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Improving oncology care with more integration of palliative care

Improving oncology care with more integration of palliative care. Thomas J. Smith, MD FACP Harry J. Duffey Family Professor of Palliative Medicine Director of Palliative Medicine Johns Hopkins Medical Institutions Professor of Oncology Sidney Kimmel Comprehensive Cancer Center

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Improving oncology care with more integration of palliative care

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  1. Improving oncology care with more integration of palliative care Thomas J. Smith, MD FACP Harry J. Duffey Family Professor of Palliative Medicine Director of Palliative Medicine Johns Hopkins Medical Institutions Professor of Oncology Sidney Kimmel Comprehensive Cancer Center tsmit136@jhmi.edi

  2. Objectives Reasons why. Smaller fixes within reach. More use of palliative care consultation services. More “primary palliative care” in oncology practices More and earlier use of hospice (live better and longer) Big fixes. Insurance: Aetna’s Compassionate Care Program Sutter Health Advanced Illness Model

  3. Medical care costs 2-fold more in the US than any other country $8100 $4500 OECD Health Data 2011

  4. Cancer care costs are rising exponentially- $173 billion at 2% growth rate Mariotto AB, et al. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst. 2011 Jan 19;103(2):117-28. Claxton G, et al. Health Aff (Millwood). 2010 Oct;29(10):1942-50.

  5. Quality of care is not optimal

  6. We are still hospital oriented and not hospice oriented near the very predictable end of life.

  7. QOL concerns are not raised or discussed in cancer clinical settings. Q: After diagnosis and before starting treatment, did anyone on care team ask what is important to you/family in terms of QOL? 2010 ACS CAN National Poll on Facing Cancer in the Health Care System (www.acscan.org)

  8. 3/4s of patients with lung and colon cancer think they could be cured with chemo (Weeks J, et al. NEJM 2012) Half of all lung cancer patientshave had NO discussion with any of their doctors about hospice 2 months before they die. Huskamp HA, et al. Arch Intern Med. 2009 Only 37% of patients have any conversation about dying. (Wright AA, JAMA 2008) 60% of us prefer not to have “hard conversations” (DNR, AMDs, hospice) until “there are no more treatment options left”. Keating NL, et al. Cancer. 2010 Telling some one they are “incurable” is not enough – people want information about prognosis, what will happen to them, and their options.

  9. Definition of palliative care “Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.” – Diane Meier, MD, Director, Center to Advance Palliative Care, July 1, 2011

  10. Palliative care in addition to usual oncology care allowed lung cancer patients to live almost 3 months longer than those who got usual oncology care. Temel J, et al. NEJM 2010; Temel J, et al, JCO 2011 • Longer and better survival • Better understanding of prognosis • Less IV chemo in last 60 days • Less aggressive end of life care • More and longer use of hospice • $2000 per person savings to insurers and society

  11. The American Society of Clinical Oncology now recommends “…combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden.” • Now 5 randomized trials showing the same results. • No trials showing harm or increased costs.

  12. Hospice in the United States Hospice is defined as a Medical Benefit Truly managed care: $150 a day outpatient, $500 a day inpatient Everything must be paid from that Must have a 50/50 chance of death in the next 6 months if the disease runs its natural course Hospice eligibility: Hospice in a Minute

  13. How do we better integrate palliative care into our care? • Primary PC: every oncologist should be able to do. • Communication (ask, tell, ask) • Symptom Assessment and management (ESAS, MSAS) • Spiritual assessment (FICA, SNAP, AMEN) • Hospice referrals • Secondary PC: referral, just like referral to cardiologist. • Tertiary PC: specialized inpatient and research programs. • Need more PC people • Fellowships • Advanced training (EPEC-O, ELNEC, OncoTalk)

  14. How to do palliative care in the office.Cheng J, King L, Alesi ER, Smith TJ. J Oncol Practice, 2013

  15. There are opportunities to improve our practice on hospice referrals

  16. How do we better integrate hospice into our care? • Have a “hospice information visit” when we think the person has 3-12 months to live. • Can’t hurt. OK to predict wrongly. • Can dramatically help • Makes us address difficult issues like “code status” • Informs family that the situation is serious and their loved one is dying • MOLST • Will, Living Will, DPMA, Life Review, Dignity therapy Smith TJ, Longo DL. Talking with patients about dying. N Engl J Med. 2012 Oct 25;367(17):1651-2. doi: 10.1056/NEJMe1211160.

  17. Hospice eligibility is straightforward The SURPRISE QUESTION: “Would you be surprised if this person were to die in the next 6 months?” Failure to thrive: BMI < 22, involuntary weight loss CHF NYHA Class IV, EF < 20% COPD: hypoxemia at rest, FEV1 < 30% Dementia < 6 words Liver disease: INR > 1.5, albumin < 2.5 Cancer – much easier. Salpeter et al. J Palliat Med. 2012 Feb;15(2):175-85 Hypercalcemia, any malignant effusion, spinal cord compression, ECOG PS 2 or higher

  18. The benefits are straightforward…better care, and people who use hospice for even one day live longer. Connor SR, et al. J Pain Symptom Manage. 2007 Mar;33(3):238-46.

