National Trends in Palliative Care Tom GualtieriReed MBA Spragens amp Associates LLC Chicago Regional Leadership Summit for Supportive Care Chicago Illinois May 1 2015 Agenda What is Palliative Care ID: 729686
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Meeting the Needs of Those with Serious Illness: National Trends in Palliative Care
Tom Gualtieri-Reed, MBASpragens & Associates, LLC
Chicago Regional Leadership Summit for Supportive Care
Chicago, Illinois
May 1, 2015Slide2
AgendaWhat is Palliative Care?
The Impact of Palliative Care on ValueNational Trends & ChallengesQ&A
2Slide3
3What is Palliative Care?Slide4
What is Palliative Care?4Palliative care is
an approach to medical care for people with serious illness. It focuses on providing patients
and their families with
relief
from the symptoms, pain, and stress of a serious illness—
whatever the diagnosis or stage of the disease.
The
goal is to
improve quality of life
for both the patient
and
the family.
It is provided by a
team
of palliative care doctors, nurses and other specialists who work
together with a patient’s other doctors
to provide
an extra layer of support
.
It
is appropriate at any age and at any stage in a serious illness and
is
provided along with
regular disease treatment. Slide5
Palliative Care is Delivered Concurrent with Disease TreatmentSource: Morrison and Meier. N
Engl J Med 2004;350(25):2582-90.5Slide6
6An 88 year old man with 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 5 gm
of acetaminophen/day.Admitted 3 times in 2 months for pain (2x), falls, and altered mental status due to constipation.His family (83 year old wife) is overwhelmed.
Case Example: Mr. B
Source: Diane E. Meier, MD, FACP, Director of the Center to Advance Palliative Care (CAPC).
Used with permissionSlide7
7Case Example: Mr. B
Mr. B: “Don’t take me to the hospital! Please!
”
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.
”Slide8
8
Usual Care
4
calls to 911 in a 3 month period, leading to…
4
ED visits and
3
hospitalizations, leading to…
Hospital acquired infection
Functional decline
Family distress
Palliative Care
House calls referral
Pain management
24/7 phone
coverage
Support
for
caregiver
Meals on Wheels
Friendly visitor program
No 911 calls, ED visits, or hospitalizations in last 18 months
Before and AfterSlide9
Clinical Skills: Pain and symptom
managementGoal settingCaregiver support
Social & spiritual
support
Structural
Elements:
Targeting of those with serious
illness
Interdisciplinary
team-based care
Flexible levels of care delivery
“dose”
C
are across settings
and
24/7
access to care
team
Delivered concurrently or independently of
disease treatment
Characteristics of Quality Palliative Care
Note: Derived from the
National Quality
Forum’s framework
and preferred practices for
quality palliative care and
the National Consensus
Project for
Quality Palliative Care
guidelines
9Slide10
Understanding the Need:Sickest 5% Account for 50% of Expenses
Source: Agency for Healthcare Research and Quality analysis of 2009 Medical Expenditure Panel Survey.
Distribution of health expenditures for the U.S. population,
by magnitude of expenditure, 2009
1%
5%
10%
50%
65%
22%
50%
97%
$90,061
$40,682
$26,767
$7,978
Annual mean expenditure
10Slide11
Source: IOM Dying in America Appendix E http://
www.iom.edu
/Reports/2014/Dying-In-America-Improving-Quality-and-Honoring-Individual-Preferences-Near-the-End-of-Life.aspx
Who
Are the Costliest 5% of Patients?
11Slide12
Who are the 5%?Risk is concentrated among those with:Functional LimitationDementia
FrailtySerious illness(es)12Slide13
13The Impact of Palliative Care on ValueSlide14
The Value EquationValue =
Quality Cost14Slide15
Crisis preventionWhat is the Impact of Palliative Care?
Quality:Relieves pain and symptomsPatients live
longer
Better family support
Cost:
Setting & treatment aligned with patient goals
Reduces 911 calls, ED visits, and hospitalizations
Reduces unnecessary tests, procedures
15Slide16
Palliative Care Improves Outcomes For Patients
151 lung cancer patients randomized to usual care versus usual + palliative care consultationCompared to usual care only patients, palliative care patients were observed to have:Significantly improved quality of lifeLess depressionFewer burdensome treatments
Improved survival: + 11 weeks
Temel et al, NEJM 2010
16Slide17
Palliative Care Improves Outcomes for FamiliesCaregivers of patients receiving palliative care have:Better quality of life, experience less regret, and show improvements in physical and mental health
Compared to dying at home with hospice:Dying in hospital associated with:9 fold increased risk of prolonged grief disorder in caregiversDying in an ICU associated with:5 fold increased risk of posttraumatic stress disorder (PTSD) in caregiversWright AA et al, JAMA,
2008; JCO, 2010,
17Slide18
Live Discharges
Hospital Deaths
Costs ($)
Usual
Care
(n=18,2347)
Palliative Care
(n=2,630)
Δ
Usual
Care
(N= 2,124)
Palliative
Care
(2,278)
Δ
Per Admission
$11,140
$
9,445
$1,696
**
$22,674
$17,765
$4,908
**
ICU
$7,096
$1,917
$5,178
*
$14,542
$7,929
$7,776
*
Died in ICU
18%
4%
14%*
*P<.001 **P<.
