Innovation in Palliative Care

Transcription

1 Innovation in Palliative Care Dr. Caprice Knapp MAY 15, 2015

2 Objectives Motivation for innovation (US and Canada) Legislation and programs that are changing the way we think about hospice in the US: Affordable Care Act, CMMI, PCORI, Office of the Duals, etc. Innovative Delivery Models Innovative Payment Models Innovative Research Final thoughts

3 Motivation Palliative care is an important model and philosophy of care With the goal of improving health related quality of life and reducing suffering, palliative care also has the potential to reduce cost and improve quality at the end of life In the US hospice is traditionally focused on the last 6 months of life, whereas palliative care has a longer timespan The focus is on the patient as a whole and care is teams based

4 Motivation NAHPCO Facts and Figures on Hospice Care % of Medicare beneficiaries used hospice before death 34.5% length of stay <7 days 66% of hospice care received at home 5,800 hospices in US Medicare pays for 83.7%

5 Motivation 2012 CHPCA Fact Sheet In Canada 15% have access to palliative services Disparities exist in access, quality, and out of pocket costs in palliative and end of life care in Canada 75% of deaths in Canada still take place in hospitals 6 of 13 provinces have policies on nursing and personal care services 24/7 The population is aging rapidly

6 Motivation 2012 CHPCA Fact Sheet Call for a National Palliative and End of Life strategy to develop national standards Call for a National Pain Strategy Need to develop a strategy for continuing care that would integrate home, facility, hospice, long term care in health systems Funding continues to be an issue hospices are funded ~50% by charitable donations $3M commitment to study community-integrated models in 2011

7 Motivation

8 Motivation Clearly overall costs and costs of hospice care are a motivation for innovation As hospice payment models become stagnant, or perhaps increase at a rate lesser than medical costs, all hospices are forced to do more with less As the population ages, the demand for hospice services will grow and the portion of the total health dollar that goes to hospice will grow Continues to be a debate about costs at the end of life and whether or not they should occur and if they are too much or too little and what role hospice plays (i.e. Being Mortal by Atul Gwande) In general, all aspects of health care don t have a choice but becoming more efficient and competitive as they operate on smaller and smaller margins (i.e. Lakewood hospital in Cleveland)

9 Innovative Payment Models

10 Innovative Payment Models What is Value in Health Care? Porter, NEJM 2010 Value=Health outcomes achieved per dollar spent= outcome/cost Outcomes can be many things such as mortality, patient reported health status, blood pressure, etc Getting the most for your money.

11 Innovative Payment Models Starting with he numerator we must define outcomes in palliative care, what is the measure and who is compliant Then we look at the denominator, should some people be excluded? (i.e. cognitively impaired with no proxy) Under the Affordable Care Act hospices will begin collecting and reporting quality data in 2014 Rate adjustments being considered

12 Innovative Payment Models National Quality Forum has endorsed 14 measures* 1634: Pain Screening 1637: Pain Assessment 1617: Patients treated with opioid who are given a bowel regime 1626: Patients admitted to ICU who have care preferences documented 1628: Patients with advanced cancer treated for pain at outpatient visits 1638: Dyspnea treatment 1639: Dyspnea screening * NQF Endorses Palliative and End-of-Life Care Measures, February 14,

13 Innovative Payment Models 1641: Treatment preferences 1647: Percentage of hospice patients with documentation in the clinical record of a discussion of spiritual/religious concerns or documentation that the caregiver did not want to discuss 0209: Comfortable dying 1625: Hospitalized patients who did an expected death with an ICD that has been deactivated 0208: Family evaluation of hospice care 1632: Consumer Assessment and Reports of end of life 1623: Bereaved Family Survey

14 Learning Collaborative Model Methodology to employ rapid testing in health care Invite teams from hospices around Saskatchewan Choose a basket of measure to work on Provide teams with tools and strategies Face-to-face time is critical F2F>>>>>Action Period>>>>F2F>>>>>>Action Period>>>>F2F Monthly data and progress reporting Examples in medical home, hospital, perinatal, NICU, etc.

