Metrics That Matter

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26 February 2016

Session Objectives

At the end of this session, you will be able to

1. Identify core metrics to benchmark the performance of a palliative medicine program

2. Enter data in formats that facilitate rapid analysis

3. Identify organizational support staff who can provide access to relevant data

The National Environment for Palliative Care Teams

• 4.4% of patients admitted to an acute care hospital in the US had a palliative medicine consultation in 2014 (range 0.3%-16.8%)

• In 2012, 3.6% of patients had palliative medicine consultations

• Source National Palliative Care Registry sample of ~10% of US hospitals

Palliative Care Registry and Outcomes Evaluation

Aim: To provide metrics on palliative care program characteristics and outcomes across fellowship sites to improve patient care and costs

1. Palliative Care Registry – Study of characteristics of palliative care programs at all participating

sites

– Administered in 2015 for program information, 2012 – 2014

2. Outcomes Study – COMPData: Hospital inpatient billing information for patients

discharged to hospice or died in-hospital

Types of Services offered by Palliative Care Services for Responding Institutions to the Registry (N=23)

• 74% have an inpatient consultation service

• 52% have outpatient clinics

• 43% have home palliative care programs

• 22% have services in skilled nursing facilities

• 9% have an inpatient palliative care unit

• 9% have inpatient hospice units

Staffing Models: 2012 and 2014, N = 12

Provider 2012 FTEs

Median (25 – 75%) 2014 FTEs

Median (25 – 75 %)

Physician 0.9 (0 – 2.3) 1.1 (0.2 – 2.7)

Advanced nurse practitioner

1.0 (0.8 – 1.0) 1.0 (0.8 – 2.0)

Social worker 0.3 (0 – 0.5) 0.4 (0.1 – 1.0)

Chaplain 0 (0 – 0.5) 0 (0 – 0.5)

Other 0.2 (0 – 1.0) 0.2 (0 – 1.3)

Proportion of Hospitals with Each Provider Type in the Palliative Care Program (N = 11)

83% 83%

75%

42%

92%

75%

Physician Advanced nursepractitioner

Social worker Chaplain At least 2 typesof providers

At least 3 typesof providers

--Interprofessional Teams--

Discharges to Hospice by Team Composition % of hospital discharges to hospice versus in-hospital death

2011 2012 2013 2014With SW and APN both on team (n = 16,349)

Without SW or APN on team (n = 10,830)

0%

10%

20%

30%

40%

50%

2011 2012 2013 2014With social worker on team (n = 17,353)

Without social worker on team (n =8,460)

Palliative Care Consults as a Percent of Total Discharges

Beauchamp TL. Principles of Biomedical Ethics, 5th ed. Oxford Univ Press 2001.

4.4%

8.0%

National Coleman Fellowship Hospitals

N = 9 hospitals reporting the number of palliative care consultations for 2014

Within the Coleman Fellowship Hospitals

Range: 1.0% - 24.4%

Patients with a palliative care consultation were…

45% less likely to have any care in the

intensive care unit

4.8 times more likely to be discharged

to hospice

For patients discharged to hospice or who died in-hospital at Rush University Medical Center

Discharge dates: Oct 2011 – Sep 2012; Oct 2013 – Sep 2014

0

1000

2000

3000

4000

5000

6000

Nu

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er o

f V

isit

s

New visits

Return visits

Hosp A Hosp B Hosp C Hosp D Hosp E Hosp F

Inpatient Palliative Care Service Utilization at Local Academic Medical Centers in Fiscal Year 2014

0

200

400

600

800

1000

1200

Nu

mb

er

of

Vis

its

New visits

Return visits

Hosp A Hosp B Hosp C Hosp D Hosp E Hosp F

Outpatient Palliative Care Service Utilization at Local Academic Medical Centers in Fiscal Year 2014

Funding of Palliative Medicine Teams in the Chicagoland Area (FY-14)

• The mean support from professional revenue 34.5% (range 0 to 100% of the cost of supporting a team)

• Six programs had 100% support from their hospital hospital (range 0 to 100%), and mean support is 63.9%

• The support from hospice range is 0-50%, and mean support is 12%

• Philanthropy supported an average of 16.5% of operational support (range 0% to 100%)

Metrics That Matter: Some Key Metrics

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• Number of inpatient consultations

• Number of outpatient consultations

• Full-time equivalent staff by role

• Discharges to hospice versus in-hospital death

– Length of hospital stay

– Intensive care unit use

– Reason for admission

And From These Metrics…

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• Ratio of inpatient consultations to outpatient consultations

• Inpatient consultations per palliative care team FTE

• Outpatient consultations per palliative care team FTE

• Length of hospital stay for patients discharged to hospice versus in-hospital death

• Number of ICU days for patients discharged to hospice versus in-hospital death

Palliative Care Consults and End of Life Outcomes, 2013 - 2014, Rush University Medical Center

97

332

280

160

Hospice In-Hospital Death Hospice In-Hospital Death

Without Palliative Care Consult With Palliative Care Consult

23% discharged to hospice

64% discharged to hospice

Tips on Collecting Data

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• Think about how the data should be organized and what you want to accomplish

• Use a spreadsheet

• Create a data dictionary

• Use consistent coding

• Pilot data collection with a few records

• Review pilot data and plan for how you will use it

Example

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Patient Identifier Consultation Date Reason for Consultation Provider

ABCD Jan 1, 2016 Don't know T. Johnson

EFGH 1/2/2016 cancer SPM

IJKL Jan-05-16 cancer, lung Johnson, T.

Example

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Patient Identifier Consultation Date Reason for Consultation Provider

ABCD 01/01/2016 99 021

EFGH 01/02/2016 1 022

IJKL 01/05/2016 1 021

Provider Look-up Table

021 Johnson, Tricia

022 Miller, John

023 Jones, Mary

Reason Look-up Table

1 Cancer

2 Stroke

3

…

99 Unknown

Key Organization Support Areas

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• Quality: Performance metrics, outcomes, benchmarking data

• Finance: Cost per admission, billing information

• Information services: Electronic medical record information; billing information