managing advanced illness to advance care executive briefing - aha annual meeting tuesday, april 30,...

Managing Advanced Illness to Advance CareExecutive Briefing - AHA Annual Meeting

Tuesday, April 30, 201310:45am – 12:15pm

© 2012 American Hospital Association

Advanced Illness Management Strategies: Part I

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The first CPI report framed AIM as a four-phase process to be addressed through three strategies—access, workforce and awareness

The report also examined in depth how hospitals can increase access to AIM programs and change the way medi cal services are utilized to improve outcomes and honor the wishes of patients and families.

Advanced Illness Management Strategies: Part II

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This second and follow-up report:

• Expands and explains more precisely the three key strategies of AIM—access, workforce and awareness

• Provides health care systems strategies and case examples that focus on patient and community awareness and engagement and a ready, willing and able workforce.

Why Integrate AIM Programs?

AIM programs allow hospitals to navigate the first-curve to second-curve transition and fill the gap.

In the hospital setting, AIM programs are proven to:

• Provide patients with improved quality of life, reduced major depression and increased length of survival

• Lower utilization of clinical treatments and hospital admissions among enrolled patients

• Improve satisfaction scores for patients, family, caregivers and the multidisciplinary AIM-trained staff

• Reduce aggregate spending

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Phases of AIM

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Managing the Gap: Strategies to Developing a Successful AIM Program

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Three Key AIM Strategies

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AccessPatient access to AIM

services can be greatly increased when all hospitals and care

systems are able to support and delivery high-

quality AIM.

WorkforceExcellence in AIM depends

upon the education and training of health care professionals that can deliver quality hospice, palliative and end-of-life

care.

AwarenessPatient and family AIM

awareness and understanding of the benefits of advanced illness planning and management can be significantly raised

through communitywide strategies.

(1) Strategies to Increase Access to AIM Services

• Develop a multidisciplinary care team with leadership buy-in

• Identify qualifying patients through evidence-based protocols

• Think beyond the traditional four walls of the hospital to promote AIM collaboration throughout the surrounding community

• Use a performance improvement framework to measure, monitor, evaluate and adapt the program between disease states and throughout time

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(2) Strategies to Expand Patient and Community Awareness and Engagement

• Increase patient accessibility to information about end-of-life care by developing awareness and “conversation-readiness” among health care professionals; work with stakeholders on the importance of conversations, advance directives and early decision making; provide effective language assistance services; and address low health literacy

• Launch community development strategies that spread awareness of cultural diversity and support partnerships with local leaders and organizations that cater to the patient population’s demographics, education levels, culture and language

• Develop a workforce that embraces diversity to address the needs of patients and families from a variety of backgrounds and is equipped with the skills and knowledge necessary to support and guide those facing end of life

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(3) Strategies to Build a Ready, Willing and Able Workforce

• Develop educational programs that offer ongoing training for health care professionals to learn the necessary skills and competencies for engaging in sensitive conversations and that train health care providers on the role and impact of spirituality in end-of-life care

• Use a multicultural guide/spiritual toolkit to support understanding and meeting diverse patient needs

• Create a solid program infrastructure to sustain a successful palliative and end-of-life care program

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Thank you!http://

www.aha.org/about/org/cpi.shtml

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http://www.aha.org/about/org/cpi.shtml



AHA Annual Meeting AIM Panel April 30, 2013Laura Mavity, MD, Clinical Director Katie Hartley, BSN, CHPN, Administrative Director

Centers of CareAdvanced Illness Management

•Sole Community Four Hospital System – Pioneer Memorial Hospital (CAH, 25 beds)– St. Charles Bend (261 beds)– St. Charles Madras (CAH, 25 beds)– St. Charles Redmond (48 beds)

•Primary Care and Subspecialty Practices•Home Health and Hospice Services•Behavioral Health Services

St. Charles Health System

Central Oregon

Bend Site

Redmond Site

Madras Site

Prineville Site

•WHAT: Our IDS is designed to achieve the Triple Aim

•HOW: Delivered through the Centers of Care model

St. Charles Health System IDS

Centers of Care

•To Improve the Health of Our Population (Better Health)– Complex planning and management of advanced illness patients eases stress

for 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

Triple Aim and Palliative Care

Centers 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– Advanced 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

SCHS Advanced Illness Management Center of Care

Palliative Care Delivery

• The Clinical Approach:- Basis is family conference- Time intensive assessment of patient and family values,

symptoms and their understanding of disease and prognosis to develop patient-centered care goals

