1. 1. Community Based Palliative Care: Trends, Challenges, Examples, and Collaboration with Payers/Insurers Eric Wall, MD, MPH NW Medical Director United Healthcare
2. 2. Disclosures United Healthcare University of Washington School of Medicine
3. 3. Agenda Goals of Palliative Care The Cast of Players Trends Challenges Examples of Community-based initiatives Working with Payers/Insurers
4. 4. Oh Death Oh death, oh death Won't you spare me over till another year Well what is this that I can't see, With ice cold hands taking hold of me Well I am death none can excel, I'll open the door to heaven or hell Whoa death someone would pray, Could you wait to call me till another day I'll fix your feet till you can't walk, I'll lock your jaw till you can't talk
5. 5. Palliative Care Care, not cure Relief- from symptoms, pain, stress Focus= quality of life- patient and family Control over choices and care: patient and family
6. 6. Lean On Me Sometimes in our lives, we all have pain we all have sorrow. But if we are wise, we know that theres always tomorrow. Lean on me, when youre not strong and Ill be your friend, Ill help you carry on. For it wont be long, til Im gonna need somebody to lean on. Please swallow your pride, if I have faith you need to borrow. For no one can fill those of your needs that you wont let show. You just call on me brother, when you need a hand. We all need somebody to lean on. I just might have a problem, that youll understand We all need somebody to lean on.
7. 7. Who Really Provides Palliative Care? Individual (Patient) Family Community Everyone Else?
8. 8. The Players in Palliative Care Palliative Care Hospice Family Community Medical Care Payers
9. 9. The Medical Care Team PCP Nurses Palliative Care Specialists Case Managers Social Worker Complementary Care
10. 10. Youll Never Walk Alone When you walk though a storm hold your head up high and dont be afraid of the dawn. At the end of the storm is a golden sky and the sweet silver song of the lark. Walk on through the wind, walk on through the rain, though your dreams be tossed and blown. Walk on, walk on, with hope in your heart and youll never walk alone. Youll never walk alone.
11. 11. Trends/Statistics 90 million Americans with serious chronic illness (expected to double in 25 yrs) 1/1000 in commercially insured populations 5-10/1000 estimated in Mcare population 46% of family caregivers perform medical/nursing tasks for care recipients with multiple chronic physical and cognitive conditions (AARP, 2012) 20% of Mcare recipients with 5 or more chronic conditions= 2/3 of Mcare spending Approximately half of all dying patients will receive some form of pain management care >35% of patients referred to hospice had length of service < 7 days
12. 12. Bridge over Troubled Water When youre weary, feeling small When tears are in your eyes, I will dry them all. Im on your side, when times get rough And friends just cant be found Like a bridge over troubled water I will lay me down When youre down and out When youre on the street When evening falls so hard I will comfort you When pain is all around Like a bridge over troubled water I will lay me down
13. 13. Challenges
14. 14. Challenges Glass half empty: FINANCIAL: need for bundled payment/creative financing models that are sustainable Resistant hospital/medical community Unfamiliar public and provider Uncoordinated care Piece of the action/Turf wars Quality of care issues
15. 15. Challenges Glass half full: Patients/families have high satisfaction with care Providers have high satisfaction in care delivery NO one is closer to the patient than the caregivers and care providers Payers know palliative care saves money
16. 16. Making it Personal: Studs Terkel 2001
17. 17. Elements of Quality Palliative Care Structure/process of care Physical care Psychological support Social support
18. 18. Elements of Quality Palliative Care (cont.) Spiritual care Culturally appropriate Care of the imminently dying patient Ethical/Legal aspects
19. 19. Making it Personal
20. 20. Questions for Community-based Palliative Care Start-ups Local needs assessed? Well-articulated goals? What will it provide? Who will it serve? How will it be financed? Who will orchestrate, coordinate, define services provided (e.g. Governance)?
21. 21. Theres a Bright Side Theres a bright side somewhere I aint gonna rest until I find it Theres a bright side somewhere Theres more joy somewhere I aint gonna rest until I find it Theres more joy somewhere Theres more love somewhere I aint gonna rest until I find it Theres more love somewhere Theres more peace somewhere I aint gonna rest until I find it Theres more peace somewhere
22. 22. Examples Community-based Hospice care Hospice hub with palliative care community outreach/clinic: Lexington, KY; Falls Church, VA; Flat Rock, NC MD led Financially challenged Promotes earlier hospice referrals Outpatient clinic-based palliative care Most often affiliated with an oncology practice Typically subsidized by hospital/health system Health system integrated palliative care (Kaiser, VA, Sutter Health, etc.) Other models (IPA, medical group, home health, etc.)
23. 23. Community Example: Midwest CareCenter Community based nonprofit started 1978 Hospice and Palliative care based in Chicago area providing care in 150 Illinois communities Home based or inpatient hospice Your goals=our goals Palliative care, hospice care Organization: Executive staff, medical staff Volunteer Board Advisory Council: Medical/Community Leaders Service Board: generates funding/community awareness Cost/Coverage: Insurance, Medicare, charity care, financial assistance
24. 24. Payer Example: Blue Shield of CA HMO- Patient-Centered Management (PCM) of Complex Patients Complex care team: Goal-oriented care plans for seriously ill patients Care manager (RN): onsite assessment/education/ongoing contact, home visits Team manager (RN): coordinated team reviews/liaison to health plan MD: provided clinical information, anticipated medical problems, liaison with patient;s treating MD Not provided: medical treatment, home care, authorization of medical services No added expense to patients/families
25. 25. Blue Shield of CA HMO- Patient-centered Management of Complex Patients- Intervention In-Home evaluation: domain weakness, knowledge, treatment plan, terminal care plan, benefit plan management, family/living environment, provider support Weekly team meetings: link to providers, health plan High frequency outbound patient calls (2-3x wk) Intervention ended when goals set out at beginning (understanding, hospice plan) were achieved
26. 26. Blue Shield of CA HMO- Patient-centered Management of Complex Patients: Results Different treatment choices made Increase adherence with care plans/understanding of medications Decreased use of hospital/ER Increased use of home care/hospice Reduced expenses (+ ROI) Huge patient/caregiver satisfaction
27. 27. Youve Got a Friend When youre down, and troubled And you need a helping hand And nothing, no nothing is going right. Close your eyes and think of me And soon I will be there To brighten up, even your darkest nights When you call out my name You know wherever I am, Ill come running to see you again. Wintertime, summer or fall, All youve got to call. And Ill be there. Youve got a friend.
28. 28. Making it Personal
29. 29. Working with Payers/Insurers Find an influential champion (case manager, medical director) Identify benefits (eg. medical, hospice, etc.) Collaborate on creative solutions Bundle/package services to work around non-traditional service delivery
30. 30. Making It Personal
31. 31. Thank You!