Palliative Care in MiPCT : Extending the Continuum of Care
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Palliative Care in MiPCT: Extending the Continuum of Care
Phil Rodgers, MD FAAHPMAssociate Professor, Department of Family Medicine
Associate Director for Clinical Programs, Palliative Medicine ProgramUniversity of Michigan Health System
MiPCT 2013 Annual SummitOctober 2013
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Colleen Tallen, MD Medical Director Pain and Palliative Care Cancer Survivorship Mercy Health Saint Mary’s Grand Rapids, MI
I have no potential conflicts of interest or financial relationships to declare related to today’s presentation.
No Potential Conflict of Interest to Declare
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Objectives
Understand the fundamentals of palliative care, and its value to securing the continuum of high quality primary care
Identify specific opportunities to provide primary palliative care to your patients with advanced illness
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Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.
73 FR 32204, June 5, 2008Medicare Hospice Conditions of Participation – Final Rule
What is Palliative Care?
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Traditional Model of Care
Curative Care
Hosp
ice
Presentation/Diagnosis
Death
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HOSPICE CARE
HEALTH
Diagnosis Death
Curative & Life Prolonging Care
Prevention
CURATIVE CARE
ILLNESS DEATH
Bereavement
Palliative CareSymptom
Management
Life
Closure
EOL/
Dying
New Model of Palliative Care
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How is Palliative Care Different than Hospice?
o Palliative care is appropriate at any point in a serious illness. It is provided at the same time as life-prolonging treatment. No prognostic requirement, no need to choose between treatment approaches.
o Hospice is a medical benefit that supports care for those in the last weeks to few months of life. Patients must have a 2 MD-certified prognosis of <6 months, and often must give up insurance coverage for curative or life prolonging treatment in order to be eligible.
(Medicare Hospice Benefit: 84% Medicare, 5% Medicaid, 3% uninsured)
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Palliative care in the US Today
75% of US hospitals >50 beds have Palliative Care programs 85% of US medical schools have hospital-based palliative care
programs Palliative Care now recognized by ACGME, ABMS, NQF, and CMS States in the US with higher hospital palliative care penetration
have: Fewer Medicare hospital deaths Fewer intensive care unit / cardiac care unit (ICU / CCU) days Fewer admissions during the last 6 months of life Fewer ICU / CCU admissions during terminal hospitalizations Lower overall Medicare spending / enrollee
Goldsmith BA, Dietrich J, et al. J Palliative Med 2008; 11(8):suppl 1-9 Teno JM, Clarridge BR, Casey V et al. JAMA 2004;291(1):88-93
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Why Palliative Care Now?
We’re living longer, with more illness Burdens of symptom management and
care needs are increasing Treatment options and outcomes are
more complex Family caregivers and supports systems
are strained, eroded or absent Increasing emphasis on value in health
care delivery
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Target Population for Complex Care Coordination and Palliative CareDistribution of Total Medicare Beneficiaries and Spending
10%
63%
37%
90%
Total Number of FFS Beneficiaries: 37.5 million
Total Medicare Spending: $265 billion
Average per capita Medicare spending (FFS only): $7,064
Average per capita Medicare spending among
top 10% (FFS only): $44,220
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, 2005.
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100
90
80
70
60
50
40
30
20
10
%Claimants
Cost perClaimant
ManagementApproachPatient Type
Care Management Targeted to Needs of Patients
• Worried well• Self-resolving illness• Low grade acute illness Demand
ManagementLow
CaseManagemen
t
• Chronic diseases• Moderate to severe acute illness
DiseaseManagementMedium
HighComplex CareManagement
Palliative Care
Complex Patients• Significant diagnosis• Multiple co-morbidities• Often terminal• Several providers of care• Psychological / social / financial
upheaval
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Outcomes of Palliative Care
Improved patient and family satisfactionReduction in symptom burdenReduced costsProlonged Survival
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Improved Family SatisfactionMortality follow back survey palliative care vs. usual care
Casarett et al. J Am Geriatr Soc 2008;56:593-99.