- Ongoing intensive communication and support for patients and families with accessibility for questions or concerns

• The Conceptual Model:

Dedicated team Focus + Time

Decision Making + Clarity + Follow through

Foundations of Palliative Care

• Dying is normal• Advance care planning is important• Coordination of care and services is imperative• Medical care provided should be based on the patient

and his or her family’s goals and values

St. Charles AIM Palliative Care Consultations• St. Charles Bend 2009

- 2009 - 222 consults

- 2010 - 382 consults

- 2011 - 436 consults

- 2012 - 500+ consults• St. Charles Cancer Center 2010• AIM Center of Care 2011• Outpatient Consultations Spring 2012• St. Charles Redmond Fall 2012


AIM Consultation Requests by Specialty

*OTHER4%

CRITICAL CARE1%

CARDIOLOGY2%

ER1%

RENAL2%

ONCOLOGY10%

PULMONARY22%

HOSPITALIST55%

NEUROSURG3%

*OTHER: CT SURGERY, NEUROLOGY, GEN SURG, ORTHO, GI, REHAB, INTERNAL MED, VASCULAR SURGERY

Disposition after AIM Consultation

DEATH24%

HOME HEALTH10%

SNF11%

HOME 10%

INPATIENT REHAB2%

HOMEHOSPICE

27%

INPATIENTHOSPICE

16%

Diagnosis Classes for AIM Consultation

151

128

73

54

42

9 7 6 61 1 1

0

20

40

60

80

100

120

140

160

# o

f P

ts

AIM Payer Classification

MEDICAID9%

SELF PAY4%

AUTO1%

COMMERCIAL0.4%

GOVERNMENT PROGRAMS

2%

MANAGED CARE8%

MEDICARE76%


2012 Data Highlights:

• $4,000 average direct variable cost avoidance per inpatient

• AIM consultation• AIM patient 30 day readmission rate 4.86% (expected

10.4%), overall readmission rate 8.74%

• Average time from admission until AIM consultation: 4.1

days

• Average LOS after AIM consult: 2.7 days• Most common reason for consultation: Goals of Care

Discussion/Advance Care Planning


2012 Data Highlight

Average symptom burden (ESAS) before and after consultation

BEFORE AFTER

PAIN 0.83 0.47

ANXIETY 0.36 0.11

DYSPNEA 0.59 0.28

N/V 0.14 0.04

•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


Outpatient Consultation Service Development • Justification = most patients spend most of their time

outside of hospitals• Opportunity

– Improves quality patient care– Potentially decreases in-hospital mortality– Increases efficiency in health care systems

and accountable care organizations

AIM Center of Care Initiatives: ACCESS

Needs Assessment

Why are you considering outpatient services? • Staffing• Patient Focus • Stakeholders


Model: Embedded Clinic • Collaborative relationship between a host clinic and

palliative care staff• All costs of the clinic operations are born by the host

clinic• Patients referred predominately from the host clinic• Defined clinical pathways or protocols may exist

defining patient flow between the host and palliative care staff


Finances: Support and alignment • Most outpatient palliative care practices operate at loss• Primary cost is labor

– Billing = <50% of expenses• NEJM 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. Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer. NEJM 2010; 363:733-742


Outpatient AIM Consultation ServiceCancer Center Advanced Stage Lung Cancer initiative

2011Inpatient - 7 consultations

2012Inpatient - 35 consultations•Disposition:

- 9 died in the hospital - 15 left the hospital with hospice - 5 discharged with home health - 1 discharged to SNF- 1 discharged to inpatient rehab - 1 discharged home without services

Outpatient:•Quarters 1, 2, and 3 - 1 consultation•Quarter 4 - 11 consultations


System standardization of processes and procedures• AIM consultation availability at all four hospitals

- St. Charles Bend, Cancer Center, Outpatient

- St. Charles Redmond, Cancer Center, Outpatient

- Pioneer Memorial Hospital and St. Charles Hospice Prineville

- Expand hospice staff role to include palliative care consultations- St. Charles Madras and Hospice

- Expand hospice staff role to include palliative care consultations• Coordination with multiple regional hospices, other service

organizations• Quality/Performance Improvement Program


St. Charles AIM Team/Center of Care expansion

• 2009: 1 part-time palliative care MD

• 2013: 3 palliative care MDs (2.35 FTE) and 2 hospice medical directors, dedicated AIM team SW, AIM RN case manager, AIM chaplain pending (shared position with Cancer Center)