15 Innovative Payment Models Centers for Medicaid and Medicare Medicare Care Choices Model Will allow 30 hospices to drop the 6-month certification requirement and offer concurrent services with curative care. For Medicare beneficiaries who have HIV, COPD, and cancer. 3-year demonstration project. We have been doing this in pediatrics since Hospice of the Valley- tiered payment system for supportive, enhanced, and hospice care. Worked with insurance companies to develop.

16 Innovative Payment Models Accountable Care Organizations (ACOs) Group of doctors, hospitals, and other health care providers who come together to give coordinated care to the Medicare patients Delivering high quality care at a lower costs Pioneer ACOs 400M savings over various procedures This is about bundled payments (i.e. joint replacement, bypass)

17 Innovative Payment Models Accountable Care Guide for Hospice and Palliative Care Could Accountable Care Be a Good Thing for Palliative Care and Hospice Providers? Recommended Approach for Developing Specialists Accountable Care Strategies Process Followed for Creation of ACO Guide for Hospice and Palliative Care Providers Recommended ACO Initiatives Metrics Savings Pool Negotiation Tips

18 Innovative Payment Models integrated health systems in the US Kaiser Permanente, VA, Geisinger etc. They have all three stages of information, communication, and financing Several are experimenting with palliative care models (Partners in Boston and Long Island Jewish System in NY) They will be able to adopt models quickly once there is an alignment with incentives Monarch Health System- a group of doctors received pall care training, do home visits to pall care patients, looking at savings under capitation and avoided ER

19 Innovative Delivery Models

20 Innovative Delivery Models- Canada The Way Forward End of Life Care Coalition by the Canadian Hospice and Palliative Care Association Conducted an 11-country report on Innovative Models of Integrated Palliative Care Goal is to increase capacity in primary care, home care, and long term care settings to provide palliative care This would create a seamless system from primary care to community to hospital to hospice der%20%28final%29%20en.pdf

21 Innovative Delivery Models- Canada The Way Forward focuses on the following factors Vision People Care delivery single access point that is available 24/7 focused on coordination, continuity, and is culturally competent Use supportive tools such as E MR, standardized assessment tools, performance measures, and monitoring Integrate palliative care into the management of life-limiting illnesses

22 Innovative Delivery Models- CA Next Generation of Palliative Care: Community Models Offer Services Outside the Hospital November 2012 Report What happens when patients leave the hospital, but do not fit in neatly with hospice because of rules and regulations? California survey found that most hospitals have palliative care programs (53%), only 18% have outpatient palliative care services (meaning not offered by hospice) The between care of hospital>>community>>hospice is not well defined or regulated

23 Innovative Delivery Models- CA Finances are the biggest barrier to addressing palliative care in the outpatient setting Capitation helps this somewhat, but only if providers can be convinced that palliative care leads to efficiencies in their services or health system Other challenges Lack of evidence on cost avoidance Difficulty establishing partners to align incentives in a system Lack of qualified personnel in outpatient setting Lack of clarity in specialist-primary care roles Increasing consumer understanding of palliative care

24 Innovative Delivery Models- CA Evidence that outpatient palliative care works and it cost effective? Morrison study 2008 Cost savings associated with US hospital pall care consultation programs. Arch Inter Med. 168:1,783. Brumley RD et al. Increased Satisfaction with Care and Lower Costs Results of a RCT of in home pall care. JAGS : Berge et al. Prevalence and Characteristics of Outpatient Pall Care Service in CA. Arch Inte Med, 2011 Rabow, Smith, Braun, and Weismann. Outpatient Pall Care Practices. Arch Int Med. 2010; 170:

25 Innovative Delivery Models- CA 1. Hospices can provide community-based services that are non-hospice. This could be consultation services in long term care facilities, or partnering with primary care providers to co-manage patients. Examples include Hospice of the Bluegrass in KY, Capital Caring in VA, Four Seasons in NC 2. None of these programs has been able to show break even, but they have demonstrated earlier referrals to hospice and more enrollees in hospice overall helping with economics of scale

