developing specialist services and leveraging …...PC in the Safety Net: Developing specialist...
Transcript of developing specialist services and leveraging …...PC in the Safety Net: Developing specialist...
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PC in the Safety Net: Developing specialist services and leveraging community resources
Anne Kinderman, MD
Director, Supportive & Palliative Care Service San Francisco General Hospital
Assistant Clinical Professor of Medicine, UCSF
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Roadmap
• Landscape for seriously ill Medi-Cal patients
– Past
– Present
– Future
• Illustrate opportunities for collaboration
– Partnership: Health Network & SF Health Plan
– San Francisco Palliative Care Task Force
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What is the landscape like for seriously ill Medi-Cal members?
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Common needs and concerns for patients like Ms. O
• Symptom management
• Advance care planning
• Assistance with activities of daily living
• Psychosocial support
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Typical resources to support Ms. O
• Caring physicians
• (Limited) social work support
• Short-term home health services
• IHSS
Providers have excellent intentions but run into many barriers in coordinating care in current system
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What support would be available to Ms. O while she is in the hospital?
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Supportive & Palliative Care Team
Included on team: Physician, RN, social worker, chaplains
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SFGH Palliative Care Service
• Launched Dec 2009
• Interdisciplinary, expert consultation, available hospital-wide, 24/7 phone support
• Support for patients and family
• Support for staff
• Participation in educational & quality improvement initiatives
• Steady increase in consultation requests
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Who are our patients?
0
5
10
15
20
25
30
35
40
Non-HispanicCaucasian
Hispanic AfricanAmerican
Asian PacificIslander
21% 21% 24%
33%
40% 38%
6%
13% Perc
en
t Po
pu
lati
on
SFGH PC CA average (2010 census)
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Communication Barriers
0%
20%
40%
60%
US California SFGH PC
21%
44%
9%
20%
42%
Language Other than English
Limited English Proficiency
2010 US Census
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Who are our patients?
• >20% marginally housed or homeless
• Medical Conditions
– Cancer (40%)
– Devastating brain injuries (14%)
• 10% unbefriended
(no surrogate/caregiver)
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What do we do for our patients?
• Help clarify wishes/goals (62%)
• Manage distressing symptoms
– Pain (22%)
– Shortness of breath, Nausea, other (20%)
• Hospice discussion/referral (23%)
• Counseling/support for patient, family (18%)
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What happens to our patients?
Palliative care 2%
Died in hospital
35%
Hospice 38%
ECF 8%
Home nursing
14%
Acute care 3%
25% of patients could have benefitted from additional community-based palliative care
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What about patients we’re NOT seeing?
• “Too soon”
– Diagnosis not confirmed
– New diagnoses
– Still seeking life-prolonging treatments
• Providers have difficulty prognosticating
– Heart failure
– Emphysema/chronic bronchitis
– Dementia
– AIDS
What about QOL & support needs?
Can we help to identify patients?
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What happened to Ms. O?
• Continued with life-prolonging treatments
• Limited, short-term home nursing
• Fragmented care across health systems
What will she do if she gets short of breath at home?
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Planning Ahead: Better Care for Patients Like Ms. O
• More support (patients, families)
• Attention to symptom management
• Advance planning – Clarifying goals and wishes
– Urgent/Emergent issues
• Proactive identification of patients at high risk – Distress
– Discomfort
– Unwanted/unnecessary care
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Planning Ahead: Better Care for Patients Like Ms. O
• More support (patients, families)
• Attention to symptom management
• Advance planning – Clarifying goals and wishes
– Urgent/Emergent issues
• Proactive identification of patients at high risk – Distress
– Discomfort
– Unwanted/unnecessary care
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Planning Ahead: Community-Based Palliative Care
Slide courtesy Center to Advance Palliative Care
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Dreaming Big: Efficient, High-quality Services
• Flexible options for community palliative care
– Clinic-based services
– Home-based services
– Case management/telephone support
• System for providing appropriate services to the patients who need them most
How do we identify patients in need?
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Ways to identify patients
• Clinician-dependent
– Referrals from inpatient palliative care team
– Referrals from outpatient providers
• Automatic “triggers”
– Specified diagnoses
– Screening tools
• Payer data
– Utilization patterns
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Forecasting need for community-based palliative care in SF
• Cancer patients
– High proportion of patients referred to inpatient PC
– High symptom burden
– Easier to prognosticate
– Partnership with oncology
– Many studies demonstrate benefits of early PC
What impact could “early” PC have on cancer patients in our system?
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SFGH Study: Utilization Patterns of Cancer Patients
• Retrospective analysis of cancer patients who died over 3-year period
• Data sources
– Tumor registry
– Finance/quality management departments
– Palliative care database
• Examined care utilization patterns in last 6 months of life
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SFGH Study: Utilization Patterns of Cancer Patients
• 403 patients died in 3-year period
• Heavy inpatient utilization – In last 6 months
• 76% of patients were admitted to SFGH
• 39% had multiple admissions (avg. 1.9 admissions)
– In last month of life • 47% of patients visited the SFGH Emergency Dept.
• 45% of patients were admitted to SFGH
• 21% had multiple admissions
• 16% were admitted to the ICU
– 1/3 of patients died in hospital
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SFGH Study: Impact of Inpatient Palliative Care
• Inpatient palliative care reaches many patients, but too late
– Cared for 44% of the entire decedent population and 58% of those who were hospitalized
– Median of 22.5 days between first inpatient PC contact and death
– In 60% of cases the initial contact with the PC team took place in the final month of life
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SFGH Study: Predicting Impact of Early PC
• Greatest impact when contact with patients is at least 3 months prior to death
– Symptom management
– Clarification of goals of treatment, goals of care
– Advance care planning
• Outpatient PC programs for cancer patients have shown 40% reduction in ED visits, hospitalizations for patients seen early
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SFGH Study Conclusion: We Can Make an Impact!
• About 1/3 of SFGH patients who die of cancer present early enough (>3 months prior to death) to be referred to an OP PC clinic
• Based on analysis, OP PC clinic could expect to make an impact on 50 patients/year
Expect 40% reduction in inpatient utilization (38 admissions, $25,814 ea.)
Expected cost avoidance: $980,932
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SFGH Study: Business Case
• Would only need 0.2 FTE for team to see expected patient volume in 2 half-day clinics/week
• Salary for MD, APRN, SW + 17 % Benefits = $88,290
$980,932
Direct costs avoided
$88,290
Staffing Cost
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SFGH Study: Next Steps
• Submitted business plan to City/County
• Partnering with SF Health Plan
– Service delivery model
• Staffing
• Location
• Triggers for referral
– Analysis of utilization patterns for patients with other serious illnesses
$980,932
Direct costs avoided
$88,290
Staffing Cost
$980,932
Direct costs avoided
$88,290
Staffing Cost
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Gap analysis: Opportunities to Improve Care
• From SFGH perspective
– Which patients need PC post-discharge?
– In what setting(s) would CBPC services have the greatest impact (for which patients)?
– What are the priorities of our partners, stakeholders?
• From system’s and payer’s perspective
– What quality standards should we track?
– How can we most efficiently use limited resources?
• Leverage existing resources
• Add new programs/providers where critical gaps exist
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SF Palliative Care Task Force
• Community collaboration, June-Aug 2014
• Supported by CHCF, co-sponsored by: – SF Dept of Public Health
– SF Dept of Aging and Adult Services
• Mix of community and hospital-based providers, social service agencies
• Purpose: “to develop strategic recommendations to meet San Francisco’s current and future palliative care needs”
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SF Palliative Care Task Force
• 3 main deliverables:
1) Definitions for palliative care and a palliative care target population;
2) Inventory of dedicated palliative care services currently available in San Francisco; and
3) Short- and long-term recommendations aimed at improving access to quality palliative care
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SF Palliative Care Task Force: Outcomes
• Successfully produced deliverables over short time-frame, on voluntary basis
• Report written, presented to SF Health Commission, LTC Coordinating Council
• Creation of new workgroup to carry recommendations forward – Community education
– Finance
– Quality
– Systems issues, including gap analysis
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Ambulatory Care
Transitions SFGH
Primary Care
Behavioral Health
Maternal, Child, &
Adolescent Health
Jail Health
Acute Care SNF Specialty Care
Existing Palliative Care Services
Laguna Honda Hospital (SNF)
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SF Health Network: Next Steps
• Piloting community-based PC for cancer patients
• Partnering with SF Health Plan
• Formal needs assessment
• Develop strategic plan for improving care
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Strategic, Efficient Approach toPalliative Care Delivery
Specialty PC
Trained PC
Primary
Palliative Care
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Strategic, Efficient Approach to Palliative Care Delivery
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Strategic, Efficient Approach to Palliative Care Delivery: Ms. O
Specialty PC
PC champions (GMC, Chest Clinic, Home
Health, Rheumatology)
Education for Providers
(System-wide; focus on
primary care)
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Take-Home Messages
• Tremendous need – Uncontrolled symptoms, distress
– Heavy inpatient utilization as members approach end of life
• Tremendous opportunities – Early PC delivery improves outcomes
– Early PC is feasible in resource-limited systems
– Natural partnerships between public health systems and managed care payers
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THANK YOU
Juliet Wood, Arbol de la Vida