  19. We miss opportunities to recognize hospice-eligible patients, they are readmitted, and cost more. • U of Iowa Hospitals. • 688 in-hospital deaths • 209 decedents had preceding admission • 60% of decedents were eligible for hospice on the penultimate admission, based on NHPCO, National Hospice and Palliative Care Organization worksheets. • -Only 14% had any discussion of hospice, despite being eligible; 14 of 17 enrolled, all from ONE service • - Hopkins among the lowest of UHC Hospitals for hospice discharges from Cardiology, some other services Freund K, et al. J Hosp Med. 2012 Mar;7(3):218-23. doi: 10.1002/jhm.975. Epub 2011 Nov 15.

  20. We miss opportunities to recognize hospice-eligible patients, they are readmitted, and cost more. Freund K, et al. J Hosp Med. 2012 Mar;7(3):218-23. doi: 10.1002/jhm.975. Epub 2011 Nov 15. WeckmannMT, et al. Am J Hosp Palliat Care. 2012 Sep 5.

  21. People who use hospice are re-admitted less often, use less medical resources, and get better care. Table 2. Readmission Rate by Post-discharge Medical Service Use Post-discharge medical services Ratio of readmissions Percent Hospice 11/240 4.6 Home-based palliative care 5/60 8.3 Home health 2/15 13.3 Nursing facility 14/58 24.1 Home no care 9/35 25.7 Enguidanos S, Vesper E, Lorenz K. 30-Day Readmissions among Seriously Ill Older Adults. J Palliat Med. 2012 Dec;15(12):1356-61. doi: 10.1089/jpm.2012.0259. Epub 2012 Oct 9. Hospice saves Medicare $2309 per decedent, and the longer the hospice Length of stay, the bigger the savings. Taylor DH Jr, Ostermann J, Van Houtven CH, Tulsky JA, Steinhauser K. What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Soc Sci Med. 2007 Oct;65(7):1466-78. Epub 2007 Jun 27. Better care, consistent with what people would choose. Smith TJ, Schnipper LJ. The American Society of Clinical Oncology program to improve end-of-life care. J Palliat Med. 1998 Fall;1(3):221-30.

  22. Identifying hospice eligible patients makes a difference PC program

  23. Change our standards of care to incorporate national guidelines and best practices about palliative care.

  24. 7. Set guidelines like the U S Oncology pathways that preserve survival, reduce cost by 35% in lung and colon cancer Less chemo Less hospital More hospice 2x↑ LOS, use • Someone in the office • AMDs • DPMA • Hospice info visit Generics Limit to 3 “lines” Of chemo Equal survival With no 3, 4, 5th Line chemo For NSCLC and colon cancer, equal results, less toxicity, less cost. Neubauer M, et al. J Oncol Pract. 2010 Jan;6(1):12-8. Hoverman JR, et al. J Oncol Pract. 2011 May;7(3 Suppl):52s-9s

  25. Advanced Care:How choice, comfort and dignitycan drive cost reductionin a shared risk/shared savings worldBrad Stuart MDstuartb@sutterhealth.org “Bending the Cost Curve for Seriously Ill Patients” Annual Assembly of AAHPM & HPNA March 8, 2012

  26. EHR • Patient Registry •Telesupport Center • HOSPITALS • • Emergency Dept. • • Hospitalists • • Inpatient palliative care • Case managers • Discharge planners • CRITICAL EVENTS • •Acute exacerbation • Pain crisis • Family anxiety HOME-BASED SERVICES • Home health • Hospice • MEDICAL OFFICES • Physicians • Office staff Moving Care Out of the Hospital 911 • Care Liaisons • Transitions Team New Advanced Care staff & services • Care managers • Telesupport

  27. Tracking the Process of Personal Choice HOSPITALS HOME-BASED SERVICES PHYSICIAN OFFICES TELESUPPORT EHR Continuity at high or low acuity • Start the conversation • Inpatient PC • Hospitalist • PCP Shared decisions made over time at the patient’s own pace Trained team linked across all settings Handoff

  28. Advanced Illness Management (AIM)90 Days Pre/Post Enrollment – Hospital • 54% reduction in admissions • 80% reduction in ICU days • 26% reduction in inpatient LOS (2 days/case) • Physicians • 52% reduction in MD visits – Home • 60% increase in hospice enrollment •49% increase in home health enrollment

  29. Net System, Payer SavingsPayer Mix = 71% Medicare • Per Beneficiary Per Month: • System savings $1125 • AIM rollout expense ($ 912) • Net system gain $ 213 PBPM • Total payer savings $ 760 PBPM Potential Medicare Savings: $ 14.2 billion 312 million x 5% x $760/mo. x 12 mo/yr. x 10% =

  30. Lessons Learned in Advanced Care • Re-engineer, re-brand, integrate • Add services people, clinicians want & need • Integrate MDs, AC, PC & Hospice • Personal goals drive cost savings • Person-centered trumps “patient-centered” • Seriously ill people don’t want to be patients • Turn the business model upside down • Get the heads out of the beds • Invest in home and community

  31. Conclusions

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