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1 The presentation will begin shortly.

2 Laura Mavity, MD, Clinical Director Centers of Care Advanced Illness Management AHA CPI Webinar January 23, 2013 Katie Hartley, BSN, Administrative Director

3 St. Charles Health System Four Hospital System St. Charles Medical Center Bend (261 beds) St. Charles Medical Center Redmond (Rural designation, 48 beds) St. Charles Madras (Critical Access, 25 beds) Pioneer Memorial Hospital (Critical Access, 25 beds) Primary Care and Subspecialty Practices Home Health and Hospice Services Behavioral Health Services

4 Central Oregon Madras Site Redmond Site Bend Site Prineville Site

5 St. Charles Health System IDS WHAT: Our IDS is designed to achieve the Triple Aim HOW: Delivered through the Centers of Care model

6 Centers of Care

7 Triple Aim and Palliative Care To Improve the Health of Our Population (Better Health) Complex planning and management of advanced illness eases stress for patients and their loved ones Intensive support for caregivers and families To Improve the Patient Experience (Better Care) Improve pain and symptom control Address emotional, psychosocial, and spiritual suffering in life-limiting illness Clear and realistic patient-centered care goals Seamless discharge planning to community resources Improved patient and family satisfaction Improved hospital staff and physician support and satisfaction To Reduce the Cost of Care (Better Value) Streamline healthcare avoid undesired or non-beneficial care Reduce inappropriate resource utilization Avoid hospital readmissions

8 Centers of Care

9 SCHS Advanced Illness Management Center of Care Realistic patient and family-centered care goals Re-evaluated throughout the duration of illness Empowering patients and families about healthcare choices Facilitate referrals to appropriate community programs Advance care planning Expert symptom and comfort management Whether pursuing aggressive life prolonging care or comfort measures only Independent of prognosis Focus on patients with progressive life limiting illness with prognosis of two years or less

10 SCHS Advanced Illness Management Center of Care St. Charles AIM Palliative Care Consultations St. Charles Bend consults consults consults consults $4000 estimated average direct variable cost avoidance per consult St. Charles Cancer Center 2010 AIM Center of Care 2011 Outpatient Consultations Spring 2012 St. Charles Redmond Fall 2012

11 SCHS Advanced Illness Management Center of Care Develop seamless care flows for patients with advanced illnesses throughout our regional health care system Collaboration/Partnerships St. Charles AIM Program: Inpatient consultations all four hospitals Outpatient consultations all four sites including St. Charles Cancer Center Bend and Redmond Regional hospice and Transitions programs Regional physicians, practices, and community programs

12 SCHS Advanced Illness Management Center of Care Program Initiatives Outpatient palliative care consultation service Cancer Center: all patients with stage IV lung cancer Advance Care Planning The Conversation Project Cambia Health Foundation Sojourns Pathway Grants $237,000 CAPC Palliative Care Leadership Center training and mentorship UCSF palliative care program financial data analysis pilot project Quality/Performance Improvement Program Integrative Therapies - partnership with Cancer Center System standardization of processes and procedures Four hospitals, regional hospices, other service organizations

13 SCHS Advanced Illness Management Center of Care Program Highlights AIM patient readmission rate 6.8% (expected 10.4%) AIM team members provide >30 educational/outreach presentations per year Average hospital LOS approximately three days after AIM Team consult AIM Center of Care Newsletter distributed to community partners three times per year Bloom Project Comfort Care Program and Cart Creation of Mosaic art piece with AIM Center of Care partners

14 SCHS Advanced Illness Management Center of Care Mosaic Art Piece

15 SCHS Advanced Illness Management Center of Care Mosaic Art Piece

16 QuickTime and a decompressor are needed to see this picture. 16

17 The Coalition to Transform Advanced Care (C-TAC) is a national non-profit, non-partisan alliance of patient and consumer advocacy groups, health care professionals and providers, private sector stakeholders, faith-based organizations, and health care payers. Members include: 17

18 Developing a Person- and Family- Centered Advanced Care Model Brad Stuart, M.D. Co-Chair, Clinical Models Workgroup 18

19 C-TAC s Principles of Advanced Care Management The primary goal of Advanced Care is to provide the most appropriate level of care as determined by the ill person, avoiding either over- or under-treatment. The free and personal choices of the patient drive the plan of care. The central setting of intervention is the ill person s place of residence, where through repeated encounters over time, education and advance care planning can proceed at the ill person s own preferred pace. 19

20 C-TAC s Principles of Advanced Care Management Continued Advanced Care provides for the ill person s needs across the entire continuum of late-stage illness for a period of years rather than a shorter period of time. Any savings compared to usual care result strictly from the ill person s free choice to pursue a care plan that often includes less invasive, and therefore less costly, treatment alternatives. 20

21 Care Coordination Coordination in Space Place team members in: Hospital Physician office Home Coordination in Time Advance care planning evolves as illness progresses Trained team ensures care follows personal goals Goal: Total Care Coordination Heal artificial split between treatable & terminal 21

22 EXAMPLE: Advanced Illness Management AIM coordinates changes in goals, condition, and care plans with providers and sites of care based on ongoing experiences/goals of persons living with advancing illness. AIM provides care and support (palliative and other) to improve health in terms of quality of life and care delivery, and lower cost of services for persons with advancing illness in the last 12 months of life. (AIM)

23 EXAMPLE: AIM Program Coordination Home Based AIM Transitions team; RN Care Coordinators AIM MSWs Telemanagement & Office Based Case Management RN Care Coordinators & AIM MSW Primary Physician Person with Advanced Illness & Family Home Health AIM Team; RN Care Coordinators AIM MSWs PT, OT, ST Hospital Based: AIM Care Liaison (RN) Key Connections: Care Team Interfaces with: Hospital case management, hospitalists, IPPC Primary Care Physicians Other providers AIM Leadership Interfaces with: Affiliate, Foundation, and Regional Physician, Case Management, Hospitalist Leaders 23

24 C-TAC Member Clinical Models Aetna s Compassionate Care Ascension Health home health palliative care Gundersen Health System s Respecting Choices Hospice & Palliative Care of Western Colorado Sutter Health s Advanced Illness Management US Veterans Health Administration s Home-Based Primary Care (HBPC) 24

25 The 2-day National Summit on Advanced Illness Care is bringing together innovators in policy and advocacy as well as inter-professional providers, faith leaders, patient/family members and business executives, who can and are, creating solutions to improve care for America sickest and most vulnerable population. The Summit s panel discussions will include: Putting clinical and community models that work in place, including advanced care management models that improve patient/family quality of life, lower costs and affect other key metrics. Providing patients/family members care that meets their needs at the right time, in the right place. Training and supporting the inter-professional team of providers. Bring about policy change through targeted advocacy 25

26 Questions? 26