N=524 family survivors Overall satisfaction markedly superior in palliative care
group, p<.001 Palliative care superior for:
Emotional and spiritual support Information and communication Care at time of death Access to services in community Well-being and dignity Care type and setting concordant with patient preference Pain and symptom control
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Improved Symptom ControlBakitas M et al. JAMA 2009;302(7):741-9
N= 322 advanced cancer patients in rural NH+VT Improved quality of life and less depression (p=.02) Trend towards reduced symptom intensity (p=.06) No difference in utilization, very low in both groups Median survival: intervention group 14 months,
control group 8.5 months, p=.14
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How Palliative Care Reduces Length of Stay and Cost
Palliative care:Clarifies goals of care with patients and familiesHelps families to select medical treatments and
care settings that meet their goalsAssists with decisions to leave the hospital, or to
withhold or withdraw death-prolonging treatments that don’t help to meet their goals
capc.org/research-and-references-for-palliative-care/citations Lilly et al, Am J Med, 2000; Dowdy et al, Crit Care Med, 1998; Carlson et al, JAMA, 1988; Campbell et al, Heart Lung, 1991; Campbell et al, Crit Care Med, 1997; Bruera et al, J Pall Med, 2000; Finn et al, ASCO, 2002; Goldstein et al,
Sup Care Cancer, 1996; Advisory Board 2002; Davis et al J Support Oncol 2005; Smeenk et al Pat Educ Couns 2000; Von Gunten JAMA 2002; Schneiderman et al JAMA 2003; Campbell and Guzman, Chest 2003; Smith et al. JPM 2003; Smith, Hillner JCO 2002; www.capc.org; Gilmer et al. Health Affairs 2005. Campbell et al. Ann Int Med.2004; Health Care Advisory Board. The New Medical Enterprise 2004. Elsayem et al, JPM 2006;
Fromme et al, JPM 2006; Penrod et al, JPM 2006; Gozalo and Miller, HSR 2006; White et al, JHCM 2006; Morrison RS et al Arch Int Med 2008
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Palliative Care Shifts Care Out of Hospital to Home
Service Use Among Patients Who Died from CHF, COPD, or Cancer Palliative Home Care versus Usual Care, 1999–2000
13.211.1
2.3
9.4
4.6
35.0
5.3
0.9 2.4 0.90
10
20
30
40
Home healthvisits
Physicianoffice visits
ER visits Hospital days SNF days
Usual Medicare home care Palliative care intervention
Brumley, R.D. et al. 2007. J Am Geriatr Soc.
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Hospital Palliative Care Reduces CostsCost and ICU Outcomes Associated with Palliative Care Consultation in 8 U.S. Hospitals
Live Discharges
Hospital Deaths
Costs Usual Care
Palliative Care Δ Usual
Care Palliative
Care Δ Per Day $867 $684 $183* $1,515 $1,069 $446*Per Admission
$11,498
$9,992 $1,506*
$23,521
$16,831 $6,690*
Laboratory $1,160 $833 $327* $2,805 $1,772 $1,033*ICU $6,974 $1,726 $5,248* $15,53
1$7,755 $7,776***
Pharmacy $2,223 $2,037 $186 $6,063 $3,622 $2,441**Imaging $851 $1,060 -
$208***$1,656 $1,475 $181
Died in ICU X X X 18% 4% 14%**p<.001**p<.01***p<.05
Morrison, RS et al. Archives Intern Med 2008;
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Palliative Care Can Improve Survival
Randomized controlled-trial, 151 patients with metastatic NSCLC
Palliative care plus cancer treatment vs. usual cancer care
Intervention group showed: Better QOL and symptom scores Less ‘aggressive care’ at end-of-life Prolonged survival (~2 months)
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Temel J, et al. New Engl J Med 2010; 363(8): 733-42
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What does Palliative Care Do?
Pain and physical symptom management Clear communication Difficult or complex treatment decisions Managing care transitions Detailed and practical help at all stages of care Emotional and spiritual support
“Right Care, Right Place, Right Time”
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Palliative Care Delivery
Tertiary Palliative CareDelivered by subspecialty Palliative Care Teams
Secondary Palliative CareDelivered by clinicians frequently caring for seriously ill patients
Primary Palliative CareDelivered by all interdisciplinary clinicians to patients with serious illness, and their families
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Primary Palliative Care
Many patients die in the care of their PCP Effective palliative care is high-quality primary
care through the end of life Primary care providers are uniquely situated to
provide comprehensive care to patients and families facing life-limiting illness
Our growing challenge is to provide this care in a coordinated, sustainable way
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Primary Palliative Care ‘Tasks’
Prognosis – help communicate prognosis to inform patient/family decision-making
Planning – establish goals of care consistent with patient/family desires and values
Palliation – carefully assess and address physical, emotional, interpersonal and spiritual symptoms
Prescribe Hospice – discuss when/if hospice care is an appropriate option
Smucker D. Clin Fam Prac; Elsevier, June 2004
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Prognosis: Consider and
communicate
Palliation:Integrate Palliative
and Disease-Oriented Measures
Planning:Clarify Patient’s
Values and Goals of Care
Prescribing Hospice:Understand eligibility criteria and explain
options for care
Tasks of Primary Palliative Care
Smucker D. Clin Fam Prac, June 2004
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Why is Prognosis Assessment Important?
Important to medical teams Assist clinicians in their decision making Avoid costly interventions that may cause
suffering Guides recommendations for interventions likely
to be beneficial Optimization of resource allocation and
utilization of support services
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Why is Prognosis Assessment Important?
Important to patients and their families: Information helps patients and families in
choosing therapeutic options
Planning for emotional and financial management through advancing illness and end-of-life
Not receiving a prognosis is the most common reason families say they are dissatisfied with end-of-life care
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Karnofsky Performance Scale
100% Normal, no complaints, no evidence of disease 90 Able to carry on normal activity: minor symptoms of disease 80 Normal activity with effort: some symptoms of disease 70 Cares for self: unable to carry on normal activity or active work 60 Requires occasional assistance but is able to care for needs 50 Requires considerable assistance and frequent medical care 40 Disabled: requires special care and assistance 30 Severely disabled: hospitalization indicated, death not imminent 20 Very sick, hospitalization necessary: active treatment necessary 10 Moribund, fatal processes progressing rapidly 0 Death
DA Karnofsky, JS Burchenal, 1949
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Predictions of survival
Time predictions: “How long do you expect this person to live”?
Outcome predictions: “ What is the probability you think this person will be alive in 6-12 months”?
or
“Would I be surprised if this patient died within the next 12 months”?
Outcome predictions more accurate than time predictions
Br J Cancer 1990;62:685-689
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Planning: Outcomes
Advanced DirectivesLiving WillsDurable Power of Attorney for Health
Care (DPOA-HC) “Do-not-resuscitate orders”
Prolonged mechanical ventilationArtificial nutrition (tube feeding)
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Starting the Conversation
“What are you hoping for?” “What are you afraid of?” “What is most important to you in your life?” “Have you thought about what it might be
like if we can’t help you live the way you want to live?”
“Have you thought about dying? Have you talked to anyone about it?”
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When to Start: Clinician Cues
At time of serious diagnosis Advanced CHF, cancer, dementia, etc.
At time of functional change
At time of crisis or disease progressionHospitalizations, ICU staysInitiation of advanced therapies
• Artificial nutrition/hydration• Dialysis, LVAD, tracheostomy, etc.
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. . .Patient and Family Cues
“I don’t know if I can do this much longer” “I don’t want to come back to the hospital
again” “We can’t stand to see Mom like this” “What happens if this (procedure/
medicine/treatment) doesn’t work?” “I’m so tired, I just want to die”
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Shared Decision-Making
Patient/Family Goals Values Hopes Resources
Medical Providers Clear information Prognosis Recommend plans
to meet goals, be consistent w/values
Commitment to always provide care
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Words that Work
“We want to help you live as well as you can, for as long as you can”.
“You’re sick and it’s serious, but we’ll be with you no matter what happens”.
“What can I do for you now?” “We will do all we can to get you the best
care possible”.
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Resources
Hospice Finder (www.mihospice.org) Palliative Care Programs and Resources (
www.capc.org) Educational Tools (www.eperc.mcw.edu) Patient and Family Resources
www.theconversationproject.orgwww.fivewishes.org