Palliative Care Across the Health System: Different Systems and Levels of Care

1. Palliative Care Across the Health System: Different Systems and Levels of Care Catholic Health East November 17, 2011 Vicki Christian-Baggott

2. OBJECTIVES • At the end of the presentation, participants will be able to identify: • The programs and services along the continuum of care after acute care (hospital) that are essential opportunities for the development of palliative care programs. • The challenges that clinicians face in developing palliative care programs in continuing care services. • The demographic imperative and critical need for palliative care programs in continuing care services. • The need to continuity of care for the patient and family members. • The various models of palliative care programs that are successful in continuing care services.

3. WHAT IS CONTINUING CARE? • Continuing care consists of programs and services that are provided to a patient after acute care (hospital care). These programs and services include: • LTCH – long term acute care hospital • Outpatient clinic programs • Sub acute care • Home Health care • Assisted living or independent living • Nursing Home care (skilled care or custodial care) • PACE – program for all inclusive care of the elderly • Hospice

4. DEFINITI0N OF Palliative CARE • FROM THE NATIONAL CONCENSUS PROJECT FOR QUALITY PALLIATIVE CARE, PALLIATIVE CARE IS….. • …. A care delivery model that has a goal to prevent and support the best possible quality of life for patients and their families, regardless of the stage of disease or the need for other therapies or treatment modalities.

5. DEFINITI0N OF PALLIATIVE CARE (C0NT.) • A philosophy of care • An organized, highly structured process for care delivery • Facilitates patient autonomy, access to information, and choice; gives • people the support they need and the ability to make choices about • their care • Enhances traditional medical model treatments to include the goals of • improving the quality of life for the patient and family, optimizing • function, and assisting with decision making • Can be provided concurrently with life prolonging care or as the main • focus of treatment (hospice)

6. Medicare Hospice Benefit Life Prolonging Care Life Prolonging New Hospice Care Care Bereavement Palliative Care Dx Death palliative care model Old

7. CORE ELEMENTS OF PALLIATIVE CARE PROGRAM • Patient and family centered care • Timing of care • Comprehensive care • Interdisciplinary team • Proactive • Focus on relief of suffering • Effective communication skills • Continuity of care • Smooth transitions • Access to care • Quality and patient safety • The right care for the right patient at the right place and time.

8. Patient centered palliative care

9. Why palliative care programs are needed • Prolonged length of stay, frequent readmissions • High degree of unmanaged or under-managed symptoms in patients with chronic and/or debilitating illnesses • Poor to non-existent communication regarding patient goals of care • Lack of coordination with patient and family preferences-need for “life plan” • Significant fiscal impact on hospitals and other institutions

10. Typical palliative care referral issues seen in continuing care programs • Pain and symptom management • Patient and family weighing aggressive treatment options versus hospice care • Advance care planning • Conflict Resolution

11. Barriers to Providing Palliative CareServices in continuing care programs • Inadequate staffing/financial support/culture/environment. • Lack of education/philosophy/consensus of End Of Life (EOL) care/grief & bereavement/communication skills/advanced directives. • Staff often believe that they are already giving palliative care and are not open to changing their opinion. • Lack of sharing information/politics. • Difficulty implementing team work. • Lack of hospice service availability. • Lack of palliative care specialists. • Provider believes he/she can provide palliative care services on own. • Lack of assessment for pain and symptom management. • Lack of equipment. (pain/infusion pumps, etc.) • Poor transition of care or lack of communication among caregivers. • Culture of organization • Staff perception of a greater workload, more paperwork, meetings, etc.

12. Challenges for hospital palliative care teams when transitioning their patients • Once discharged, can the receiving staff support the complex needs of the patient? • A lot of work has been accomplished for patient and family goals of care – will this continue to be the goal after discharge or if the patient goes to yet another level of care or gets readmitted? • Will the limited number of nursing staff be able to manage the patient’s pain and symptom management needs? This can be especially challenging for home-bound patients, nursing home patients, or those who go out into the community with little to no follow-up care. • The discharge plan was solid prior to discharge, but the physician who is now caring for the patient has changed the orders and the patient now is back in the ED or gets readmitted to acute care. • There is no adequate link between the hospital case managers and the continuing care case managers or other outpatient systems of care resulting in inadequate after care, poor communication and serious potential for medical errors.

