Living with a Serious Illness · •Mismatch verbal and non-verbal •Assume •Interrupt. ... enes...
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Living with a Serious Illness Part 1: Provider Perspective Jody Rothe, RN MetaStar, Inc. Patricia Neuman, DO Agrace Hospice and Palliative Care Health Care Quality Symposium November 14, 2018
Transcript of Living with a Serious Illness · •Mismatch verbal and non-verbal •Assume •Interrupt. ... enes...
Living with a Serious IllnessPart 1: Provider Perspective
Jody Rothe, RN
MetaStar, Inc.
Patricia Neuman, DO
Agrace Hospice and Palliative Care
Health Care Quality Symposium
November 14, 2018
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Learning Track Objectives
• Describe the current state of palliative care in
Wisconsin
• Demonstrate skills of serious illness
conversations
• Examine challenges and exchange options
related to beneficiaries accepting palliative care
as an option for chronic illness
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
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National Palliative Care Landscape
• America’s Care of Serious Illness 2015 State-By-
State Report Care on Access to Palliative care in
Our Nation’s Hospitals
• H.R.1676 - Palliative Care and Hospice Education
and Training Act
• S.693 – Palliative Care and Hospice Education
and Training Act
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
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Wisconsin Palliative Care Landscape
• Wisconsin 2017 Assembly Bill 633
• Wisconsin 2017 Senate Bill 548
• America’s Care of Serious Illness 2015 State-By-
State Report Care on Access to Palliative care in
Our Nation’s Hospitals
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
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Rural Community-Based Palliative Care
• MetaStar and Wisconsin Office of Rural Health
working with Stratis Health
• Goal to increase access to palliative care services
in rural communities to improve quality of life and
quality of care for those with advanced illness and
complex care needs
• Wisconsin Environmental Scan began in May of
2018
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
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Rural Community-Based Palliative CareWisconsin State Environmental Scan
46 percent of Wisconsin counties are
defined as rural (46/72)
66 percent - Western region
93 percent - Northern region
53 percent - Northeastern region
64 percent - Sothern region
25 percent - Southeastern region
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
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MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
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Rural Community-Based Palliative CareWisconsin State Environmental Scan
• 21 Acute Care Hospitals
• 43 Critical Access Hospitals
• 158 Long Term Care
Facilities
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
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Rural Community-Based Palliative CareWisconsin State Environmental Scan
• 81 Hospice Organizations
• 33 Palliative Care
Organizations
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
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Advanced Care Planning or Health Directives in Wisconsin
Elements Respecting Choices Honoring Choices WI Serious Illness Care
Program First Steps®, Next
Steps, or Last Steps®
Shared Decision
Making in Serious
Illness (SDMSI) or
the creation of a plan
for implementation of
multiple services over
time
First Steps® Model
with common advance
directive and patient
education materials,
providing standard
messaging on advance
care planning
Serious Illness
Conversation Guide
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
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Advanced Care Planning or Health Directives in Wisconsin
Elements Respecting ChoicesHonoring
Choices WI
Serious Illness
Care
Connection with
Palliative CareSupports patient decision making
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
Living With Serious Illness: Provider Perspective
Patricia Neuman, DO
Nature gave us one tongue and
two ears so we could hear twice
as much as we speak
Epictetus (55AD-135AD)
Barriers to CommunicationBarriers to Communication
Other Provider Barriers
• Personal grief issues
• Ethical concerns
• Fear of mortality- our own
• Lack of experience- have we dealt with this before?
• Avoidance of emotion- are we afraid we’re going to “lose it” in front of the patient?
• Sense of guilt- failure to make them feel better?