26 Innovative Delivery Models- CA Outpatient palliative care is new in CA, but a survey showed that most often this is done in oncology-related practices, with about 500 patients per year They offer pain and symptom management, understanding prognosis, advance care planning, and help with medication management Inpatient physicians really like this for help with discharge Often these services are subsidized by hospital or health system

27 Innovative Delivery Models- CA Hospice of the Valley in San Jose Nonprofit, community-based hospice Barriers with the model include Medicare rules that say hospices should be primarily engaged in provision of hospice care- leads to corporate reorganization, have to develop market fair prices for palliative care services, hard to establish relationships with inpatient facilities, can be time consuming, hospice reimbursement became more strict so harder to justify these services

28 Innovative Delivery Models- CA What to consider? Stand alone or integrated Assume primary responsibility or co-manage Referral process and triggers Protocols for communication Quality metrics Payment authorization Staffing, logistics

29 Innovative Delivery Models- CA UCSF clinic called Symptom Management Services Offers consultations and co-management services in cancer center s outpatient clinic 1 physician and 1 nurse Expanding to heart failure and transplant Costs subsidized by management (for ½ of costs)

30 Innovative Delivery Models- CA Other policy ideas Consider having pall care nurse practitioner in all nursing homes Home care pall care done by home health agencies Biggest need is new reimbursement mechanisms for incentives to support coordination and palliative care- could get paid for coordination of services in home or community

31 Innovative Delivery Models- RWJ Promoting Excellence at the End of Life Each of the following programs has tools, materials, brochures, etc.

32 Innovative Delivery Models- RWJ 1. Incorporating palliative care in ESRD. Teaching an interdisciplinary team about palliative care instead of using hospice. 2. Indigenous palliative care in Alaska whereby community health workers provided care via communication radio and phone with Anchorage 3. Children s hospital in WA- development of a decision aid tool, QOL, creation of flexible insurance benefits that cover kids 4. Integrating palliative care into advanced cancer care planning 5. Training given to church groups and other community members on how to support end of life patients. Palliative care based in a community health dept. Does this mean we need courses in general on death and dying?

33 Innovative Delivery Models- RWJ 1. Project ENABLE coordinating care with local cancer hospital and hospice. Formed palliative care teams of which hospice had one seat at the table. 2. CD and booklet on deciding what decision to make at end of life. Good because developed in Detroit a low-literacy population 3. Palliative care resources for HIV patients 4. Integration of hospice and mental health for those with profound mental illnesses. Best practices for this group. 5. Integration of community case management and palliative care.

34 Innovative Delivery Models- RWJ 1. St. Louis pediatric program developed tools, trained 4000 in community, and advanced directives for kids 2. CHOICES program for pre-hospice, those who are about 2 years from death but high risk. 3. Training for rural and prison workers on palliative care. (i.e. Terminal Prison, an HBO documentary) 4. PEACE palliative care best practices for Alzheimer s patients 5. Palliative Care Information and Referral Center for rural areas and developed a hospice in Indian tribe only 2 nd in the US 6. Palliative care in nursing homes

35 Innovative Delivery Models- CAPC Center to Advance Palliative Care IPAL (Improving Palliative Care) programs for ICU, outpatient, and ER. Tools and best practices. Collaborative models, collaborative-agreements and hospital owned hospices. NPC Registry where you can voluntarily input your data. Has tools to help you track your progress over time and compare to others. Community services- post acute transitional services, embedded in cancer centers or other specialty care, advanced illness management programs.

