PALLIATIVE CARE BEYOND THE HOSPITAL WALLS. SSM Health 10/7/14

Transcription

1 PALLIATIVE CARE BEYOND THE HOSPITAL WALLS Michelle Schultz, MD SSM Health 10/7/14

2 Panelists Carla Beckerle, DNP, APRN-BC Esse Health Diane Pierce, RN, BSN, CCM, CNLCP Esse Health Yvonne Schwandt, RN, BSN Pathways Palliative Care Kathleen Meyer, RN, MBA SSM Palliative Home Health Phillip Beyer, DO - Tradewinds Palliative Care

3 Essence of Palliative Care National Quality Forum Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and facilitating patient autonomy, access to information, and choice Current system of care fails to meet these needs High degree of unmanaged or under-managed symptoms in patients with chronic and/or debilitating illnesses Poor communication regarding patient goals of care Lack of coordination with patient and family preferences- Need for advanced care planning

4 Why Outpatient Palliative Care? Filling the Gap Patients with advanced illness spend most of their time out of the hospital Unmet needs of patients not ready for hospice Symptoms Psychosocial needs Hospitals recognizing need for post-acute care and smoother transitions Frustration of evaporation of careful post-acute plan after inpatient palliative care consult Ability to institute Plan B if/when Plan A fails Meier D. J Pall Med. 2008;11:823

5 Potential Benefits of Outpatient PC Improved disease management/integration Avoid hospitalizations/readmissions Inpatient follow-up care Advance care planning outside of crisis situation Earlier transitions to hospice care Meeting people where they are, both literally and philosophically

6 Ideal Vision of Non-Hospice Non-Hospital Palliative Care Everything we do, Nothing we don t do And more Symptom management Family support Interdisciplinary team Advance care planning Home visits by Palliative Care MD or NP Rehab services No limitations on pursuit of aggressive interventions

7 Barriers Care Silos: Hospitals, SNF, Payers, Physicians Poor transitional care Reimbursement constraints Gaps in knowledge: providers and consumers Myths and misconceptions

8 Stakeholders Patients and families Hospitals Health Systems Hospices The American People

9 Coalition to Transform Advanced Care (C-TAC) Advanced Illness Management (AIM) Advanced illness defined as one or more conditions serious enough that general health and functioning decline and treatments begin to lose their impact Trajectory leads to death BUT AIM can Improve QOL Lower utilization of clinical treatments and hospitalizations Increase patient and family satisfaction Reduce aggregate spending

10 Phases of AIM AHA. Advanced Illness Management Strategies Part 2

11 CAPC Models for Outpatient Palliative Care

12 Type of Services Consultation (single or few visits) Plan implemented by referring MD Co-Management Ongoing management of specific issues Referral Transfer of primary care responsibilities Advisory only (e.g. Medical director, Non-billable) Challenges Identifying patients who could benefit Requires Buy-in from referring provider, patient, family Financial

13 Clinic Models Hospital-based: Linked to Inpatient PC program Provides continuity for immediate hospital f/u May provide primary PC without prior admission Share PC staff with inpatient program Participate in cost-avoidance financial model Decreased readmissions, ER visits Embedded within other specialty clinics (oncology, cardiology, etc.) Convenient for patients same day visits Collaboration with host clinic Borrow clinic staff (RN, MA, billing, etc.) All costs of the clinic operations are born by the host clinic Immediate attention to uncontrolled issues Defined clinical pathways may exist defining patient flow between the host and palliative care

14 Community-Based Model Ideal for debilitated homebound patients Home, Assisted Living, SNF Assess living environment simultaneously Partner with Home Care or Hospice Time consuming with travel Decreased productivity Loss leader Recoup costs through increased home care or hospice revenues Cost-avoidance through decreased utilization of hospital, ER, expensive therapies (ACOs, managed care)

15 Diversity in Outpatient Palliative Care No Standards (unlike hospice) Many variables State regulations Sponsor Funding Goals If you ve seen one palliative care program, you ve seen one palliative care program Bob Parker, RN, AseraCare

