Enhancing Palliative Care in Nursing Homes: Challenges and Strategies

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