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

AIM Center of Care Initiatives: WORKFORCE

AIM Team members and Center of Care provide caregiver education

• 3 grand rounds delivered by AIM Team

• Dr. Diane Meier 9/12

• Dr. Ira Byock pending 11/13

• Palliative Care education for caregivers by AIM Team (palliative care, symptom management, hospice benefit, end of life process, care goal discussions, advance care planning)

• Over 30 presentations delivered annually

AIM Center of Care Initiatives: WORKFORCE

AIM Team members provide regular community education

• Heart Failure University

• Pulmonary Rehabilitation “Better Breathers” group

• Kiwanis, Rotary Club presentations

• Wholeness Seminars at a local hospice agency

• System board presentations

AIM Center of Care Initiatives: AWARENESS

The Conversation Project

• Co-founded by Pulitzer Prize-winner Ellen Goodman and developed in collaboration with IHI

• A public engagement campaign with the transformative goal to have every person’s end-of- life wishes expressed and respected


The Conversation Project Pioneer Sponsor Program

• An IHI-sponsored Initiative

• Purpose is to better prepare health care delivery systems to receive and respect patients’ wishes about end-of-life care

• 12 Pioneer Sponsors committed to ensuring health systems are “Conversation Ready” by developing and piloting processes to create these systems within health care


The Conversation Project “Pioneer Sponsor” Program

• St. Charles Health System is the only West coast “Pioneer Sponsor” with hospitals holding a rural designation within the system

• Reframe the provider-patient relationship around the question, “What matters most to you?”

• Ultimate objective is to package proven methods and provide programs with new tools and strategies to achieve these goals


St. Charles “Pioneer Sponsor” Projects

• Pilot at Heart Failure UniversityA program attended by newly diagnosed patients with heart failure as well as those with disease exacerbations

• Pilot of St. Charles Health System Caregiver EngagementPersonally engage our own caregivers in the conversation project’s process. Model program:


• AIM Center of Care Newsletter

– Distributed to community partners three times per year, relays educational opportunities, resources

• Bloom Project

• Comfort Care Program and Cart

• Integrative Therapies - partnership with Cancer Center

• Creation of Mosaic art piece with AIM Center of Care Partners


SCHS Advanced Illness Management Center of CareMosaic Art Piece

Sharp HospiceCare’sTransitions Program

A New Model for Late Stage Disease Management

Daniel R. Hoefer, MD CMO, Outpatient Palliative Care and Hospice

Suzi K. Johnson, MPH, RNVice President Sharp HealthCare Hospice and Palliative Care

• First generation outpatient palliative care• Second generation outpatient palliative care

1. UCSF2. Kaiser3. Sutter (AIM)4. VA5. Care More6. Health Care Partners7. Partners Medical Group (Boston)8. University of Pittsburgh9. Long Island Jewish10.Hospice of the Valley11. Sharp HealthCare

CMS Goals:

1.Better individual patient care

2.Better population care

3.Lower growth in health care expenditures

4.Prevent readmissions

Sharp Transitions Goals:

5.Better individual patient care

6.Better population care

7.Reverse the growth in heath care expenditures

8.Better professional caregiver support

9.Better professional family support and conflict resolution

10.Prevent any admissions including primary admissions

Goals

Principles of Transitions

• Proactive In home Disease Management• Proactive Psychosocial Management• Accurate description of what the health care industry

can and cannot provide

“The continued application of traditional treatment strategies which are valuable to the patient at an earlier time in their health experience has the opposite effect on patients at end of life resulting in inferior outcomes.”

Daniel Hoefer, MD CMO, Outpatient Palliative Care and HospiceSharp HospiceCare

Cultural Mind Shift

Issues Important in the Management of a Pre-terminal Aging Population:

Mobility Deficit Transportation Deficit Financial Restraint Social Support/Family Deficit Cognitive Deficit Compliance Deficit Change in Goals of Care

It is better to bring healthcare to patients at this time, than to bring patients to healthcare.

