Bargaining in Institutionalized Sttings - The Case of Turkish
Palliative Care 2020: Matching Care to Patient and Family ... · NOTE: FFS is fee-for-service....
Transcript of Palliative Care 2020: Matching Care to Patient and Family ... · NOTE: FFS is fee-for-service....
Palliative Care 2020:
Matching Care to Patient and
Family Needs
Diane E. Meier, MD
Director
Center to Advance Palliative Care
www.capc.org
www.getpalliativecare.org
@dianeemeier
Disclosures
• I have no disclosures to report.
Objectives
1. How is palliative care important to improving care of the most vulnerable?
2. How do we change the delivery system to improve access to quality palliative care for all persons with serious illness and their families?
Concentration of Spending Distribution of Total Medicare Beneficiaries and Spending, 2011
10%
63%
37%
90%
Total Number of FFS Beneficiaries: 37.5 million
Total Medicare Spending: $417 billion
Average per capita Medicare spending (FFS only): $8,554
Average per capita Medicare spending
among top 10% (FFS only): $48,220
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. Improved
quality reduces 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 a lot of
acetaminophen.
• Admitted 4 times in 6 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: “I told the Dr. that I never
wanted to go back to the hospital
again. It’s torture—you have no
control and can’t do anything for
yourself. And you get weaker
and sicker. Every time I’m in the
hospital it feels like I’ll never get
out.”
• 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 ED and the ICU
• Half of older Americans visited ED in
last month of life and 75% did so in
their last 6 months of life.
• 90% of ED visits in those >65 due to
symptom distress.
• 50% increase in ICU admissions from
ED in people >85 years. Smith AK et al. Health Affairs 2012;31:1277-85.
Pines JM et al. JAGS 2013;61:12-17.
Mullins et al. Acad Emerg Med 2013;20:479-86.
Dementia Drives
Utilization
Prospective
Cohort of
community
dwelling older
adults
Callahan et al. JAGS 2012;60:813-
20.
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
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.
•Highest risk, highest cost
population: functional limitation,
frailty, cognitive impairment +/-
serious illness(es)
•What are the roles of primary care
teams in improving care of this
population?
The 5%
What is Palliative Care? • Specialized or generalist 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-opinion-research/2011-public-opinion-research-on-palliative-care.pdf
Conceptual Shift for Palliative Care
“Don’t ask what’s the matter with me. Ask
what matters to me.” Palliative Care Teams Address 3 Domains
1. Physical, emotional, and spiritual distress
2. Patient-family-professional communication about achievable goals for care and the decision-making that follows
3. Coordinated, communicated, continuity of care and support for social and practical needs of both patients and families across settings
Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.
Palliative Care Language
Endorsed by the Public
Palliative Care Models
Improve Value (Quality/Cost)
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
The Future of Palliative Care
• Not enough to have access to
palliative care in hospitals
• Most illness occurs at home and in
communities
• Home palliative care needed without
regard to prognosis or goals of care
• Goal = insure access to palliative care
across all settings and stages of illness
Access to Palliative Care Across
the Continuum: The Future
Hospital
Consult Service
Inpatient Unit
Outpatient Specialty Clinics
Cancer Center
Outpatient PCP
Clinics
NH Services
Provider Home Visits
21
Palliative Care Improves Quality in
Office Setting
Randomized trial simultaneous standard cancer care with palliative care co-management from diagnosis versus control group receiving standard cancer care only:
– Improved quality of life – Reduced major depression – Reduced ‘aggressiveness’ (less chemo < 14d
before death, more likely to get hospice, less likely to be hospitalized in last month)
– Improved survival (11.6 mos. vs 8.9 mos., p<0.02)
Temel et al. Early palliative care for patients with non-small-cell lung cancer NEJM2010;363:733-42.
Palliative care in addition to usual oncology care
allowed lung cancer patients to live almost 3 mos
longer than those who got usual oncology care. Temel J, et al. NEJM 2010
Palliative Care at
Home for the Chronically Ill Improves Quality, Markedly Reduces Cost
RCT of Service Use Among Heart Failure, Chronic Obstructive Pulmonary Disease, or Cancer Patients While Enrolled in a Home
Palliative Care Intervention or Receiving Usual Home Care, 1999–2000
13.211.1
2.3
9.4
4.6
35.0
5.3
0.92.4
0.9
0
10
20
30
40
Home health
visits
Physician
office visits
ER visits Hospital days SNF days
Usual Medicare home care Palliative care intervention
KP Study Brumley, R.D. et al. JAGS 2007
Palliative Care in the Nursing Home • Retrospective case control study comparing care
processes in 125 end stage dementia patients receiving palliative care consultations (2007-2009) to 125 historical controls (2006) receiving usual care
• Single facility (Hebrew Rehabilitation) in Boston
• Data source: MDS
• Primary outcome: a composite outcome based on utilization patterns, depression, and pain and other clinical Indicators, and change on this composite score (and the individual outcomes) over a 1-year period.
• Results: Residents receiving palliative care consultation had fewer ED visits (p<.001) and less depression (P=.03). Change in the composite score indicated a significant difference over time between the 2 groups (p = .013).