13. Are these issues valid? • Approximately 1/3 of patients with chronic illness and hospitalization had no post discharge follow-up arrangements. • Less than 50 percent of primary care physicians were given any discharge information or communication. Many are never notified that their patients have been discharged. • 3 percent of the primary care physicians are involved in communication with hospitalists for topics such as discharge plans. • Reference: “Coordinating Care-A Perilous Journey Through the Healthcare System” (T. Bodenheimer, MD, NEJM 358 March 2008).

14. Readmissions to acute care • At least one in five Medicare patients are readmitted within 30 days of discharge. • At least half of these were not seen by their outpatient physician. • This results in an estimated 17.4 billion dollars!!! • Primary diagnoses include CHF, COPD, pneumonia and infections (such as UTI)

15. Persistent and critical challenges for QI • Medication Reconciliation • Transitions of Care • Communication Among Caregivers

16. Benefits of Palliative Carein continuing care services • 1) Improved pain and symptom management therefore, improved quality of life • 2) Saves time for facility staff including Medical Director • 3) Marketing tool for the institution • 4) If no hospice presence then can serve as alternative • Communication liaison between patient, family, staff • Enhanced patient and family satisfaction • 7) Enhanced staff satisfaction • 8) Contribute to Quality Improvement efforts

17. Palliative Care in continuing care • ALWAYS PUT THE PATIENT FIRST – WHAT DO PATIENTS WANT? • Pain and symptom control (that meets his/her own goal not the staff’s goal) • Improve quality of life to the extent possible • Avoid inappropriate prolongation of the dying process • Achieve a sense of control • Relieve burden on family members • Strengthen relationships with loved ones • To be at home whenever possible (whatever “home” means)

18. Why palliative care in nursing homes? • By the year 2030 the number of people living in nursing facilities in the United States is expected to double, to over 3 million people. • A growing number of nursing facility residents today are seriously ill or are actively dying. This dynamic influences several aspects of nursing home care: • Un-treated or under-treated pain in nursing homes is well documented, at least 50 percent of the residents in nursing homes today suffer from untreated pain. • Sixty-five percent of nursing home residents are functionally impaired and need assistance with 3 or more ADLs. • At least one-third of residents in the US suffer from malnutrition or dehydration according to a study done in 2000. • Although 70% prefer to die at home, only 25% do so, with the remainder dying in institutions (50% in hospitals and 25% in nursing homes). Deaths in nursing homes are expected to rise to over 40% by the year 2030.

19. Evolution of Nursing Homes • Provide around the clock skilled nursing care and rehabilitation services to people with illnesses, injuries or functional disabilities. • Now provide much of the nursing care that was previously provided in a hospital setting a decade ago. Med-Surg units in most nursing homes today, and the acuity continues to increase. • Patients less likely to be transferred back to acute care and will be treated for illnesses in the nursing home rather than in the Emergency Department.

20. Who Lives (and Dies) in nursing homes • 2004 – 1.5 million nursing home residents • 88% aged 65 years and older • 45% aged 85 years and older • 71% female • Approximately 48% to 66% of the residents have dementia • 25% Americans die in nursing homes • Projected that by 2030 >3 million Americans will reside in institutional long-term care

21. Palliative Care models in Nursing Homes • Palliative care consult service model • 1. Outside trained palliative care consultant contracts with organization • to provide assessments, recommendations, follow-up visits, staff • training. Clinical expert in pain and symptom management. • 2. Consults are written by attending physician or Medical Director. • 3. Best to have a physician “champion” to help implement program. • 4. Nurse practitioner role is essential and rapidly becoming the standard • of practice in nursing homes – should have both nursing home and • palliative care experience. • 5. Palliative care practitioner bills insurance – Medicare Part B, • insurance or Medicaid. • 6. Allows those on skilled care to receive services.

22. Palliative Care models in Nursing Homes • Hospice-Based Palliative Care Services • 1. Hospice staff come to nursing home to provide NON-HOSPICE • PALLIATIVE CARE consultation services. • 2. The interdisciplinary team services are available. • 3. Develop contract to include clinical services, education and training • for staff. • 4. Order written for consult by attending physician or Medical Director. • 5. Many of these patients will transition to hospice services later in their • care.