Current Culture of Health Care

• Reactive versus Proactive• Paternalistic

• Dependent

27% of patients with incurable terminal disease believed they could have been cured

Unresectionable non-small-cell lung cancer 54%

AIDS 32%

CHF 22%

ALS 16%

COPD 12%

Daniel P Sulamsy, OFM, MD, PhD, et al, The Accuracy of Substituted Judgment in Patients with Terminal Diagnoses, April 1998, Annals of Internal Medicine, Vol 128(8), PP 621-29

The Traditional Medical Model “This Disease Can Be Cured”

Hospitalizations last year of life - CHFAcceptable or Not?

• Historical average hospitalizations for CHF during the last year of life 3.5

Where Patients with CHF DieAcceptable or Not?

• Historically 63% of CHF patients died in the hospital (2005)

Expanding the Care Continuum

• Home Setting• Focus on high risk late stage chronic illnesses• Skilled Clinicians• Flexible Models • Cost efficient

Four Pillars of Transitions

Comprehensive in-home patient and family education about their disease process; proactive medical management

Evidence-based Prognostication

Professional Proactive Management of the Caregiver

Advance Health Care Planning

Extending the evidence based benefits of Hospice Care to patients at an earlier point in their healthcare.

Pillar OneIn Home Proactive Disease Management

Registered Nurse

Medical Social Worker

Spiritual Care

Primary Care MD

Palliative Care MD

Improved Compliance

Decrease Primary Admissions & Re-admissions

Improved Symptom Management

Improved DiseaseManagement

The best medication reconciliation occurs in the home

Pillar TwoEvidenced-Based Medical Prognostication

British Medical Journal; Extent and Determinants of Error in Doctors Prognoses in Terminally Ill patients; Prospective Cohort Study; Vol 320(7233), 19 Feb 2000 pp.469-473

1. 343 doctors2. Estimates on 468 terminally ill patients3. Mean patient survival – 24 days4. Considered accurate if estimate within 33% for any

give patient5. 20% of the time accurate

a. 80% of the time inaccurateb. 63% over-optimistic

The Clinical Consequences of Institutionalized Over-optimism

(Pillar Two Continued)

6. The average over-optimistic estimate was off by 530%

a. Increases the risk that treatment decisions by patients, families and healthcare providers are NOT consistent with reality

b. Leaves patients and families emotionally unready for inevitable outcomes

c. Increase risk that providers will lose credibility

British Medical Journal; Extent and Determinants of Error in Doctors Prognoses in Terminally Ill patients; Prospective Cohort Study; Vol 320(7233), 19 Feb 2000 pp.469-473

Diagnosis and Treatment

vs.

Diagnosis, Treatment and Prognosis

Biometric models + functional decline patterns + specific biological data + general biological data + adjusting for your personal tendencies = accurate,

effective, professional and compassionate information.

Event Prognostication – Prognostication which guides the patient in an expected

series of events.

Anticipatory Guidance

CHF82 Year old maleCo-managed with specialistFunctional DeclineProgressive decline SOBSlow rise in ADL decline

Pillar ThreeProfessional Evidence-Based Care

for the Caregiver

Evidence based medicine - Hospice care is associated with an absolute reduction in death rates in the caregiver at 18 months post death of the patient of 0.5% (1 in 200)

Nicholas Christakis, et al, The Health Impact of Health care on families: a Matched Cohort Study of Hospice Use by Decedents and Mortality Outcomes in Surviving, Widowed Spouses, Social Science and Medicine 2003, vol57 pp.465-475

Pillar FourAdvance Health Care Planning

Evidence based medicine shows that AHCDs (which would include POLST) do not consistently match the health care desired by the patient with the care received by the patient

Problems with Advance Health Care Directives

They are not disease specific

They are too vague or contradictory to be interpreted in the context of the care which is being provided

Resolve Morale Conflict Proactively

Create Disease Specific Directives

TransitionsCase Management Design

• Active Phase

• Maintenance Phase

• Role of Hospice

– 24 hour call availability

– Full integration and hand offs between programs

TransitionsActive Phase

RN Case Manager

4-6 visits in 6 week time frame

MSW

1-2 visits for goals of Care discussion; completion of POLST

TransitionsMaintenance Phase

RN Case Manager

Telephonic case management – every 2-4 weeks until transferred to hospice

Home visits as needed for assessment

Coordinate care with MD ongoing

Transfer to hospice when appropriate

Hospitalization ER Utilization: All cause

During Transitions

94% reduction in primary CHF admissions

Synergy

Transitions to Hospice

….The impact of change…

Cost of Care

Thank You

managing advanced illness to advance care executive briefing - aha annual meeting tuesday, april 30,...

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