16 Review of Published Evidence of the Impact of Outpatient Palliative Care 4 Randomized Controlled Trials Numerous observational studies Results Outpatient Palliative Care can Improve patient satisfaction Improve symptom control and QOL Reduce health care utilization Rabow M: J Pall Med. 2013; 16:1540

17 Temel Study Newly diagnosed metastatic non-small cell lung cancer Early palliative care concurrent with oncologic care vs usual oncologic care Monthly clinic visits with PC MD Results Higher QOL scores Less depression (16% vs 38%) Less likely to receive chemo w/i 2 wks of death Less likely to receive aggressive EOL care (33% vs 54%) More likely to receive hospice care Significantly longer survival (11.6 vs 8.9 months) Temel JS:NEJM. 2010;363:733

18 Kaiser Permanente Home-Based PC 298 Home-bound patients with CHF, COPD or cancer Randomized to PC vs Usual care Interdisciplinary team similar to hospice including home MD visits and 24 hour on-call Results Improved patient satisfaction No change in survival time More likely to die at home (71% vs 51%) Overall 33% decreased total costs Increased home care costs Decreased ER, hospital days, MD office visits, SNF days Brumley R: J Am Geriatr Soc.2007;55:993

19 Results from Kaiser Permanente s In-Home Palliative Care Intervention Pilot

20 Summa Health System Akron, OH Innovative Models of Palliative Care Delivery in a Community Setting Multiple projects PEACE - Promoting Effective Advanced Care for Elders CAHC Home based palliative care Long Term Pall Care Program PharmD Integration Palliative Care Units PACT: Pediatric to Adult Care Transition Partnering with the ACO Steven Skip Radwany, MD, FACP, FAAHPM NHPCO Virtual Conference

21 PEACE TRIAL: Promoting Effective Advanced Care for Elders RCT pilot study of a palliative care case management intervention Intervention involves collaborative care between a hospitalbased IDT, Area Agency on Aging, and PCP Outcomes for PEACE Pilot: Home PC for Dual Eligibles* Study Group Control ED Visits 29% 37.5% Hospital Admissions 41.9% 50% NH Admissions 13.3% 25% *Not statically significant, N=90 Allen, et al. Pop Health Manag 2012, Radwany, et al. Pop Health Manag 2013

22 Comprehensive at Home Care: CAHC Pilot at one year Home-based PC for SummaCare Medicare Advantage patients Eligible diagnoses: CHF, COPD, Advanced cancer Team: RN Coordinator, Case Manager, Social Worker, Aide, MD, NP PRN Chaplain, Nutritionist, PharmD, Mental Health RN Weekly team meeting ~23% transition to hospice 8% expired in program High satisfaction from patient, family and providers

23 SummaCare Coordination Network The formation of a coordinated and integrated voluntary network of preferred SNFs intended to: Reduce fragmentation and redundancy Improve the discharge planning process Decrease hospital LOS and unnecessary readmissions Impact the delivery of care without owning facilities Enhance quality and patient outcomes NH PC consultation service run by NPs with support from other disciplines Weekly team meetings

24 Palliative Care Consults in Nursing Homes: Sampled Data Through 2012 Discharge Outcomes N % Enrolled in Hospice Died Left Facility/Signed Off Re-hospitalized Missing data

25 PRIME by AseraCare (Progressive Illness Management Expertise) Seriously ill patients at high risk for futile care On downward path toward terminality Community NP Model Homebound patients 1+ years from hospice NP SNF Model Periods of improving/stabilizing and periods of decline - Rehab to home 2+ years from hospice NP Payer model NP as medical case manager 4+ years from hospice Focus on utilization of resources and cost avoidance

26 PRIME by AseraCare (Progressive Illness Management Expertise) Palliative Care best practices to enhance QOL Pain and symptom management Medication management Setting management and transitions of care Advance care planning Providers bill for services NP (or MD) as community case manager providing medical care LCSW for counseling (need DSM Dx) 0.3% rehospitalizations 23.5% hospice conversions

