LifeCourseTM: An innovative approach

to late life care in the community

Eric Anderson, MD, Principal Investigator

Allina Health

September 29, 2015

Disclosure

There are no conflicts of interest or relevant financial interests in

making this presentation.

I have indicated that my presentation does not include discussion of

an unlabeled use of a commercial product, or an investigational use

not yet approved for any purpose.

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Learning Objectives

• List the key activities of a lay healthcare worker providing patient-

centered and family-oriented care to individuals with advanced

serious illness.

• Describe how late life support several years before death impacts

- Quality of life for patients,

- The experience of care for families,

- Use of hospital and hospice in the last 6 months of life

- Completion of advance directives, and

- Total cost of care

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7 out of 10 Americans

will die from serious

illness with an end-of-

life period that can be

drawn out over years,

not just weeks or

months.

Too often, serious illness

care is fragmented and

doesn’t support our

nonmedical needs.

With limited resources and

pressure to reduce

healthcare spending, we

have an opportunity to

make sure we are spending

our healthcare dollars as

wisely as possible – on the

care that matters most to

individuals.

Serious Illness Care Today

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Home & Community

HospitalsService Lines& Specialties

Clinics

Allina Health Impact

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• Individuals living with serious illness touch all parts of Allina

Health.

• They interact with multiple providers in different settings in

order to manage their increasingly complex care.

The Felt Experiences of Care

• A wife of a chronically ill husband: “We’ve been in the

hospital and five different care centers. It’s like starting over

every time.”

• A son caring for his father at home: “The only time I felt out

of control of my dad’s care was when we went into the

hospital.”

• A surgeon at Abbott Northwestern Hospital: “How can we

reclaim the heart of medicine?”

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An Opportunity

“…our most cruel failure in how we treat the sick and the aged is the

failure to recognize that they have priorities beyond merely being

safe and living longer;

that the chance to shape one’s story is essential to sustaining

meaning in life;

that we have the opportunity to refashion our institutions, our

culture, and our conversations in ways that transform the

possibilities for the last chapters of everyone’s lives.”

- Atul Gawande, Being Mortal: Medicine and What Matters in the End

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LifeCourse

LifeCourse is a late life supportive care approach that helps

individuals and families navigate serious illness.

It is part of a system strategy for addressing complex, serious

illness so that we can be more responsive as a health system to

the things that matter most to our patients.

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Timeline

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2012 2013 2014 2015 2016 – 2020

Pilot PhaseResearch and Program

DevelopmentProgram Expansion and

Community Impact

• Develop model

• Enroll 23 patients

• Enroll and study

over 1500 patients

plus family

members and

comparison patients

• Develop program

evaluation

• Test model with early

adopters

• Integrate LifeCourse across

Allina Health

• Promote public engagement

around late life care issues

• Pursue government policy

and reimbursement agenda

Key Components

Whole Person

Care

Care Guide

Family-Oriented Approach

What Matters

Most

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Identified by multiple factors in the EHR

Screened by a research nurse

Target Population

Study Participants

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Recent clinic or hospital

encounter

1 or more chronic

illnesses in an advanced

stage

Allina Health

provider

Comorbidity score ≥ 4

Electronic eligibility report

Individuals living with serious illness who may be in the last two to three

years of life

Visit Approach

Care guides have monthly, in-person visits with patients

and their caregivers.

Care guides discuss patient goals, and they review what

matters most.

In their Excellian notes, care guides reflect the whole

person.

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Implementing Whole Person Care

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Visit #1

Visit #2

Visit#3

Visit #4

Visit #5

Visit #6 On-going

Qu

est

ion

Set

s

Physical Social Cultural Financial & Legal

Revisit and Update

Questions

Revisit and Update

Questions

Revisit and Update

QuestionsPsychological Cultural Spiritual

Family Legacy

Care at End of Life

Ass

ess

me

nts

Physical Physical Ethical Reassess-ment:

Physical

Reassess-ment:

Physical

Revisit Assessments

Social

Financial & Legal

Supplemental Visits: Advance Care Planning, Supportive Family Conference

Implementing Whole Person Care

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Visit #1

Visit #2

Visit#3

Visit #4

Visit #5

Visit #6 On-going

Qu

est

ion

Set

s

Physical Social Cultural Financial & Legal

Revisit and Update

Questions

Revisit and Update

Questions

Revisit and Update

QuestionsPsychological Cultural Spiritual

Family Legacy

Care at End of Life

Ass

ess

me

nts

Physical Physical Ethical Reassess-ment:

Physical

Reassess-ment:

