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Palliative Care and IPOSTHospital Engagement Network

June 5, 2012

Jim Bell, MDMedical Director

St. Luke’s Palliative Care and Hospice

Palliative Care

“The interdisciplinary specialty that focuses on improving quality of life for patients with advanced illness and for their families through pain and symptom management, communication and support for medical decisions concordant with goals of care, and assurance of safe transitions between care settings.” (Morrison, Arch Intern Med 9/8/08)

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Palliative Care

Key domains• Goals of care• Symptom management• Resuscitation status• Advance Directives/DPOA• Psychosocial/Spiritual issues

Key components• Focus on quality of life• Team approach for holistic care

– Physician, nurse, social services, spiritual • Primary “procedure”: FAMILY MEETING• Location– Inpatient, Outpatient, LTC, ED

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Typical Diagnoses in Palliative Care

• Cancer• Heart Failure• Chronic lung disease• Kidney failure• Dementia/stroke• Multiple comorbid conditions

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Palliative Care vs. Hospice

• Palliative Care is upstream. Primary determinant is potentially life-limiting disease (this differentiates from well elderly, frail, chronically ill but stable)– Often continue to seek aggressive treatments– Discussing choices with filter of quality of life

• Hospice is that specialized form of Palliative Care with 2 requirements– Life expectancy of < 6 months– Focus on comfort

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National Landscape• DEMOGRAPHIC

– Population over 85 will double to 10 million by 2030– 20% of U.S. population will be over 65 by 2035

• FISCAL– Total health care costs:

• 2008-- $2.4 trillion (16% of GNP) • 2010-- $2.9 trillion (18% GDP)• 2015– 20% GDP (predicted)

– Medicare hospital expenditures• 2001: $93 billion (39% of total)• 2004: $136 billion (44% of total)• 2009: $220 billion (44% of total)• 27-30% of total Medicare budget consumed in last year of life

– Medicare Hospice expenditures 2008-- $11.4 billion (3% of total Medicare budget)

• CLINICAL– U.S.– 53% die in hospital (not where they want)– With predicted 6 month survival of 50/50, 38% spend >10 days in ICU and 10% spend 4

weeks in ICU– 50% of patients report moderate or severe pain at least half of the time in the last three

days of life– Source: SUPPORT investigators, JAMA 1995

– USA has poor ratings on quality measures of health care among industrialized countries (40th overall, 27th in life expectancy)

National Landscape

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Target Population for Palliative Care

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Palliative CareClinical Benefit

• Quality of life– Metrics, symptom burden

• May prolong life– Early Palliative Care for Patients with

Metastatic Non-Small-Cell Lung Cancer–NEJM, August 19, 2010

• Cost savings/avoidance

Hospice/Palliative Care Landscape

• Hospice enrollment 1.5 million/year (2008)– 40% of all deaths – <50% cancer

• 4000 Board certified HPM physicians (2010)– 1 physician/31,000 eligible patients

• Specialty status under ABMS (began 2007)• Palliative care programs

– 33% of all hospitals– 55% with >50 beds– 80% with >250 beds

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Cost and Quality of Life

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Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11

Comparison of Average Initial Pain Score with 48/72 Hour Score

Initial 48/72 Hours

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Comparison of Average Initial Dyspnea Score with 48/72 Hour Score

Initial 48/72 Hours

Palliative CareCost Savings/Avoidance

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$200

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$1,400

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2005 2006 2007 2008 2009 2010

Avg

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St. Luke's Hospital Palliative Care Avg Direct Cost Per Initial Acute Inpatient Day

AVG DIRECT COST Up To & Including Day of Consult AVG DIRECT COST After Day of Consult

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Palliative Care at HomeImproves Quality and Reduces Cost

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10152025303540

HomeHealthvisits

PhysicianOfficevisits

ER visits HospitalDays

SNF Days

Usual Medicare Home CarePalliative Care Intervention

Source: KP Study Brumley, R.D. et al. JAGS 200

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• The case for a strong presence of Palliative Care and Hospice in the US is clear and based on:– The need for fiscal responsibility in health care reform– The high burden of illness and suffering (and cost of care)

in the population we naturally serve– The changing demographics of our population– Our poor performance in worldwide measures of quality

health care

• Palliative Care and Hospice has grown and developed significantly over the last decade, and there is a developing framework for best practices

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National Initiatives

• National Consensus Project (NCP)– Clinical Practice Guidelines for Quality

Palliative Care – 2004• National Quality Forum (NQF)

– National Framework for Palliative and Hospice Care Quality Measurement and Reporting – 2007

National Initiatives

Both the NCP Guidelines and the NQF Frameworkbegin the formalization of the concepts of palliative care, and structures the theory and practice of palliative medicine into specific domains. The NCP Guidelines present recommended practices within each domain, while the NQF Framework defines each domain as a particular issue to be addressed through a specific set of preferred practices. The NQF Framework will lead to palliative care standards, with implications for reimbursement, internal and external quality measurement, regulation, JCAHO certification and accreditation.

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Iowa Rankingswww.capc.org

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Iowa Physician Orders for Scope of Treatment

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What is IPOST?• 1-page, 2-sided form based on the national POLST movement that

consolidates and summarizes patient preferences for key life-sustaining treatments including: CPR, general scope of treatment, artificial nutrition on a standardized, clearly identifiable form.

• IPOST complements advance directives by translating patient treatment choices into actionable medical orders which can be relied upon across all care settings.