36 Other federal initiatives driving change. Readmissions CareMore and Health Partners addressing readmissions through cross disciplinary teams, post-discharge clinics, and use of extensivists These are hospitalists who extend their services into primary care Medicare Independence at Home demonstration projects Bundled payment pilots in Medicare Concurrent care pilot programs in Medicare

37 Innovative Research

38 Cycle of Research Programmatic description Descriptive of structure and process Identification of outcomes Testing of interventions to improve outcomes (pre-post design) Testing interventions using the most robust methods (comparative effectiveness or RCT) Spread and sustainability of those interventions that proven to be effective

39 Motivation for Innovation in Research Pace and intensity of moving through the research continuum is motivated by outside forces Could be political, economic, historical, social, cultural etc. Industry is typically ahead of research in that interventions and innovations are tested several years before researchers However, the testing may or may not be robust and for many in the industry there are not discretionary funds to test these innovations.

40 PCORI: Palliative Care Research Patient Centered Outcomes Research Institute Palliative care provided in 30 nursing homes in New York Relapsed childhood neuroblastoma as a model for parental end of life decision making. Evaluating parental decision making at many points in time, does the decision to use PC change their choices to use aggressive therapies, only neuroblastoma. Follow 120 kids at 8 institutions at relapse and for 18 months. Computerized PAIN Relieve It protocol for cancer pain control in hospice. System level intervention of computerized tools of patient reported pain outcomes. 3 languages with decision support for physicians. 1 week, for patients in 2 Chicago hospices. And provides patient education. Daily updates to families and clinician. Health system intervention to improve communication about end of life care for vulnerable patients. Tailors patient-physician discussions. Feedback form provided to patients, clinicians, families communicating needs and preferences. 120 clinician, 6 patients per clinician,

41 NINR Innovative Research Questions National Institute of Nursing Research How do we overcome barriers in underserved, hard-to-reach populations in order to implement culturally congruent, patient- and caregivercentered palliative care strategies? What palliative care interventions/strategies best align with patient and caregiver goals? How do type, intensity, complexity, and fluctuation of symptom burden impact individual and family goals for care? What are the best models for community-based palliative care? What are the strategies for assessing caregiver preparedness and self-care abilities for palliative care early in the illness trajectory? For symptom management at end of life, what are the best minimally invasive methods to monitor functional status, physiological status, and patient reported outcomes? What electronic data collection methods can be used by health care providers to monitor, evaluate, and improve palliative/end-of-life care? What are the best ways to measure patient reported outcomes using standardized, widely used instruments or common data elements? What are the most effective ways to motivate and engage individuals, caregivers, and families in conversations about end-of-life goals and values that inform decision making? How do we operationalize and individualize palliative care and which models best meet the supportive and end-of-life care needs of patients and families? What factors in palliative care impact the process of bereavement?

42 NINR: Palliative Care Research NINR- Conversations Matter Talking about palliative care with your patients Tear-off pad (downloadable) End of life care in the ICU VALUE approach Value what the family members say Acknowledge their emotions Listen Understand the patient as a person Elicit questions

43 NCPCR Key Areas of Research National Center for Palliative Care Research Pain and symptom management Communication Models of health care delivery Resources- tools, methods workshop etc. 10 grants in 2014 Integration of palliative care into health failure treatment PCOR for patients with heart failure QOL for stem cell transplant patients Advance Care Planning for patients with dementia

44 ACS Palliative Care Research American Cancer Society Exploring the relationship of pain and other distressing symptoms on QOL, independence, functioning, disability and develop interventions Methods of improved communication between patients, families, and health care providers Models and systems of care for patients living with advanced illness and their families

45 Innovation in Training, Education, and Supply Not much Still struggle with meaningful palliative care courses in nursing and physician curriculum Some online modules now, though the quality is variable. Small number of fellowships and residency rotations Board certification in palliative care is relatively new, however, it is unclear how to certify those who come to palliative care later in life (as most do). Requires a fellowship.

46 What inspires you? What can you do to make your organization/facility better? This doesn t have to be a big idea, but can you start today or next week? Try something new for 1 week. Write down your results. What did you find?

47 Thank you! Caprice Knapp, PhD Research Associate Professor Department of Health Policy and Administration The Pennsylvania State University