Physical

Revisit Assessments

Social

Financial & Legal

Supplemental Visits: Advance Care Planning, Supportive Family Conference

Implementing Whole Person Care

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Visit #1

Visit #2

Visit#3

Visit #4

Visit #5

Visit #6 On-going

Qu

est

ion

Set

s

Physical Social Cultural Financial & Legal

Revisit and Update

Questions

Revisit and Update

Questions

Revisit and Update

QuestionsPsychological Cultural Spiritual

Family Legacy

Care at End of Life

Ass

ess

me

nts

Physical Physical Ethical Reassess-ment:

Physical

Reassess-ment:

Physical

Revisit Assessments

Social

Financial & Legal

Supplemental Visits: Advance Care Planning, Supportive Family Conference

Outcomes

Participant Outcomes

Quality of Life1

Experience3

Goals honored

Caregiver Outcomes

Quality of Life2

Experience3

System Outcomes

Care Team wellbeing4

Hospice Days

Hospital Days

Emergency Visits

Total Cost of Care

1. FACIT-PAL (Functional Assessment of Chronic Illness Therapy - Palliative Care)2. PROMIS-29 (Patient Reported Outcome Measurement Information System)3. LifeCourse Experience tool4. Maslach Burnout Inventory

Goal: maintain patient & family quality of life while decreasing overall cost

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Participant Outcomes

Measure Hypothesis Early Results

Quality of Life

LifeCourse participants quality of life will remain stable or decrease at a slower rate than patients receiving

usual care.

+

ExperienceLifeCourse participants will have more positive care experiences than patients

receiving usual care.+

GoalsExploratory: To understand patient

goals late in life.

Patients prioritize both medical and

nonmedical goals.

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Caregiver Outcomes

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Measure Hypothesis Result

Quality of Life

Quality of life for caregivers participating in LifeCourse will remain stable or

decrease at a slower rate than caregivers of patients receiving usual care.

+/-(+ for Anxiety and Global - Health)

Experience

Caregivers participating in LifeCourse will have more positive experiences as compared to caregivers of patients

receiving usual care.

+

System Outcomes

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Measure Hypothesis Early Results

Palliative Care Utilization

LifeCourse participants utilize community and inpatient palliative care services more frequently than patients receiving usual care.

Inpatient DaysLifeCourse participants will have fewer inpatient days than participants receiving usual care.

Advance Directive LifeCourse participants will have increased advance directive completion compared to patients receiving usual care.

Hospice EnrollmentLifeCourse participants will choose to enroll in hospice at an increased rate compared to patients receiving usual care.

ED VisitsLifeCourse participants will utilize the ED less frequently than patients receiving usual care.

Total Cost of CareLifeCourse participants will have lower total cost of care than patients receiving usual care.

• One article published in the American Journal of Hospice and Palliative

Medicine, with several other manuscripts in progress

• Presentations at 11 conferences in 2015, including a symposium at the

Gerontological Society of America Annual Scientific Meeting

• One presentation confirmed for 2016 at American Academy of Hospice

and Palliative Medicine

• LifeCourse included in a presentation on HHS Delivery System Reform

given by Senator Amy Klobuchar and Allina EVP Robert Wieland

• Eight late life documentaries broadcast on Twin Cities Public Television

Dissemination

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• Fortin AH, Dwamena FC, Frankel RM, Smith RC. Smith’s Patient-Centered Interviewing;

An Evidence-Based Method. 3rd ed. New York, NY: McGraw-Hill Companies, Inc.

• Gawande A. Being Mortal; Medicine and What Matters in the End. New York, NY:

Metropolitan Books, 2014.

• National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for

Quality Palliative Care, Third Edition. Published 2013.

• National Quality Forum. A National Framework and Preferred Practices for Palliative

and Hospice Care Quality: A Consensus Report. Published 2006.

• RAND Corporation. Redefining and Reforming Health Care for the Last Years of Life.

http://www.rand.org/pubs/research_briefs/RB9178/index1.html. Published 2006.

• Schellinger S, Cain CL, Shibrowski K, Elumba D, Rosenberg E. Building New Teams for

Late Life Care: Lessons from LifeCourse. American Journal of Hospice & Palliative

Medicine. 2015: 1049909115574692.

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References

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www.lifecoursemn.org

eric.worden.anderson@allina.com

In case you missed Speaking of Being Mortal: A Life Changing

Conversation with Dr. Atul Gawande on September 18,watch

the broadcast in November on Twin Cities Public Television.

– Also available on www.lifecoursemn.org

– Event sponsored by Allina Health and LifeCourse

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To Contact Me