Hurd MD et al. NEJM 2013;368:1326-34.
In case you are not already worried…
The Future of Dementia Hospitalizations
and Long Term Services+Supports
10 fold growth in dementia related
hospitalizations projected between 2000 and
2050 to >7 million.
Zilberberg and Tija. Arch Int Med 2011;171:1850.
3 fold increase in need for formal LTSS
between now and 2050, from 9 to 27 million.
Lynn and Satyarthi. Arch Int Med 2011;171:1852.
Why? Low Ratio of Social to Health Service
Expenditures in U.S.
for Organization for Economic Co-operation and Development (OECD) countries, 2005.
Bradley E H et al. BMJ Qual Saf 2011;20:826-831
Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.
Surprise! Home and Community
Based Services are High Value
• Improves quality: Staying home is
concordant with people’s goals.
• Reduces spending: Based on 25
State reports, costs of Home and
Community Based LTC Services
less than 1/3rd the cost of Nursing
Home care.
This Requires Expertise
• Highest risk, highest cost
•
population are those with
functional limitation, frailty,
cognitive impairment +/- serious
illness(es)
What are our roles in improving
care of this population?
What is Palliative Care?
• Specialized medical care for people with serious illness
and their families
• Focused on improving quality of life as defined by
patients and families.
• Provided by an interdisciplinary team that works with
patients, families, and other healthcare professionals to
provide an added layer of support.
• Appropriate at any age, for any diagnosis, at any stage in
a serious illness, and provided together with curative and
life-prolonging treatments.
Definition from public opinion survey conducted by ACS CAN and CAPC
http://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinionresearch/2011-public-opinion-research-on-palliative-care.pdf
Conceptual Shift for Palliative Care:
Both-And, not Either-Or
Life Prolonging Care
Life Prolonging
Care
Medicare
Hospice
Benefit
Hospice Care
Old
New
Palliative Care
Dx
Death
18
Palliative Care Models
Improve Value
Quality improves
–
–
–
–
–
Symptoms
Quality of life
Length of life
Family satisfaction
Family bereavement
outcomes
– MD satisfaction
– Care matched to
patient centered goals
Costs reduced
– Hospital costs
decrease
– Need for hospital, ICU,
ED decreased
– 30 day readmissions
decreased
– Hospitality mortality
decreased
– Labs, imaging,
pharmaceuticals
reduced
RESOURCES
Key Characteristics of Effective
Models 1: Targeting
Demand Management
DM/CM
NEEDS
CCM-palliative care
Jones et al. JAGS 2004;52
Gómez-Batiste X, et al. BMJ Supportive & Palliative Care 2012;0:1–9. doi:10.1136/bmjspcare-2012-000211
Targeting on the Front Lines
Ask yourself:
• Does this patient have an advanced long term
condition or a new dx of a serious illness or both?
• Would you be surprised if this patient died in the
next 12 months?
• Does this patient have decreased function,
progressive weight loss, >= 2 unplanned
admissions in last 12 months, live in a NH or AL,
or need help at home?
• Does this patient have advanced cancer or heart,
lung, kidney, liver, or cognitive failure?
Key Characteristic 2:
Goal Setting
• “Don’t ask what’s the matter with me; ask
what matters to me!”
• Ask the person and family, “What is most
important to you?”
• “Ultimately, good medicine is about doing right for the
patient. For patients with multiple conditions, severe
disability, or limited life expectancy, any accounting of
how well we’re succeeding in providing care must
above all consider patients’ preferred outcomes.”
Reuben and Tinetti NEJM
2012;366:777-9.
Priorities for Care
Survey of Senior Center and AL subjects, n=357,
dementia excluded, no data on function
Asked to rank order what’s most
important:
Overall, independence ranked
highest (76% rank it most important)
followed by pain and symptom relief,
with staying alive last.
Fried et al. Arch Int Med 2011;171:1854
Recent E-mail from a
Geriatrician
“I have a particular interest in goals of care and
how best to convey this dialogue across the
continuum. For the last 18 months I have
spearheaded the Community Based Care
Transitions Program in New Haven….Many of the
readmissions are related to unaddressed palliative
care needs (surprise surprise)…I’m interested in
how we can develop policies to ensure
providers are discussing goals of care and not
just a menu of possible interventions.”
Impact of Goal Setting through
Advance Care Planning
• Prospective data on >3000 Medicare beneficiaries
1998-2007 (linked HRS, claims, and NDI)
• Advance directives associated with
lower Medicare spending, lower
hospital death rate, and higher
hospice use in medium-high
Medicare spending regions of the
U.S.
Nicholas et al. JAMA 2011;306:1447-53.
Key Characteristic 3:
Can We Deliver on People’s Goals? Not When
Families are Home Alone
• 40 billion hours unpaid
care/yr by 42 million
caregivers worth $450
billion/yr
• Providing “skilled” care
• Increased
morbidity/mortality/ban
kruptcy
aarp.org/ppi
http://www.nextstepincare.org/
Optimistic Baby Boomers say
“Get Ready, Kids!”
70% of those who have never received
long term care believe they can rely
solely on family in time of need as they
age.
The Scan Foundation/NORC/AP April 2013
To.pbs.org/15TQh2B http://www.apnorc.org/projects/Pages/long-term-care-perceptionsexperiences-and-attitudes-among-americans-40-or-older.aspx
Families Need Help if We Are
to Honor People’s Goals
• Mobilizing long term services and supports
is key to helping people stay home and out
of hospitals.