23. Palliative Care models in Nursing Homes • Hospice Care Model • 1. Medicare certified hospice providers bring comprehensive • interdisciplinary end-of-life/hospice care to nursing home patients • and families who are eligible for and elect the hospice benefit. • 2. Hospice is considered the gold standard for palliative care services • for terminally ill patients. • 3. Nursing homes with strong hospice collaboration have fewer unmet • patient needs and have greater satisfaction. Less invasive • treatments, fewer hospitalizations, and provide better care practices.

24. Palliative Care models in Nursing Homes • Nursing Home Services Integrated Model • 1. Base a Geriatric Nurse Practitioner in the nursing home to perform • the palliative care services. • 2. Demonstrates the decrease in hospital admissions and readmissions • 3. May also serve as a leader and mentor for nursing home staff. • 4. Important to change the culture in the organization – staff, • physicians, patients and family members. • 5. Evercare Model – comprehensive Medicare HMO product that • provides coverage for frail elderly, and chronically ill patients in • nursing homes.

25. Potential benefits of outpatient palliative care • Fosters follow-up continuity (good for both clinicians and patients). • Involvement in disease management occurs earlier and may result in improved clinical outcomes. • May avoid readmission to acute care. • Encourages earlier relationships. • May assist in earlier consumer awareness. • Improve communication. • May assist with system redesign/process improvement.

26. Palliative care outpatient clinic • Potential for high volume capacity • Clear branding • Innovative use of interdisciplinary team • Quality control and measurement options • HIGH COST • REQUIRES SUPPORT STAFFING AND RELIABLE TEAM • PROFESSIONAL MANAGEMENT NEEDED • SERVICE STANDARDS NECESSARY • MUST DO NEEDS ASSESSMENT FOR PATIENT FOCUS – cancer focus versus chronic illness, geographic scope for home based services, target patients • Challenges such as exclusions (chronic pain, mental illness, addiction)

27. Why do outpatient clinic? • Serves as a necessary hub in the continuum of services that are offered. • Staff may be able to be shared effectively and flexed with Hospice staff • It may help the needs of specific patients such as pediatric patients, transplant list patients, etc. • May serve to leverage with telemedicine. • Must be very careful with following DEA recommendations, medication agreements. • May have a large group to help such as dialysis patients or respiratory or chronic cardiac patients.

28. Long term care hospital • LOS generally greater than 25 days • Acute care nursing hours and reimbursement structure • Ventilator patients • Other critical but generally stable illnesses • May be free standing or “hospital within a hospital” • Models for consultation services or Hospice partnership successful

29. Assisted and Independent living program • Often associated with Continuing Care Retirement Community but may be independent facility • Dementia facilities may also be free-standing • Beneficial for continuity of care for those patients who have been discharged back into the community, reduce readmissions, and to ensure communication among all caregivers, patient and family members in order to provide the optimum level of quality of care and quality of life. • Type of palliative care program most likely would be consultation services or Hospice partnership

30. PACE • Program for the all inclusive care for the elderly • Generally serve the frail elderly and also long term chronically ill participants • Receive all types of health care including home health and nursing home care when necessary • Use of nurse practitioners to provide clinical management • Goal to keep participants at home in the community • Hospice partnerships, Bridge program, palliative care in the nursing home • Physicians and nurse practitioners trained in palliative care

31. Home care models • Provider home visits (billable part B) • Home care services • Bridge programs (pre-hospice services) • Case management and disease management • Transitions coaches • The design and choice of model depends upon the needs assessment and goals: • Which patients? • When in their progression of needs? • In collaboration with which other providers? • Under what payment assumptions?

32. Logistical decisions for all models • Services: days of week, hours, 24/7 coverage issues and reliability • Prescheduling or reserved for urgent appointments (flexibility and efficiency) • Which members of the interdisciplinary team are in the room or on a visit – tracking productivity is a must • Process flows for communication of findings and follow-up • Payment and funding options and payer collaboration • IS DESIGN DRIVEN BY PATIENT NEEDS, STAFF AVAILABILITY, PAYMENT STRUCTURES, OR WITHIN LARGER SYSTEM DESIGN PROCESS? • IS IT POSSIBLE TO DESIGN A RELIABLE SYSTEM OF CARE THAT IS SEAMLESS FOR PATIENTS AND MINIMIZES DUPLICATION?

