N ational Hospice and Palliative Care Organization’s Palliative Care Resource Series

1. National Hospice and Palliative Care Organization’sPalliative Care Resource Series Palliative Care in the Nursing Home Janet Bull, MD FAAHPM, HMDC

2. OBJECTIVES • Understand nursing home environments • Identify key components of a successful palliative care program • Discuss CMS Innovations model of care • Define tools, process and outcome metrics used to improve care, and demonstrate success

3. What Keeps You Up at Night? NH Administrators • Occupancy • Decreased reimbursement • Dealing with multiple payer sources – MA plans • Partnerships • Star ratings • Staff turnover • Case mix • Readmissions

4. Current Nursing Home Environment • Number of nursing facilities decreased from 16,179 to 15,650 in the last decade • Number of patients served has dropped from 1.4 million in 2005 to 1.3 million in 2015 • Multiple payors – Medicare Advantage, Medicaid and private plans • Star ratings put increased scrutiny on quality measures http://www.ahcancal.org/research_data/trends_statistics/Documents/Trend_PVNF_FINALRPT_March2015.pdf, p. 3 AHCA Fast Facts, June, 2015, downloaded February 18, 2016

5. Benefits of Collaboration and Value Proposition of Palliative Care 1. Increased Proportion of Dying Patients in SNFs • 25% Americans die in LTC • Half of these died within 5 months • 65% died within 12 months Kelly, A J Am Geriatr Soc 58:1701–1706, 2010. Length of Stay for Older Adults Residing in Nursing Homes at the End of Life

6. Benefits of Collaboration and Value Proposition of Palliative Care Dementia in LTC • Accounts for up to 2/3 of all admissions • Death rate doubled from 1996 to 2007 • Behavioral issues often drive NH admissions • Staff often ill equipped to handle

7. DISEASE MANAGEMENT

8. Benefits of Collaboration and Value Proposition of Palliative Care 2. Nursing Homes Held Accountable for Quality • 5 Star Ratings • Health Inspections – last 3 years • Staffing • Quality Measures Each category has 5 star category and is designed to help consumers compare SNFs.

9. 5 Star Ratings Quality Measures – Long Stay • Data on falls • Use of physical restraints • Urinary tract infections • Assistance with tasks of daily living • Moderate to severe pain • Pressure ulcers • Use of catheters • Use of antipsychotic medications http://www.medicare.gov/NursingHomeCompare/About/Long-Stay-Residents.html

10. 5 Star Ratings Quality Measures – Short Stays • Moderate to severe pain • New or worsened pressure ulcers • Antipsychotic medications http://www.medicare.gov/NursingHomeCompare/About/Long-Stay-Residents.html

11. Benefits of Collaboration and Value Proposition of Palliative Care 3. Readmission Rates • 25% Medicare patients readmitted within 30 days to the hospital • 2/3 of transfers are considered avoidable • SNFs will soon be penalized • HHS proposal to decrease payments by up to 3% by 2017 for NH with high readmission rates • 2018 – HHS proposes bundled payment system

12. Benefits of Collaboration and Value Proposition of Palliative Care 4. Reimbursement Shifting to Pay for Performance • 2014 IOM Dying in America report • Palliative Care Training/Education • Symptom Management • Effective Communication • Advance Care Planning • Goal Based Care • Continuity Across Settings

13. Designing a Palliative Care Program 1. Develop a Sound Business Plan • Scope of service • Team structure • Outcome metrics • Budget/financial plan • Standardization – intake, admin support, clinical care and quality defined. • Wide array of services or limited supportive services

14. Designing a Palliative Care Program 2. Decide Eligibility Criteria – Importance of Prognostication • Serious or life limiting illness • Risk stratification model • Mortality Risk Index for Dementia patients

15. Designing a Palliative Care Program 3. Collect Relevant Data • Readmission rates • Transitions to and length of stay in hospice • Symptom scores • Advance care planning completion • Billing revenue • Patient/family satisfaction

16. Designing a Palliative Care Program 4. Models of Palliative Care in the NH setting • Hospice agency/nursing home partnerships • Externally based palliative care • Facility-based palliative care

17. Designing a Palliative Care Program:Challenges and Barriers 1. Recognize benefits and need for palliative care • Improves quality of care • Provides highly coordinated care • Improved outcomes • High family and caregiver satisfaction • Improved staff satisfaction

18. Designing a Palliative Care Program:Challenges and Barriers 2. Reluctance to Refer to Hospice Care • Desire to maximize skilled days – concern over decreased reimbursement • Institutional limit to number of NH patients receiving hospice care • Revenue limited and services may need financial support

19. Designing a Palliative Care Program:Challenges and Barriers 3. Understand Legal and Regulatory Issues • SNFs under high level of scrutiny • State surveys • Auditors review delivery of care, quality of care, consumer and family complaints • Minimum Data Set (MDS) • CMS “CASPER” report

20. Designing a Palliative Care Program:Challenges and Barriers 3. Understanding Legal and Regulatory Issues • The Nursing Home Interpretive Guidelines – State Operations Manual • F-tag 309, Quality of Care • Review of Resident at or Approaching End of Life • Assessment and Management of Care at End of Life • Identify resident’s prognosis • Recognize and advise when resident is approaching eol • Review plan of care

21. Tips for Success 1. Use a Palliative Care Screening Tool • Completed by MDS/admissions coordinator on all NH admissions • Identify the following patients: • cancer diagnosis • end stage disease, such as CHF, COPD, dementia, ESRD • without Advance Directives • pain or symptom needs • multiple hospitalizations

22. Tips for Success 2. Develop Facility Preference Lists • Define your program parameters. Don’t try to be all things to all people. It is better to under promise and over deliver. • Develop facility preferences – list key decision makers.

23. Tips for Success 3. Understand What is Important for Each Nursing Home • You are a guest in their facility • Win-win situation • Define what is important so expectations can be met

24. Tips for Success 4. Evidenced Based Tools to Improve Clinical Care • INTERACT • Communication • Care paths or clinical protocols • Advance Care Planning • Available for LTCF, ALF, home health, and ACOs (under development) http://interact2.net/tools.html Interventions to reduce acute care transfers

25. INTERACT – Communication Tools • SBAR tool • Medication Reconciliation • Stop and Watch – early warning on changes with residents • Transfer forms/checklist

26. INTERACT – Care Paths • Fever • Dehydration • Dyspnea • CHF • GI sx – nausea, vomiting, diarrhea • Respiratory Illness • Altered mental status • Change in behavior • UTI

27. Tips for Success 5. Track Clinical Outcomes • Pain • Shortness of breath • Completion of ACP • Readmission • Satisfaction

28. Conclusion • Partnerships between palliative care providers and nursing homes can improve care for NH residents • Reducing readmissions and hospital deaths • Improving symptom management • Aligning care with patient goals • Improved satisfaction of care