• Predictors of model success: 24/7 phone
access; high-touch consistent and
personalized care relationships; focus on
social and behavioral health determinants;
coordinated integration of social supports
with medical services.
Payers Are Already Bringing the
Care Home
www.theatlantic.com 02.25.13 MA Full Risk PMPM contract with
HealthCare Partners/DaVita 15%+margin. >700K patients“Now
instead of 30-40 patients/day, Dr. Dougher sees 68.”
Key Characteristic 4:
Pain and Symptoms –
Disabling pain and other symptoms reduce independence
and quality of life.
HRS- representative sample of 4703 community dwelling older adults
1994-2006
Pain of moderate or greater severity that is
”often troubling” is reported by 46% of older
adults in their last 4 months of life and is
worst among those with arthritis.
Smith AK et al. Ann Intern Med 2010;153:563-569
It’s Not Only Pain:
Symptom Burden of Community Dwelling
Older Adults with Serious Illness
100
*75% or more reported symptom as
Percent of patients reporting
symptom
90
80
70
60
50
40
*
*
bothersome
*
*
*
*
*
30
20
10
Lt
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Ac
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t
Fa y
ti
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SO
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ck
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Walke L et al, JPSM, 2006
Key Characteristic 5:
Dynamic Nature of Risk
• Early advance care planning + communication on
what to expect + treatment options + access.
• As illness progresses, ability to titrate dose intensity
of services.
Morrison and Meier. N Engl J Med 2004;350(25):2582-90.
Taxonomies and Their
Discontents
• Balkanized health system: Hospital, office,
NH, AL, home, PACE, LTACH, hospice…
• Balkanized disciplines: IM, FM, geriatrics,
palliative care, cardiology, oncology,
nephrology, CCM, hospitalists, SNFists…
• Lots of evidence-based “best practices”
based on small scale programs.
• Competitive, struggling, isolated,
ineffective at meeting population needs.
We Are Confusing Our
Audiences
-Policy makers and payers and hospitals
and health systems are asking: Who has
the best impact on LOS? On 30 day
readmissions? On hospital mortality? On
HCAHPS? On total (payer) spend? For which
patient population? In which settings? Does
anyone pay for this? How can I believe your cost
avoidance arguments? How do I choose?
-Patients and families: HELP!!
What to Do? Implement, Scale
• Our challenge is broad implementation of
what’s already been shown to work in
small scale programs.
• Scaling and diffusion of innovation via
technical assistance, training, and social
marketing.
• Be at the table or be on the menu: Drive
policy change
What do systems, payers, colleagues and
people and their families need?
1. Clear, Simple Technical Assistance
for
– System integration design
– Model(s) selection and matching to
population needs
– Implementation, quality, and
standardization
– Risk stratification and targeting
– Evaluation
Move Inpatients
Through the System
Safely and Efficiently:
Keep some
patients with
acute illness
out of the
hospital:
Hospital at
Home
www.medic.org
ACE/HELP
NICHE
Palliative Care
Care
Management
Provide patientcentered,
coordinated
care: PCMH
(GRACE,
Guided Care),
Medical house
calls, ACOs
Prevent
Readmission:
Care
Transitions
Programs
What do systems, payers, colleagues and
people and their families need?
2. Workforce Training
• Not even close to enough clinicians with
specialty training to meet the needs
• Therefore, our role is to:
– Train generalists and help communities to
step up
– Provide subspecialty consultation for the
most complex
– Improve evidence base through research
What do systems, payers, colleagues and
people and their families need?
3. Public and constituency
awareness through social
marketing and PR: We need to
create a positive public vision of the
good to drive demand and access
and to help leaders to know about,
and then implement models.
Treating the person beyond the disease.
Transforming 21st Century Care of
Serious Illness
Gomez-Batiste et al.2012
Change from:
Change to:
Terminal ……………………………………Advanced Chronic
Prognosis weeks-month…………………..Prognosis months to years
Cancer ……………………………………..All chronic progressive diseases
Disease……………………………………..Condition (frailty, fn’l dep, MCC)
Mortality…………………………………….Prevalence
Cure vs. Care………………………………Synchronous shared care
Disease OR palliation……………………..Disease AND palliation
Prognosis as criterion……………………..Need as criterion
Reactive…………………………………….Screening, Preventive
Specialist……………………………………Palliative/Geriatric Care
Everywhere
Institutional………………………………….Community
No regional planning……………………….Public health approach
Fragmented care……………………………Integrated care
(Present) and Future
“The future is
here now. It’s just
not very evenly
distributed.”
William Gibson
The Economist, 2003
Upcoming Audioconference
Building the Future of Home-Based
Palliative Care
•Thursday September 19, 2013
•1:30 – 2:30 PM EST
•https://www.capc.org/products/audioconferences/2013-09-19/
•Learn from a CMS Innovation Grantee on
integration of home palliative care within a
Home Health Agency
National Seminar Nov. 7- 9 in Dallas:
Palliative Care Across the Continuum
• http://www.capc.org/capc-resources/capcseminars/dallas-2013/seminar-overview
• Early bird rate until September 25.
• Highly interactive seminar presenting
best practices from front-line
innovators in care of the sickest and
costliest 5% of patients.