Palliative Care in Oklahoma: Looking Back, Looking Forward

1. Palliative Care in Oklahoma:Looking Back,Looking Forward Jeffrey Alderman, M.D. Associate Professor Director, Palliative Medicine OU College of Medicine – Tulsa

2. Objectives • Learn about the current state of Palliative Care in Oklahoma • Understand the benefits/pitfalls of Inpatient Palliative Care Consultation • Explore reasons why physicians have difficulty with Advance Directives • Learn what you can do to help patients receive appropriate Palliative Care

3. Case Study: Zelda S. Zelda is 73 years old. She has DM-2, Stage III CKD, and worsening PVD She has been admitted to St. John 4 times in the last 6 months with symptoms from her ischemic leg.

4. Case Study: Zelda S. Zelda is widowed, but has 3 children and 5 grandchildren. Her true love is golf. Her goal of care is to continue playing golf for as long as possible.

5. Case Study: Zelda S. Zelda’s golf playing is limited by pain. Social Isolation. Unclear if Zelda can continue to live alone. Unclear if Zelda ever executed an Advance Directive How can we help Zelda? What if Zelda lives in Oklahoma?

6. How Does Your State Rate? Oklahoma F State by State Report Card Hospitals with a Program Oklahoma South Region United States 8/43 401/983 1294/2452 www.capc.org

7. TULSA WORLD Saturday October 4, 2008 State gets failing health-care grade BY KIM ARCHER (World Staff) Writer Oklahoma is failing to care adequately for the sickest of its residents and is one of only three states in the country to receive an “F” for access to palliative care, according to a report released Thursday Alabama and Mississippi also received failing grades, according to the study by the Center to Advance Palliative Care and the National Palliative Care Research Center. The study appears in the October issue of the Journal of Palliative Medicine. Palliative care refers to treatment that concentrates on reducing the severity of symptoms rather than striving to halt, delay or cure the disease itself. The goal is to prevent and relieve suffering and improve a patient’s quality of life. Nineteen percent of Oklahoma’s hospitals with 50 beds or more have a palliative care program, the report said. Most are in larger hospitals in Tulsa and Oklahoma counties.

8. What was measured? • Patient access to palliative care services in hospitals • Patient access to board-certified palliative medicine physicians • Medical student access to clinical training in palliative medicine • Physician access to specialty-level training in palliative medicine Morrison, RS. et al. AMERICA’S CARE OF SERIOUS ILLNESS: A State-by-State Report Card on Access to Palliative Care in Our Nation’s Hospitals. Center to Advance Palliative Care/National Palliative Care Research Center , 2008, p.14

9. Why did we fail? • Clearly too few Oklahoma hospitals have Palliative Care Programs • Too few Board-Certified Palliative Care Physicians • Not enough Palliative Care Education for Medical Students • No Fellowship Training Programs

10. Conclusions • More Oklahoma Hospitals need to develop Palliative Care Programs • More Oklahoma clinicians need training in Palliative Medicine • We must educate the next generation of providers in Palliative Care

11. University of Oklahoma - St. John Medical Center Palliative Care Service

12. University of OklahomaSt. John Palliative Care Service • Started in October 2004 - CAPC • Interdisciplinary Team • Inpatient Consults • Close relationship with Hospice

13. St. John Palliative Care IDT

14. University of OklahomaSt. John Palliative Care Service • The Clinical Imperative • The Financial Imperative • Patient/Family Satisfaction • Coordination of Care across Venues of Care • The Educational Imperative • The Quality Imperative • Effective, Patient-centered, Timely, Efficient and Equitable

15. Education

16. OU School of Community Medicine in Tulsa • 130 Faculty • 70 – 80 MSIII and MSIV Students • 54 Internal Medicine Residents

17. Curriculum in Palliative Care • All Senior Internal Medicine Residents spend 60 clinical hours rotating on the Palliative Care Service • All Residents attend 7 didactic lectures • All complete online training in pain and non-pain symptom management