Comart J et al. The Gerontologist 2012; dec 7. doi:10.1093/geront/gns154
RCT of Nurse-Led Telephonic
Palliative Care Intervention
• N= 322 advanced cancer patients in rural NH+VT
• Improved quality of life and less depression (p=0.02)
• Trend towards reduced symptom intensity (p=0.06)
• No difference in utilization, (but v. low in both groups)
• Median survival: intervention group 14 months, control group 8.5 months, p = 0.14
Bakitas M et al. JAMA 2009;302(7):741-9
US Oncology:
Pathways Include Palliative Care
Clinical pathways specify:
• Number of regimens
• Exact drugs to use
• Goals of care discussion early
– The Checklist Approach.
– Advance medical directives and health agent appointment “up front” as standard of care.
– Use of homecare and hospice as standard of care.
(In contrast, NCCN pathways allow 16 individual drugs in multiple combinations. No mention of non-chemo care until the end.)
U S Oncology pathways preserve survival, reduce cost by
35% in lung cancer.
For NSCLC, equal results, less toxicity, less cost.
Chemo beyond 3rd line off pathway. Neubauer M, et al. J Oncol Pract. 2010 Jan;6(1):12-8.
Less chemo More hospice Longer LOS
New guidelines have AMDs
DPMA, hospice visit
U S Oncology pathways preserve survival, reduce cost
by 34% in metastatic colon cancer.
Hoverman R, et al. Am J Manag Care. 2011 May;17 Suppl 5 Developing:SP45-
52.
Table 1: Impact of pathways in colon cancer
Overall
survival
(mos)
Chemo
Cost ($)
Total
Cost
($)
Pathway 26.9 22,564 103,379
-34%
Non-
pathway
20.1 60,787 156,020
P value 0.03 <0.001 <0.001
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 6-
8.”
Consequences of Late Referral to
Palliative Care
Serious Adverse Outcomes for Bereaved
Caregivers:
Compared to care at home with hospice,
• Care in ICU associated with 5X family risk of Post Traumatic Stress Disorder; and
• Care in hospital associated with 8.8X family risk of prolonged grief disorder
Wright A et al. Place of death: Correlation with quality of life of patients with cancer and predictors of bereaved caregivers mental health. JCO 2010; Sept 13 epub ahead of print
Effect of Palliative Care
on Hospital Costs
How Palliative Care Reduces Cost
• Improved resource use
• Reduced bottlenecks in high cost units
• Improved throughput and consistency
The Conceptual Model:
Dedicated medical team =
Focus + Time =
Decision Making / Clarity / Follow through
Key Characteristics of Effective
Models 1: Targeting
Demand Management DM/CM CCM-palliative care
RE
SO
UR
CE
S
NEEDS
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
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 more personal care
at home?
• Does this patient have advanced cancer or heart, lung,
kidney, liver, or cognitive failure?
Targeting on the Front Lines
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 MCC, 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.
Goals 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
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 say they can rely on family in time of need as they age, (compared to 55% of those who have received it).
The Scan Foundation/NORC/AP April 2013
To.pbs.org/15TQh2B http://www.apnorc.org/projects/Pages/long-term-care-perceptions-experiences-and-attitudes-among-americans-40-or-older.aspx
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.
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 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.
• This is our job.
Payers Are Already Bringing the
Care Home
Exemplar: BCBS MI and @HOMe
The “Missing Piece” Solution
Thank you Dottie Deremo!
51
Chronic Disease
Management
Hospice Care
2-20 yrs 12-18 mos
6 mos
Advanced Illness
Management
52
Improves Quality Outcomes
Supports Stressed Family Caregivers
Saves 30% Net Total Health Care Costs
for Tier 3 patients demonstrated by 3rd party independent
research
Partnership:
@HOMe: a wholly owned subsidiary of
Hospice of Michigan
Payer: BCBS Michigan
Providers: ACOs,Employers in SE Michigan
How? System Redesign
53
AIM Home Services
24/7/365
ER & Hospital Transition Coaches
Telesupport
24/7/365
Analytics
Predictive
Modeling
Outcomes
Analytics
Key Characteristic 4:
Pain and Symptoms –
• 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.
• 90% ED visits >65 years are due to
symptoms.
Smith AK et al. Ann Intern Med 2010;153:563-569.
Pines JM et al. JAGS 2013;61:12-17.
It’s Not Only Pain:
Symptom Burden of Community Dwelling
Older Adults with Serious Illness
0
10
20
30
40
50
60
70
80
90
100P
erc
en
t o
f p
ati
en
ts r
ep
ort
ing
sym
pto
m
Ltd A
ctiv
ity
Fatigue
Disco
mfo
rtSO
BPai
n
Lack
Wel
l Bei
ng
Appetite
Inso
mnia
Wea
knes
s
Dep
ress
ion
Anxi
ety
Walke L et al, JPSM, 2006
* * *
* *
* *
*75% or more reported symptom as
bothersome
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.
Integrate Palliative Care into New
Delivery and Payment Models
Adding palliative care targeted to the highest risk populations to the specifications for ACOs, bundles, PCMHs is key to their success at improving quality and reducing cost.
Major Health Systems/ACOs Get It
Making multimillion dollar investments in palliative care integration across settings:
•Partners Health System/ Harvard Medical School
•U. of Pittsburgh Health System
•Duke U. Health System
•North Shore-LIJ Health System
•OSF Health System
•Iowa Health System
•Ohio Health System
•Sharp Health System
•Banner Health System…
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