Providing Home Based Support in the 4 th Quarter

Transcription

1 Providing Home Based Support in the 4 th Quarter Winnie Teuteberg, MD Dave Thimons, DO, CMD What would be most important to you in the last year of life? 1. Physical Comfort 2. Spiritual Peace 3. Love 4. Intimacy with family and friends 5. Meaning 6. Closure What do patients get in the last year of life? Doctors Hospitals Emergency Rooms Chemotherapy Blood Draws Intensive Care Units Nursing Homes Approximately 50% of people die in hospitals or nursing homes 75-80% would prefer to die at home Number of doctors the average patient sees in the last 6 months of life = 10 Number of inpatient days in the last 2 years of life = 17 Number of SNF days in the last 2 years of life = 28 Half of older Americans visited an ED in the last month of life 75% of older Americans visited an ED in the last 6 months of life The Last Years of Life: Cost Total Medicare spending in the last 2 years of life is approximately $70,000 Targeted Medicare palliative care population spending in the last 6 months is $53,000 Average copayments in the last 2 years of life = $3572 Average out of pocket expenditures in the last 5 years of life = $38,688 Almost half of patient spending (43%) exceeded total non-housing assets Physical Suffering in the Last Year of Life Over 50% of cancer patients report untreated or undertreated pain in the last year of life 90% of COPD patients report untreated shortness of breath; 68% report untreated pain 56% of patients with CHF reported untreated pain...and...the problem is not getting better Patient perceptions in pain levels, anxiety, depression, and shortness of breath have not improved from 2000 to

2 The Challenge Care in the last chapter of life is often: -Expensive -Disjointed -Poorly aligned with patient goals and values -Unable to maintain physical comfort for vulnerable patients What we have been doing -Extend span -End of disease oriented treatment = failure -Hope is often based on next treatment -More is better Need to change locations of care, as defaults in hospitals are to do more History of Palliative Care Death in the 20 th century Conquering of illness Penicillin, polio vaccine, cancer chemotherapy Shift in focus of medicine towards curing illness and prolonging life Institutionalization of medicine Care moved from home to hospitals and clinics Most deaths now occur outside of the home Change in popular experience of death No longer commonplace Fear of the unfamiliar History of Palliative Care Philosophy of Palliative Care Modern medicine often falls short in the care of patients at the end of life Active care for patients and their loved ones should not end when illness is no longer curable By focusing on the treating the whole patient and his or her loved ones, we can improve quality of life at the end of life Evolution of Palliative Programs Movement from St. First academic Christopher's inpatient PC AAHPM centers Hospice in unit board into the London Montreal certificati community on 1996 late 2000's Home Hospice in the US 1974 PC consult services in academic centers in the US 1990's ACGME accredited fellowship training 2008 Community based palliative care TODAY Why community based PC now? Traditional reimbursement structure Restricted reimbursement for PC to CMS defined episodes of care: inpatient, longterm care, hospice Patients were often lacked palliative care during vulnerable stages of illness Affordable Care Act Shift in reimbursement from fee for service for payment for value and bundled payments Payers now incentivized to reimbursement for more innovative models of care that improve quality of care across the continuum Recognition that many costly unplanned episodes of unplanned care could be avoided with proactive patient centered care in the community UPMC Palliative Care UPMC Palliative Supportive Institute created in July 2011 Goal to ensure the overarching goals of palliative care were met across the health system Mission Ensure high quality coordinated care for patients with serious illnesses throughout the continuum of care Clinical programs Inpatient consult services at all UPMC hospitals Ambulatory clinics Community based programs 2

3 UPMC community based palliative care Skilled nursing home programs started in 2012 Home based programs in partnership with UPMC Health Plan started in 2015 Home transitions program Advanced illness program Skilled nursing facility programs Palliative care trained CRNP embedded at UPMC facilities Over 3600 visits in FY15 with current YOY growth at 19% Significant reductions in unplanned transfers that has consistently become more pronounced since program inception in 2012 Home based programs Home Transitions Addition of palliative care SW and CRNP to traditional UPMC Jefferson home care Target health plan members at moderate to high risk of readmission Goal to reduce readmission by improved social supports, symptom management and advance care planning Current census over 400 patients Home based programs Advanced Illness Care Designed to provide ongoing palliative care outside of CMS defined episodes UPMC Health Plan members with PC needs but not ready for for hospice Graduates from Home Transitions programs Direct referral from primary care as well as inpatient and ambulatory PC programs Up to 10 CRNP and SW visits during the calendar year Referring provider must designate patient as having a serious illness Current census is 145 patients Increase of 121% over last year Future directions Home-based primary care pilot Extend geographic reach of CRNP program by increasing scope of practice Increase referrals and improve care coordination through more close integration with large community primary care practices Telemedicine UPMC Health Plan telemedicine for Advanced Illness Care program Aspire / Highmark AIS Home Visit Program Who is Aspire? -Home based Palliative Care physician practice operating in approximately 16 markets; founded in Contracted with Highmark to care for all Highmark Medicare Advantage patients with an approximate 1 year life expectancy or less -Freedom blue, Security Blue, some Community Blue -Operations began here on 7/1/2016, and now seeing all eligible Highmark MA members across Pennsylvania and West Virginia Program grown off the momentum built by Highmark s former Advanced Illness Program 3

4 : Philosophy 1. Build a clear understanding of palliative care as a separate service from hospice. 2. Develop deep working relationships with PCP s and specialists 3. Provide co-management, interdisciplinary palliative care clinical services 24/7 across settings 4. Utilize robust data collection, tracking and sharing processes : The Team Palliative Care Physicians Nurse Practitioners RN s Social Workers Chaplains Unlimited number of home visits No charge or co-payment to patient Will not interfere with office transitional care code billing : Referral Sources Algorithm PCPs Specialists Hospital care management Highmark health coaches Home Care agencies Hospice agencies Navihealth Example of what we do! Enrollment: Currently over 2000 active patients; over 2600 served since inception; Anticipate census of 4000 by end of 2016 Approximately 50 NPs employed, 10 RNs, 2 social workers, 1 chaplain, 4 physicians Primary Diagnosis: 1. CHF 36.7% 2. Cancer 14.3% 3. COPD 13.4% 4. Dementia 10.9% 5. CVA 3.9% 6. Renal 3.4% ADVANCED CARE PLANNING: -99% of patients with advanced care plan discussions at every visit -76% of patients with an advanced care plan completed HOSPICE UTILIZATION: -Approximately 60% of patients pass away on hospice (Goal > 75%) -Hospice median length of stay : Approximately 35 days -Hospice mean length of stay : Approximately 80 days PATIENT SATISFACTION: 4.9 on a scale of 5 HOSPITALIZATION REDUCTION: -61% reduction in inpatient admissions compared to last 9 month baseline, -68% reduction in inpatient admissions compared to last 12 month baseline As of 12/31/15,135 ER visits averted by NPs making urgent home visits. How do we describe the program to patients? extra layer of support, experts in treating symptoms like pain, shortness or breath and nausea, help avoid unnecessary visits to hospital and ED, home visits from nurse practitioner, coordination with patient s PCP, 24/7 access to doctor or nurse practitioner. 4

5 The Future Continue to grow program and develop best practices Improve outreach and relationships with community physicians and hospitals Enhance provider education Deliver top quality care to qualifying patients TO MAKE REFERRAL: 1. Call: Fax: