the evolving role of palliative care in the health care continuum october 12, 2011 john e. barkley,...
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The Evolving Role of Palliative Care in the Health Care Continuum
October 12, 2011
John E. Barkley, MD, FCCPChief Medical Officer
Post-Acute Care ServicesCarolinas HealthCare System
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Outline
Review the Current “Curative Model” of Care & Associated Outcomes
Learn Definitions of Palliative Care, Palliative Medicine & Hospice
Review clinical, economic, demographic data that serve as the basis for need of Palliative Care across the continuum
Learn current national standards for quality Palliative Care
Review impact of Palliative Care in select patient populations
Current State
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Diagnosis of Life Threatening Illness
Death
Cure/Control/Restore/Rehabilitate Hospice
“Curative” Model Palliative care begins
Slide 5
Cancer vs. Non-Cancer IllnessTrajectories to Death
Cancer vs. Non-Cancer IllnessTrajectories to Death
Hea
lth
Sta
tus
Time
Crises
Death
Decline
Field & Cassel, 1997Field & Cassel, 1997
Cancer
End-organ disease
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30 MONTHS
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Patients are Suffering
The SUPPORT Principal Investigators. JAMA 1995; 274: 1591-1598.
Desbiens NA et al. Crit Care Med 1996; 24:1953-1961.
Singer et al. JAMA 1999;281(2):163-168.
Somogyi-Zalud E et al. JAGS 2000; 48:S140-145.
Nelson & Danis. Crit Care Med 2001; 29(2): N2-N9.
Nelson JE et al. Crit Care Med 2004; 32:1527-1534.
Nelson JE et al. Arch Intern Med 2006; 166:1993-1999.
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Caregivers are Suffering
Tolle et al. Oregon report card. 1999 www.ohsu.edu/ethics
Emanuel et al. Ann Intern Med 2000;132:451.
Steinhauser et al. JAMA 2000;284:2476-82.
Lee et al. Am J Prev Med 2003;24:113.
Teno et al. JAMA 2004;291:88-93.
Wright et al. J Clin Oncol 2010;28:4457-64.
DEATH: RR 1.8 if care giving >9 hrs/wk for ill spouse RR 1.6 among caregivers reporting emotional strain
Definitions
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Definitions of Palliative Care
Interdisciplinary care that aims to relieve suffering and improve quality of life for patients with advanced illness, and their families.
It is provided simultaneously with all other appropriate medical treatment.
www.capc.org
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…Definitions
Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.
73 FR 32204 - Medicare Hospice Conditions of Participation –Final Rule
June 5, 2008
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…Definitions
Palliative Medicine Practitioners
• Recognized by American Board of Medical Specialties – 2006
• Major or sole clinical focus is the study and care of patients with:
– Complex medical illness
– Uncontrolled symptoms
– Limited prognosis
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Definitions - Palliative Care vs. Hospice
Non-hospice palliative care
• Appropriate at any point in a serious illness
• Provided at the same time as life-prolonging treatment
• No prognostic requirement
Hospice
• Palliative care for the terminally ill
• Two physicians certify prognosis ≤ 6 months
• Medicare Part A “carve out”…give up traditional Medicare A & B coverage
• Must forgo “curative” treatments
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Primary palliative care: refers to the basic skills and competencies required of all physicians and other health care professionals.
Secondary palliative care: refers to specialist clinicians that provide consultation and specialty care.
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…Definitions
Imperatives for Palliative Care
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• Almost 50% of U.S. population has at least one chronic medical condition, consuming 80% of healthcare resources
– Hypertension is the most common chronic condition, with 50M+ people in the U.S. needing treatment for high blood pressure
– 23M people have asthma, with economic costs projected at $20B in 2010
– 24M people have diabetes; one-fourth are unaware they have it
• Between 2005 and 2030, the number of Americans with chronic conditions will increaseby almost 30%
– 20% to 30% of all Americans are projected to have diabetes by 2050
Sources: Partnership for Solutions, John Hopkins University; Health Affairs, 26, no. 1 (2007): 142-153
Large and Growing Problem: People with Chronic Medical Conditions
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125
133
141
149
157
164
171
100
120
140
160
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1995 2000 2005 2010 2015 2020 2025 2030
Number of People With Chronic Medical Conditions (in millions)
7000 people age 65 per day
International Comparison of Spending on Health, 1980–2006
0
1000
2000
3000
4000
5000
6000
7000
1980 1984 1988 1992 1996 2000 2004
AustraliaCanadaDenmarkFranceGermanyNetherlandsNew ZealandSwedenSwitzerlandUnited KingdomUnited States
Average spending on healthper capita ($US PPP)
0
2
4
6
8
10
12
14
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1980 1984 1988 1992 1996 2000 2004
AustraliaCanadaDenmarkFranceGermanyNetherlandsNew ZealandSwedenSwitzerlandUnited KingdomUnited States
Total expenditures on healthas percent of GDP
Data: OECD Health Data June 2008
5+ chronic
conditions
66%
No chronic
conditions
1%
4 chronic
conditions
13%
1-2 chronic
conditions
10%
3 chronic
conditions
10%
Source: G. Anderson and J. Horvath, Chronic Conditions: Making the Case for Ongoing Care. Baltimore, MD: Partnership for Solutions, December 2002.
Medicare Beneficiaries - Chronic Conditions & Spending
Distribution of Total Medicare Beneficiaries and Spending, 2005
10%
63%
37%
90%
Total Number of FFS Beneficiaries: 37.5 million
Total Medicare Spending: $265 billion
Average per capita Medicare spending (FFS only): $7,064
Average per capita Medicare spending among
top 10% (FFS only): $44,220
NOTE: FFS is fee-for-service. Includes noninstitutionalized and institutionalized Medicare fee-for-service beneficiaries, excluding Medicare managed care enrollees.
SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost & Use file, 2005.
Health Care Reform
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Health Care Reform = Clinical Integration
Clinical Integration = Care Coordination Across the Continuum
New “Rules of the Game”
Less $$$ not more
Value vs. Volume
“Zero Sum Game”
• Top quartile rewarded
• Bottom quartile pays the bill
Bundled/Grouped/Episode-specific payments
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Patient-Centered Care Continuum
Medical Home
Data Management
Chronic Disease Management
Pharmacy
Home Care
Ancillary Providers
Long Term Care
Public Health Agencies Hospice
Hospitals
Palliative Care
LTACH & Acute Rehab
Specialists
Patients
EH
R
EHR
EH
R
Population Health
Management
National Recommendationsfor
Quality Palliative Care
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National Consensus Project & National Quality Forum
Foundational elements
• National definition & description of high quality comprehensive palliative care
• Resource for practitioners addressing palliative care needs of patients & families
• Educational framework & blueprint for structure and provision of palliative care
Eight Domains with 38 Preferred Practices
1. Structure and Process of Care
2. Physical Aspects of Care
3. Psychological and Psychiatric Aspects of Care
4. Social Aspects of Care
5. Spiritual, Religious and Existential Aspects of Care
6. Cultural Aspects of Care
7. Care of the Imminently Dying Patient
8. Ethical and Legal Aspects of Care
CAPC Consensus Panel Papers
Operational Features for Hospital Palliative Care Programs (2008)
Operational Metrics for Hospital Palliative Care Programs (2008)
Palliative Care Inpatient Unit Operational Metrics (2009)
Clinical Care & Customer Service Metrics (2010)
Identifying Patients in Need of a Palliative Care Assessment in the Hospital Setting (2011)
Practical Road Maps to Follow
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= Primary Palliative Care
= Secondary Palliative Care
Slide 29
Early integration of palliative care with intensive care for all ICU patients, regardless of prognosis, and their families, is a clinical practice guideline.
– Selecky PA et al. Chest 2005;128:3599-610. (American College of Chest Physicians)
– Lanken PN et al. Am J Respir Crit Care Med 2008;177:912-27. (American Thoracic Society)
– Truog RD et al. Crit Care Med 2008;36:953-63. (American College of Critical Care Medicine).
Critical Care
Slide 30
Outcomes of Palliative Care
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How Does Palliative Care Work?
Interdisciplinary team (MD, NP, RN, MSW, Pastoral Care, others) with patient-centered, family focused care approach
• Addresses physical symptoms and emotional suffering
• Clarifies goals of care with patients and families
• Helps patients & families select medical treatments and care settings that match their goals
• Improves patient-physician-family communication and decision-making
• Provides practical and emotional support for exhausted family caregivers
• Enhances transitions and continuity of care across settings
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“Right Care, Right Time, Right Place”
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Temel JS et al. NEJM 2010; 363(8): 733-742.
Early PC + Oncology vs. Oncology
FACT-L 98.0 vs. 91.5 (p=.03)
Depression 16% vs. 38% (p= .01)
Resuscitation preferences documented 53% vs. 28% (p = .05)
“Aggressive Care” 33% vs. 54% (p = .05)
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Temel JS et al. NEJM 2010; 363(8): 733-742.
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P = .02; HR 1.7
Median Survival 11.6 vs. 8.9
“Coping with Cancer”
“Do you recall having a discussion with your treating MD about care preferences at EOL”
NCI funded study
7 outpatient sites from 2002-2008
638 patients with Advanced/Metastatic Cancer
37% reported having EOL discussions before baseline
Wright, A.A. et al. JAMA, 2008; 300(14): 1665-1673.
Zhang, B. et al. Arch Intern Med 2009; 169(5): 480-488.
Mack, J.W. et al. J Clin Oncol 2010; 28(7): 1203-1208.
Wright, A.A. et al. J Clin Oncol 2010; 28(29): 4457-4463.
“Coping with Cancer”
Patient Impact
EOL discussions ≠ higher rates of major depressive disorder or more worry
68% received EOL care that was consistent with baseline preferences
Less likely to receive “aggressive care”
• Mechanical ventilation
• Attempted resuscitation
• ICU admission
QOL lowest and physical distress highest with more “aggressive care”
More enrolled in hospice & had longer LOS
No survival differences
“Aggressive care” resulted in 36% higher costs
“Coping With Cancer”
Caregiver Impact
ICU or hospital deaths = psychiatric illness in bereaved caregivers
Worse QOL
More regret
Higher risk of a major depressive disorder
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Live Discharges Hospital Deaths
Costs Usual Care
Palliative Care Δ Usual
Care Palliative
Care Δ Per Day $830 $666 $174* $1,484 $1,110 $374*
Per Admission $11,140 $9,445 $1,696** $22,674 $17,765 $4,908**
Laboratory $1,227 $803 $424* $2,765 $1,838 $926*
ICU $7,096 $1,917 $5,178* $14,542 $7,929 $7,776*
Pharmacy $2,190 $2,001 $190 $5,625 $4,081 $1,544***
Imaging $890 $949 ($58)*** $1,673 $1,540 $133
Died in ICU X X X 18% 4% 14%*
*P<.001 **P<.01 ***P<.05
Arch Intern Med 2008; 168(16):1783-1790
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Health Affairs 2011; 30(3): 454-563
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Health Affairs 2011; 30(3): 454-563
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Health Affairs 2011; 30(3): 454-563
Hospital “X”
Consult Volume – 765
Length of Stay
• Mean Day of Consult – 7.4
• Mean Days to Discharge- 6.3
• Mean LOS – 13.7
Direct Variable Cost Savings - $1,865,146.00
Clinical Revenue - $110,847.00
HPCCR Invoices - $271,089.00
Net Cost Savings for Hospital “X” – $1,704,904 .00
Net Savings/Case - $2229.00 ($354/day)
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Conceptual Shift from “Curative Model”
Medicare Medicare Hospice Hospice BenefitBenefit
Life Prolonging CareLife Prolonging Care OldOld
Palliative CarePalliative Care
Bereavement
Hospice CareHospice CareLife ProlongingLife Prolonging
CareCareNewNew
Diagnosis Death
How to Proceed?
System-based approach
• “Top down & bottom up”
• Development & full integration of Primary & Secondary PC into all care including chronic disease management programs
Primary palliative care: refers to the basic skills and competencies required of all physicians and other health care professionals.
Secondary palliative care: refers to specialist clinicians that provide consultation and specialty care.
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Summary
Patient & Caregivers are suffering under current model
Many imperatives for Palliative Care making it an essential strategy going forward
National recommendations exist
Positive impact of Palliative Care well documented
Complete integration across the continuum requires:
• Top down + bottom up approach
• Development of Primary & Secondary Palliative Care
• Evidence-based practices
• QA/PI
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