27 Aetna Compassionate Care Program Improve QOL for members with <1 yr survival Telephone case manager program Identify case via hospital, medical and pharmacy claims, predictive modeling, physician- or self-referral Telephone assessment of physical, psychosocial and home needs Individualized care plans based on above and member preferences Focus on symptom management and caregiver support

28 Aetna Compassionate Care Program Case management teams have RNs with oncology or hospice experience and SW living in local community Promote coordination among doctors Connect to community resources For commercial insurance patients months of hospice benefit along with conventional care 15 days respite care to support families Proposed to CMS Medicare Care Choices Project

29 Aetna Compassionate Care Program Results (2011) 14,000 cases Zero complaints Commercial cases: Hospice election increased from 32% to 72% Hospital days reduced by 37% Medicare Advantage cases Hospice election rate 82% Hospice LOS doubled to mean of 36 days 82% reduction in hospitalization 86% reduction in ICU days

30 Finances Most outpatient PC practices operate at loss Primary cost is labor Billing < Expenses BUT Temel Study showed mean cost savings per outpatient consult $2,282 Decreased inpatient visits-mean $3,110 per patient Less chemotherapy-mean $640 per patient Longer lengths of hospice stays Temel et al. NEJM 2010; 363:733

31 Potential Sources of Support Billing Hospital/Medical Center Hospice Home Health ACO or Health Care System Academic Research/Grant Philanthropy

32 CAPC Resources Overview of Outpatient Palliative Care Models Developing a Business Plan for your Outpatient Palliative Care Program Budget and Modeling Workbook for Oupatient Palliative Care Programs Getting Started: The Outpatient Palliative Care Clinic Getting Started: Establishing Home-Based Palliative Care Services Telemedicine and Palliative Care Detailed profiles of 3 exemplary programs, homebased, co-located and clinic based

33 Outpatient Palliative Care in St. Louis Clinics Washington University, Mercy Palliative Care, St. Luke s Hospital Home Mercy Palliative Care, SSM Palliative Home Health, BJC Supportive Care, Esse Health, VA NHs and ALFs Pathways Palliative Care, Mercy Palliative Care Telemedicine Mercy Palliative Care

34 Washington University School of Medicine Clinic embedded in Adult cancer center Consultative and Co-management All referrals through Cancer Center MDs Staff MD 0.1 FTE Nurse 0.1 FTE Psychologist 0.1FTE All support through billing No outcomes yet opened 4/14

35 BJC Supportive Care Adult and pediatric All diseases Financial: billing, hospice and home care Adult Home, ALF Staff 10 nurses 1 SW Admin 1 FTE each supervisor and dietician Share PT/OT/ST/Dietician with home care No MD

36 St Luke s Hospital Adult embedded clinic Staffing: MD only Consultative, co-management and referral Cancer, cardiac pulmonary, neuro Financial billing and hospital Hospital Affiliation Referrals: inpatient, Cancer Center, MD, Self

37 Mercy Palliative Care Outpatient programs Home visits 1-2/month NH visits 45/wk ALF visits 5/wk Clinics Stand-alone 2.5 days/wk Co-located 2 half days/month Telemedicine 1/wk

38 Mercy Palliative Care 99% Adult, 1% Pediatric All diseases Affiliated with Health Care System Staffing 2 FTE MDs plus 3 FTE Post-acute 4 FTE NPs plus 4 FTE Post-acute FTE RN 1 FTE LCSW for counseling Share pastoral care with hospital and outpatient clinics 1 FTE administrative assistant FTE RN/MBA office manager Fellow planned 2015

39 Services Consultation Co-management Referral (transfer) only in NHs Referral sources Auto-consult for given parameters via EMR Inpatient Cancer center MD Home Care Hospice Self-referral