01
18Slide19
Palliative Care Reduces ReadmissionsHospital palliative care reduces readmissions by 50%. Discharge with hospice or palliative care associated with a 4-6 fold reduction in readmissions as compared to discharge to:home (home health or no home care)nursing home (without hospice)
Nelson et al, Perm J, 2011; Enguidanos, JPM 2012, Adelson et al, ASCO 201319Slide20
Palliative Care at Home for the Chronically Ill
KP Study
Brumley
, R.D. et al. JAGS 2007
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.
20Slide21
21National Trends & Challenges
Increased access to quality palliative care in hospitals
Growth in need in the office, home and post-acute settings
Our ability to meet the need through workforce development
Payer and payment trends
National attention on palliative care and serious illnessSlide22
In 2012, hospital programs were serving over 6MM patients each year.
Palliative care prevalence and # of patients served has nearly tripled since 2000
.
Palliative Care Growth: U.S.
100%
of the U.S. News 2014 – 2015 Honor Roll
Hospitals Have a Palliative Care Team.
100%
of the U.S. News 2014 – 2015 Honor Roll
Children’s Hospitals Have Palliative Care Teams.
Source: CAPC analysis of 2012 National Palliative Care Registry™ Annual Survey
22Slide23
This chart shows the mean palliative care service penetration for palliative care teams, from the lowest to highest quartiles in terms of staffing.
Higher
staffing levels are a key determinant of higher penetration rates (serving more patients in need).
Insufficient staffing continues to present a barrier to reaching patients in need.
Source: CAPC analysis of 2012 National Palliative Care Registry™ Annual Survey
23
Higher Staffing Results in Palliative Care Serving More Patients in 2012Slide24
The Modern Death Ritual: The Emergency DepartmentHalf of older Americans visited ED in last month of life and 75% did so in their last 6 months of life.
Source: Smith AK et al. Health Affairs 2012;31:1277-85.24Slide25
The Family Burden65 million caregivers deliver care at home toa seriously ill relative
Average 20 hours/week87% state they need more help33% in poor health themselvesStressed caregivers are at significantly increased risk of death, major depression, reduced quality of life, and loss of work
Emanuel et al. Ann Intern Med 2000, Levine C. N
Engl
J Med1999, Schulz et al. JAMA 1999; Schulz et al. JAMA 1999;282:2215.,
Kuhlthau
et al,
Matern
Child Health 2010,
Natl
Fam
Caregivers Assoc, 2010
25Slide26
26
Source: Center to Advance Palliative CareSlide27
Where are the Gaps?Smaller hospitals (<100 beds)HomeNursing home and assisted livingOffice practicesCancer centers
27
27Slide28
Meeting the Growing NeedExample: Over 65 Trends
1950
2000
2050
Proj*
In 2050, the number of Americans aged 65 and older is projected to be 88.5 million,
more than double
its population of 40.3 million in 2010.
In 2050, those aged 65 and over are projected to account for
20%
of the population in the U.S., up from 13% in 2010.
*Source: U.S. Census Bureau. U.S. Department of Commerce.
28Slide29
Examples:
Interdisciplinary team – leverage all skillsTrain all clinicians serving seriously illRedesign payment models to support the care that is needed
How do we Meet the Need?
29
Source:
Center to Advance Palliative Care On-line Training.
www.capc.org
29Slide30
30With funding support from the California HealthCare Foundation
Sponsored by:
www.capc.org/payertoolkit
Opportunities for Payer-Provider PartnershipsSlide31
Payer Case Examples Demonstrate Options for Impact
31Slide32
32
Payer Results
…
For
the 1% of all Medicare Advantage members enrolled in the Compassionate Care program, there is an
:
82% hospice election rate;
81% ↓ in acute days;
86% ↓ in ICU days;
High member and family satisfaction
Total cost reduction of over $12,000 per member
For those members enrolled in the Highmark
Advanced
Illness Services
program:
Satisfaction:
95
% would refer Friends/Family
Metrics:
Hospice election: 79%
Average/median LOS in hospice: 85/29 days
Acute care last six/one months of life: 14% ↓ / 33% ↓
ICU last six/one months of life: 30% ↓ / 48%
↓
ER visits in last 1 month of life: 39% ↓
Increased
health care proxy completion rates: 42% of persons 18 years of age and older across 39 counties; 47% in Rochester Region (2008) vs. 20% national completion rate
Nearly
60% of Excellus BCBS employees have completed health care
proxies.
Was
founding force behind NY’s eMOLST: the first electronic form and process documentation system in the nation that also serves as the state registry.
32
Source:
Center to Advance Palliative Care
Payer Toolkit.
www.capc.orgSlide33
33Growing National Attention and Resources to Expand Access
Tools, Training & Technical Assistance
Advanced Certification in Palliative Care
2014 IOM Report & Recommendations
Requires Palliative Care for Cancer Center Accreditation
Palliative Care Training for Nurses
Sponsoring Planning Grants for Payer-Provider PartnershipsSlide34
34Q&A