33. BASIC PRINCIPLES FOR ALL PALLIATIVE CARE MODELS • Need a tracking mechanism to monitor resource use, time use, patterns of care, costs and revenue • Administrative resource is critical for scheduling, billing, data management, and performing return calls • Plan for issues of pharmacy refills – workload, roles, quality management, and data management • Starting without a plan can create unmet expectations and team stress • If there are insufficient resources to meet all of the demands, design must include education and collaboration

34. Initial steps in developing a palliative care program • Leadership support - high visibility, and active participation • Physician “champion” preferably Medical Director • Management level clinician to serve as Coordinator of program • Organize interdisciplinary team to serve as the Steering Committee – physician, nurses, Administrator, pastoral care, social services, pharmacy and other appropriate team members • Identify external support and consultants such as hospital and Hospice program colleagues • Identify the organizational culture and readiness for implementing a palliative care program • Provide initial palliative care education presentation for leadership group and Steering Committee • Develop written work plan with established goals and timelines

35. Initial steps in developing a palliative care program • Education for staff, residents, and family members • Obtain training and development tools through resources: www.capc.org or purchase a Palliative Care toolkit through the AMDA website www.amda.com or pursue end of life training through End-of-Life Nursing Education Consortium (ELNEC): Geriatric www.aacn.nche.edu/elnec • Full list of resources: “Improving Palliative Care in Nursing Homes” available on www.capc.org • Active participation in Palliative Care Affinity Group

36. Components of palliative care education for continuing care • History and philosophy of palliative care and hospice • Pain management • Symptom management • Decision making • Communication • Cultural issues • Loss, grief, and bereavement • Spiritual care • Care when death is imminent • Economic issues • Professional issues • Please note that education is ongoing for all staff

37. Medicare independence at home (iah) • DEMO IN PROGRESS • THIS IS A CHRONIC CARE COORDINATION MODEL FOR MEDICARE • TARGET IMPLEMENTATION DATE IS 2012. • EXPECTED OUTCOMES: • Chronically ill beneficiaries receive primary care at home • Family caregivers are supported • Beneficiary choice is preserved. The beneficiary retains all existing Medicare benefits and can choose or deny participation in IAH. • Allows providers and practitioners to voluntarily form an IAH organization. https://www.cms.gov/DemoProjectsEvalRpts/downloads/IAH_FactSheet.pdf

38. Patient centered medical homes • The patient centered medical home is a health care setting that facilitates partnerships between individual patients and their personal physicians and when appropriate the patient’s family. • Care is facilitated by registries, information technology, health information exchange, and other means to assure that patients get indicated care where and when they need it in a culturally and linguistically appropriate manner. • There are 9 PCC standards including 10 “must pass” elements. • Standards are available at no cost from the NCQA (National Committee for Quality Assurance) @ www.ncqa.org

39. Hospice concurrent care • A 3 year budget neutral demonstration project. • It will allow patients eligible for hospice to simultaneously receive all other Medicare-covered services (curative care). • Up to 15 hospices from both urban and rural sites will be selected. • An independent body will evaluate the impact on patient care quality and cost. • Project specifications and site selection process TBA.

40. Accountable care organizations • The goal of ACOs is to encourage physicians and hospitals to integrate care by holding them jointly responsible for Medicare and costs. • A typical Medicare ACO would include a hospital, primary care physicians, specialists, and potentially other medical professionals. • Services would be billed under fee-for-service, but the organization’s members would coordinate care for shared Medicare patients with the goal of meeting and improving on quality benchmarks. • Because ACO members are held jointly accountable for this care, they would share in any cost savings that stem from the quality gains. • Health Care Reform Target Implementation 2012.

41. Medicare Bundled payment • Bundled payments change the way hospitals and physicians are paid for treating Medicare beneficiaries. • Under this mechanism, one payment would be provided for what is currently billed separately (for example: surgery for shoulder and several weeks/months for cancer treatment). • The goals of bundled payments are increased efficiencies and cost savings. • Target date for implementation is 2013. • Payments may be provided to the hospitals and then shared with the hospitals and the physicians based on a previously negotiated contract. • In addition to this government initiative, some insurance organizations and private organizations have developed and are testing episode based payment systems.

42. Take away thought • THERE ARE MANY OPPORTUNITIES FOR SEAMLESS PALLIATIVE CARE IN CONTINUING CARE.

43. Questions?? • Thank you for attending and participating in this webinar. • If you have any other questions or comments please feel free to contact me at vhc02@aol.com