18. Stanford Curriculum • Introduction to Palliative Medicine • Pain Management • Non-Pain Symptom Management • Communication in Palliative Care • Legal Issues • Terminal Care • Palliative Care Health Care Policy

19. Clarehouse

20. Curriculum in Palliative Care • All Medical Students spend ~9 clinical hours rotating on the Palliative Care Service • All Medical Students attend 3 didactic lectures

21. Future Directions • No formal measurement of Palliative Care Training • Exploring pre/post rotation testing tools • Expand training to the College of Nursing

22. CONSULT SERVICE Demographic Data

23. Consult Numbers

24. Patient Volume

25. Patient Volume

26. Patient Demographics

27. Patient Payor Source

28. Background Illness

29. Reason for Consult

30. Referring Physicians Nephrology 1% OB/GYN <1% Emergency Med 1% Neurosurgery 1% Cardiology 2% Non-OU Internal Med 27% Family Medicine 5% Cardiovasc. Surgery 1% Hospitalists 20% General Surgery 1% Oncology 5% OU Internal Med 35%

31. Discharges Other – 2.7% Clarehouse* – 2.3% LTAC/SNF – 9.9% Expired – 31.1% Home – 39.3% Nursing Home – 14.7% *’Clarehouse’ is a hospice home in Tulsa, providing care to patients in the last month of life

32. Clinical Outcomes

33. Reported Pain Scores Severe Mod. Mild None 212 Patients Initial Evaluation Final Evaluation 130 Patients seen on the SJMC Palliative Care Consult Service: Oct 2005 – Oct 2006 212 Patients seen on the SJMC Palliative Care Consult Service: Oct 2006 – Oct 2007

34. Comparison of Pain Scores OU/St. John Mt. Sinai Hospital, NYC* 212 Patients 3707 Patients Severe Mod. Mild None Initial Evaluation Final Evaluation *Data Reported by R. Sean Morrison, MD. Presented at ‘Building Hospital Based Palliative Care Programs.’ sponsored by the Center to Advance Palliative Care (CAPC), San Diego, CA October 2005.

35. Reported Dyspnea Scores Severe Mod. Mild None 112 Patients Initial Evaluation Final Evaluation 112 Patients seen on the SJMC Palliative Care Consult Service: Oct 2006 – Oct 2007

36. Comparison of Dyspnea Scores OU/St.John Mt. Sinai Hospital, NYC* 112 Patients 2219 Patients Severe Mod. Mild None Initial Evaluation Final Evaluation *Data Reported by R. Sean Morrison, MD. Presented at ‘Building Hospital Based Palliative Care Programs.’ sponsored by the Center to Advance Palliative Care (CAPC), San Diego, CA October 2005.

37. Other Clinical Outcomes Agitation 61.1% Reduction Nausea 82.1% Reduction Constipation 67.3% Reduction Dry Mouth 62.9% Reduction Insomnia 75.9% Reduction

38. Satisfaction Outcomes

39. Telephone Survey of 67 patients/families following discharge date of at least 30 days. Patients were picked at random. Responses from 43 completed surveys are recorded above.

40. Satisfaction Results • 83 – 94% responded very favorably, reporting ‘excellent’ or ‘very good.’ satisfaction with Palliative Care at St. John

41. Satisfaction Results • We received our highest scores in the areas of ‘treatment with dignity,’ ‘inclusion of patients in decisions about care’ and ‘addressing spiritual needs.’ • The highest number of negative comments focused on the discharge process from the hospital.

42. Financial Outcomes

43. Length-of Stay-Savings 2008

44. Length-of-Stay Savings

45. Charge Avoidance - 2008

46. Mean Charges Per Day 11 Days Prior to Death Charges/Day • 10 9 8 7 6 5 4 3 2 1 • Days Before Death

47. Charge Avoidance

48. Putting it Together, LOS and Cost Savings

49. Looking Ahead into the Future… Assume 15% Annual Growth Rate

50. Should the Palliative Care Team See Every Patient in the Hospital?