• Surplus of trust
• Time
- Studer Group
AIDET
Provider Communication Points
• Inform & empower
• Focus on the wholeunit of care
• Use your team
• Ask how much the patientand family want to know
• Know that illness can strengthenor weaken relationships
Common Communication Mistakes
•Giving pathophysiology lectures
•Not finding out the patient’s information needs
•Launching into your agenda first without negotiating the focus of the interview
•Offering reassurance prematurely
Dos and Don’ts
Dos
• Maintain appropriate eye contact
• Be at eye level with the patient/family
• Be aware of your own body language and tone
• Ask for clarification
• Ask open-ended questions
• Paraphrase
Don’ts
• Stand over patient/family
• Look away or look bored
• Mismatch verbal and non-verbal
• Assume
• Interrupt
Other Helpful Communication Tools
Manage Up
• Positions others in a positive light & creates alignment
• Builds confidence & trust with patient & family
Intentional Language
• Explain what you’re doing & how it benefits them
Teach-back
• Have them explain your instructions back to you
Common Conversations in Palliative Care• Shifting focus from cure to managing disease
• Shifting focus from quantity of life to quality of life
• Shifting focus from managing disease to preparing for death
• Discussing prognosis when time is short
• Shifting goals when the patient’s goals are not achievable
• Discussing patient’s desire to return home but patient cannot
Peer to Peer Sharing
• How does your organization ensure these difficult discussions occur?
• How do you incorporate these discussions into the process?
• What training have your found helpful?
• What items as a healthcare provider, do you still have a hard time consistently performing?
Lunch Time
• In the afternoon, we will be exploring the patient perspective.
Living with a Serious Illness Part II: Patient Perspective
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Rural Community-Based Palliative CareWisconsin State Environmental Scan
• 3.5 per 1,000 people are hospitalized for coronary
heart disease
• 457 per 1,000,000 people are newly diagnosed with
cancer
• 10 percent report frequent physical or mental distress
• 10 percent are diabetics
• 47 per 1,000 preventable hospital stays
• 2 percent do not receive needed healthcare
• 12 percent live below Federal Poverty Line
• 28 percent of 65 or older people live alone
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
Data Update: Q1 2015 – Q2 2017
MetaStar, Inc.
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Components of the Report
• Average Cost for Beneficiaries per Year – Part A
(Chart and Graph)
• Admissions in Last Year of Life vs. Living
Beneficiaries
• Readmissions in Last Year of Life vs. Living
Beneficiaries
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
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Average Cost for Beneficiaries Per Year
Type of Service Claims Did Not Die Claims Died
Advance Care 98 $9,191.48 15 $11,429.75
Palliative Care 1,667 $10,477.95 950 $9,212.96
Both Suppressed $5,048.92 Suppressed $11,245.43
No Service 75,498 $5,466.68 6,340 $11,489.94
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
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Average Cost for Beneficiaries per Year
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
Beneficiaries who did not die during Q12015-Q22017 (yearlycost)
Beneficiaries who died during Q12015-Q22017 (last year of life)
Average Beneficiary Cost per Year-Part A
Advance Care Palliative Care Both No Service
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
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Admissions – Dead Beneficiaries
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
1 2 3 4 5
% o
f to
tal
ben
es
Number of Admissions
Number of Admissions per year - for dead beneficiaries
Advance Care Palliative Care Both No Service
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
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Admissions – Living Beneficiaries
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
1 2 3 4 5
% o
f to
tal b
en
es
Number of Admissions
Number of admissions per year - for living beneficiaries
Advance Care Palliative Care Both No Service
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
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Readmission Rate –Dead Beneficiaries
25.0%
20.0%
25.0%
2.0%1.3%
0.0%0.0% 0.0% 0.0%
20.3%21.6%
17.5%
0%
5%
10%
15%
20%
25%
30%
2015 2016 To Q2 2017
Read
mis
sio
n R
ate
Readmission Rate for Patient - dead beneficiaries
Advance Care Palliative Care Both No Service
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
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Readmission Rate –Living Beneficiaries
12.5%13.3%
16.7%
3.6%
0.8% 0.7%0.0% 0.0% 0.0%
15.8%
14.9%
12.4%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
2015 2016 To Q2 2017
Read
mis
sio
n R
ate
Readmission Rate for Patient - living beneficiaries
Advance Care Palliative Care Both No Service
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
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Chippewa Valley Continuum End of Life Analysis Summary
• Higher costs during the last year of life, particularly for those who
did not receive a palliative care consult, or have an advanced
care planning consultation
• During the last year of life, decreased hospital readmission rate
for beneficiaries who received a palliative care consult
• Decreased number of admissions for beneficiaries receiving
palliative care consult, or have an advanced care planning
consultation
• Increased need for beneficiaries to receive palliative care consult
prior to last year of life
• Increased awareness of advanced care planning consultation
covered by Medicare
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
Living With Serious Illness: Patient Perspective
Patricia Neuman, DO
Difficult Conversations: Barriers for Patients• Family dynamics (disagreement over treatment options,
“blinders” to prognosis, etc.)