40 Funding Billing 90% Health system 10% (Hospital) Fellowship (2015) Philanthropy for education and marketing

41 Pathways Hospice & Palliative Care Pathways Hospice Life-limiting illness < 6 months prognosis Medicare A Benefit Interdisciplinary Team Home, SNF, ALF Pathways Palliative Care Serious illness with no life expectancy requirement Medicare B Fee for Service NP Consultation Visits Social Worker and Chaplain PRN SNF, ALF

42 Palliative Care Referral Triggers Advanced or serious illness with disease progression Uncontrolled or chronic symptoms that interfere with quality of life such as pain, dyspnea, anxiety, fatigue, weight loss, nausea, sleeplessness Two or more ER visits or hospital admissions in last 2 months for same symptoms or diagnosis Expected transition from curative to comfort care End of life decisions need to be made Patient/family/ medical team disagree or confused about goals of care

43 Palliative Care Team Nurse Practitioner Collaborating Physician Social Worker Chaplain Office staff

44 Palliative Care Services Pain and symptom management Person-centered goals of care discussions and advance care planning Education about disease process, prognosis and care options Medication reconciliation Triage to other social and spiritual resources including use of Hospice social worker and/or chaplain if needed

45 Payment Methods Medicare B Fee for Service Medicaid Commercial Insurance Facility Pay Patient Pay

46 Outcomes Reduces suffering and distress Reduces pill burden, increasing comfort Reduces hospitalizations Reduces cost Improves communication and understanding of disease and treatment Improves timeliness of hospice referral Improved patient and family satisfaction

47 SSM Palliative Home Health Specialty service of SSM Home Care Must meet Home Care criteria: Homebound Skilled need Requires RN, PT, OT, ST or SW Skilled observation and physical/emotional assessment of unstable condition Skilled procedure: IV/IM/SQ med administration, catheter irrigation or insertion, tube feedings, wound care, ostomy care Teaching and training related to disease management, medication, diet, selfmonitoring, risk factors and complications Services are reasonable and necessary Follow plan of care established and approved by physician

48 SSM Palliative Home Health 3 FTE RNs with previous hospice experience Previous unsuccessful attempts borrowing home care nurses and partnering with hospice nurses 2 Part time (~ FTE) SWs Shared with Hospice and Home Care Chaplain PRN (borrowed from Hospice) Medical director in advisory capacity (0.1 FTE) Unable to prescribe meds No direct discussion with patient and family Not billable PT/OT/ST, Dietician, Wound care RN via home care Administrative support borrowed from Home Care Weekly IDT meeting

49 SSM Palliative Home Health Diagnosis Cancer 50% COPD 10% CHF 12% OTHER 28% Referral Source MD 33% Hospital 78% SNF 4% Home Care 3% Outcomes (thru July) New Cases Admitted to Hospice 12% 37% 30 Day Hospitalization 11.5% 11.1% 30 Day Hospitalization general Home Care 18.7% 18.8% LOS Palliative 69.4 days 39.2 days LOS Hospice 81.3 days 72.9 days

50 Trade Winds Palliative Care Covered by Medicare B, Medicaid, and most 3rd party insurances Coincides with home health care services. Works as a liaison with PCP, specialist and home health care. Is not an emergency service.

51 Rural Palliative Care Step 1: The Referral Referral can come from the patient, family, Dr, ER, hospitalist, discharge planner, etc. Step 2: The Admission Assessment Completed by palliative care physician or our nurse practitioner. Step 3: The Follow-up Follow-up visits are to be done on as-needed basis after a phone interview (visits are 30 days apart).

52 Trade Winds Statistics Since January 01, % of patients transferred to hospice with an average LOS Days. As of January 01, admissions, 24 deaths and 103 discharges or transfers to Outreach.

53 Esse Health C.A.R.E. Program Impact of High Touch Model for frail elderly with health risks Mission: focus on commitment to frail and chronically ill patients by prevention and relief of suffering, enhanced quality of life and personal growth. Esse Health believes quality of life can be enhanced by putting the patient and the physician at the center of health care decisions. Joint goals are recognized and valued and effort is expended to honor the goals of this population.

54 C.A.R.E. ENROLLMENT PROCESS

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