• It is primarily intended to be used by: • the chronically, seriously ill individual in frequent contact with health care

providers• an individual with a life-limiting illness• the frail and elderly

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National POLST Movement

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Iowa Legislative Movement

• Iowa had a legislatively authorized pilot project from 2008-2011 in Linn and Jones counties.

• The Iowa Department of Public health provided oversight.

• A state advisory group recommended that the legislature authorize adoption of IPOST statewide.

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IPOST Becomes Law

On March 7, 2012 Governor Terry Branstad signed

IPOST (House File 2165) into Iowa State Law.

IPOST History• Focus group established 2006

• Collaboration St. Luke’s Hospital & Mercy Medical Center in Cedar Rapids• IPOST officially began in 2008 when included in HF 2539 of

Iowa’s Health Care Reform Act • Piloted in Linn County• Implemented IPOST tool in nursing homes, assisted living, acute care

facilities and hospices• Highlights of Legislation

• 1st POLST pilot in US directed by state legislature• Collaboration with Iowa Department of Public Health and Linn County

Public Health• Physician immunity• Physician’s order may cross healthcare settings• Does not require terminal status or have age restrictions

• In 2010, project extended to Jones County• Need for outreach and portability to rural Iowa

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Developing the System

The goal is a standardized, systematic model that can be implemented in many ways yet maintain integrity of process.• Identify Champion

• Establish Community Coalition

• Train those having conversations

• Establish operational processes

• Educate healthcare providers

• Evaluate

Champion and Coalition

• Identify Champion (one or two people)

• Establish Community Coalition– Identify key stakeholders for inclusive community

membership– Suggestions: Physicians/ARNP/PA’s, Hospital

(admin., ED, palliative care, social work), EMS, Home care, Faith community, Hospice, Long term care, Residential and assisted living, Ethicist, Legal, Public health, Community member

– Coalition drives the operations, education and provides oversight

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Training and Education• Facilitator Training

• Respecting Choices from LaCrosse, WI – The Gold Standard

• An informed decision by patient involving family

• Two Day POLST Facilitator And Instructor Certification Course

• Faculty Mentoring Program

• Education to Healthcare Providers

• Education to Community

Operations and Evaluation• IPOST at front of patient’s medical chart

• IPOST transfers with patient from one healthcare setting to another including to and from home

• Update or void IPOST when the patient’s treatment choices change or substantial change in person’s health status

• Regular review of IPOST at quarterly care conferences in facilities or physician appointments

• Data collection to determine implementation rate and effectiveness

IPOST belongs to the patient

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IT’S WORKING!Effecting culture change through the increase in

honoring a person’s healthcare treatment choices

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Pilot Project Medical Chart Review

• Number of IPOSTs completed: 1,306 total• Randomized chart review completed summer 2011• Medical charts reviewed in nursing facilities and hospitals

• Medical record reviews • 62 Linn County• 67 Jones County

• Living Wills• 45% of patients completing IPOST had Living Will in medical chart• 100% consistency between Living Will and IPOST wishes

• Treatment provided consistent with IPOST (N=31)• 100% consistency between IPOST choices and treatment provided when transferred to acute care

Results

• DNR patients (N=107): 58% of patients reflected preferences for life-prolonging treatment in at least one other category

• Resuscitate patients (N=18): 88% of patients reflected preferences forlife-limiting treatment in at least one other category

• We found that healthcare providers make treatment decisions based on the patient’s resuscitation status

• Based on treatment preferences indicated in the IPOST medical chart review…this would result in 62% of the patients receiving treatments that they would not have preferred

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Healthcare Provider SurveyWas treatment altered to respect patient choices

based on having an IPOST available?

• 28% (n=16) surveyed indicated IPOST form altered treatment

• Most frequent treatment altered was Comfort Measures Only. • 33% indicated treatment would have been more aggressive without IPOST

• Second most frequent treatment altered was Type of Resuscitation. • 22% indicated CPR/Attempted Resuscitation was reevaluated due to presence of

IPOST

• No Intubation (19%), No Intravenous Line started (15%), and Increased Level of Treatment (11%) were also indicated by those surveyed that these treatments were altered based on the IPOST

Healthcare Provider Survey

What do healthcare providers think about IPOST?

• 90% wished more patients in the area had IPOST forms, the other 10% were neutral

• 92% agreed that the IPOST form provides clear instructions about patient’s preferences

• 87% feel more comfortable knowing what to do when an IPOST form is available

• 80% agreed that the IPOST form has made more difficult decisions easier

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IPOST Challenges• Time and resources to implement and sustain IPOST

• On-going IPOST Education to trained faciliators– Portability of original IPOST form– How to handle situations where conflicting orders exist

• Additional and continual facilitator training to improve and sustain the quality of the IPOST conversations

– Turnover of staff– Ensure that the patient is making an informed decision regarding his/her

end-of-life treatment preferences

IPOST Strengths

• Converts patient treatment choices into immediately actionable medical orders readily accessible to medical personnel, including EMTs

• IPOST alters treatment: The presence of the IPOST changed the treatment that the healthcare provider would have given if patient did not have IPOST

– Treatment changes included: comfort measures only, type of resuscitation, no intubation and no intravenous line started

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In Summary

• IPOST may be used in the state of Iowa beginning July 1, 2012

• Best Practice is to pursue a facilitated train the trainer model for facilitator education

• Utilization of toolkit that provides education and resources for implementation

References

• https://www.legis.iowa.gov/index.aspxBill Quick Search: HF2165