• Feeling rushed
• Perceived health status
• Health Literacy
• Hx of distrust/dissatisfaction with healthcare
• Misunderstanding of diagnosis
• Symptomatic vs Asymptomatic
• Fear of “looking stupid”
• Other life stressors
Difficult Conversations: Barriers for Patients• Patient sensory problems (sight, hearing, speech)
• Cognitive barriers (dementia, stress, literacy, health literacy)
• Language (ESL, medical terminology)
• Environment (noisy, lacking privacy)
• Fear of not knowing
• Disagreement with decisions
• Lack of understanding culture or goals
Jane Brown
Jane Brown is 66 years old with a clinical diagnosis of early dementia. Her husband John, age 72, is in good health following treatment for prostate cancer three years ago. The Browns have three adult married children, who live in other states and have not visited their parents in several years. Jane makes an appointment with her primary care provider to talk about her dementia, what she might expect in the future, and what decisions she or her family might need to make. She is concerned about being “kept alive” for many years in a facility if she is not able to recognize her family. She has had personal experience with a family member who died of dementia.
Her primary physician asks if there is someone who could arrange a family conference with Jane, John and their adult children (linked in by phone). As the family physician for this couple, she knows that John has a history of alcohol abuse and is at risk for recurrent prostate cancer. The physician anticipates that the discussion at the family conference will include providing medical information about the course of dementia, potential future treatment decisions and planning how to provide psychosocial and spiritual support for Jane and John. How might your community respond to this situation?
Patient Voice
• https://youtu.be/oyuCBNoHhWw
• People Change
• https://youtu.be/teNAFduixCE
• What if Family Members Disagree
Institute for Healthcare Improvement (IHI) Resources• IHI also has 10 steps for end-of-life conversations
http://www.ihi.org/education/IHIOpenSchool/Courses/Documents/IHIGuideforEOLConversations.pdf
• IHI also provides a shared vocabulary document: http://www.ihi.org/education/IHIOpenSchool/Courses/Documents/IHIWordsforEOLCare_Vocabularly.pdf
• And reframing the conversation: http://www.ihi.org/education/IHIOpenSchool/Courses/Documents/IHIWordsforEOLCare_Reframing.pdf
Additional Tools for Difficult Conversations• The Conversation Project Starter Kits:
http://theconversationproject.org/starter-kit/intro/
• Easy-To-Read Advance Directive Library:https://prepareforyourcare.org/advance-directive-library
• Patient Centered Website for Preparing for Your Care: https://www.prepareforyourcare.org/welcome
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Bringing The Conversation Together
• What one to three items are you going to
implement in the next 30 days?
• If you or your organization would like to learn
more or potentially participate in the Rural
Community-Based Palliative Care project as a
stakeholder or participant, do not hesitate to see
me after the presentation.
MetaStar represents Wisconsin in
Lake Superior Quality Innovation Network.
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Questions?
This material was prepared by the Lake Superior Quality
Innovation Network, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the
U.S. Department of Health and Human Services. The
materials do not necessarily reflect CMS policy.
11SOW-WI-A1-18-48 110718
