1 conversations at the crossroads joanne lynn, md, director altarum institute center for elder care...
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Conversations at the Crossroads
Joanne Lynn, MD, Director
Altarum InstituteCenter for Elder Care and
Advanced Illness“From SUPPORT to
Effective Reform”Center for Practical Bioethics
April 10,2013Kansas City MO
5th Annual National Healthcare Decisions Day
to inspire, educate, and empower the public and providers about the importance of advance care planning
April 16, 2012 (Death and Taxes)
http://www.nhdd.org
Presentation by: Center for Elder Care and Advanced Illness
For Altarum Staff—April 24, 2012
Effective Health Care Reform for When We are Frail and Old
Joanne Lynn, MD, MA, MSDirector, Center for Elder Care and Advanced Illness
Joanne.Lynn@Altarum.org
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Study toUnderstand
Prognoses andPreferences for
Outcomes andRisks of
Treatments
JAMA 1995; 274:20:1591-1598
4
Description of Decision-Making
Interviewed Patients/Surrogates Told Us PhysiciansDid Not Discuss CPR During Hospitalization
70%
JAMA 1995; 274:20:1591-1598
5
Description of Decision-Making
Late DNR Orders: Written Within 2 days of Death
46%
JAMA 1995; 274:20:1591-1598
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Patients Dying in Hospital Prolonged Suffering: A week or more
in ICU, in Coma, or on Ventilator
50%
JAMA 1995; 274:20:1591-1598
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Conscious Patients Dying in Hospital
Experienced Moderate or Severe Pain at Least Half of the Time Within Their Last Few Days
50%
(by family report)
JAMA 1995; 274:20:1591-1598
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Patients Dying in Hospital Families Who Used All
or Most Savings
31%
SUPPORTJAMA 1994; 272:73:1839
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About Advance Directives in SUPPORT
▲Only 12% of ADs had physician counseling
▲Only 42% of ADs had been discussed with a
physician
▲Physicians were aware of only one in four ADs
0.0
0.2
0.4
0.6
0.8
1.0 CHF
Lung Cancer
6 5 4 3 2 1
Median Prognosis by Day Before Death for Lung Cancer and CHF, in SUPPORT
Days before Death
Med
ian
2-m
onth
Sur
viva
l Est
imat
e
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Results – Phase II
Intervention did not improve• Communication between physicians and
patients/families• Physician understanding that patient wanted to avoid
CPR• Timing of DNR orders• Days spent in ICUs, in coma, or on ventilator prior to
dying• Pain control• Hospital resources used
JAMA 1995; 274:20:1591-1598
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Selected Lessons from SUPPORT – Joanne Lynn version
▲Excellent information and skilled counseling was insufficient to overcome habit and culture
▲Planning ahead was not valued and too non-specific to make much difference
▲Advance planning helped families some
▲Prognosis remains uncertain until near death
▲Pain is a tough target
▲Costs affect even the well-insured
Clinical Algorithm for Evaluation and Care of Patients with Heart FailureU.S. Department of Health and Human Services, AHCPR
Patient Presents with symptoms of Heart Failure
Initial Evaluation
Alternative Diagnosis Identified?
Require Hospital Management
Clinical volume overload?
Measure LV function
Ejection fraction >35-40%
No
Not covered by this guideline
Yes
Yes
No
No
Initiate diuretics
Yes
Yes
Consider diastolic dysfunction
No
Patient and family counseling
Initial pharmacological management
Contraindication to revascularization
Yes
Counseling and decision
No angina but MI
No angina and no MI
Revascularization acceptable Angina
No
Counseling and decision
Physiological test: significant positive findings?
Coronary angiogram: significant positive findings?
No
Counseling and decision
Revascularize
Good Outcome?
Continue medical management
Refer for evaluation for heart transplant
Candidate for heart transplant
yes
Additional pharmacological management
No
Follow-up
Yes
No
Clinical Algorithm for Evaluation and Care of Patients with Heart FailureU.S. Department of Health and Human Services, AHCPR
Counseling and Decision
Continue medical management
Revascularize
Good Outcome?
Follow-up
Yes
Additional Pharmacological Management
Candidate for heart transplant
Evaluation for heart transplant
Yes
No
No
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US Hospitalist PhysiciansViews on Terminal Sedation
0%10%20%30%40%50%60%70%80%90%
100%
Want Sedation for self
Offer Sedation toPatient
Lynn, Goldstein, Annals Int Med, May 20,2003
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New occasions teach new duties; time makes ancient good uncouth;
They must upward still and onward who would keep abreast of truth.
James Russell Lowell
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My Mother’s Broken Back
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The Cost of a Collapsed Vertebra in Medicare
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STRONG CLAIMS FOR SERIOUS REFORM
1. We are buying the wrong product, and we should not focus on re-financing that purchase but on revising the product (and the price).
2. We can have what we want and need when old and frail, at a dramatic reduction in per capita cost, but only through deliberate redesign of the service delivery arrangements
3. We cannot keep doing what we are now doing. Without reform, we will have to learn to turn away from elderly people, even those who have no other options.
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What We Really, Really Need…
1. The Cohort – Frail elderly
2. The Care Plan – For each frail person, at all times
3. The Services - Adapted
4. The Scope – Social services equally important
5. Local Monitoring & Management-
AND THE WILL TO MAKE THESE CHANGES!
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22
U.S. consumption (private plus public in-kind transfers), 1960, 1981, and 2007(Ratio to average labor income ages 30-49).
0
0.5
1
0 10 20 30 40 50 60 70 80 90
1960
0
0.5
1
0 10 20 30 40 50 60 70 80 90
1981
0
0.5
1
0 10 20 30 40 50 60 70 80 90
2007
Public Other
Private Other
Owned HousingPrivate Health
PublicHealth
Public Education
Private Education
22Source: U.S. National Transfer Accounts, Lee and Donehower, 2011. Also in Aging and the Macroeconomy, National Academy of Sciences, 2013
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About the Frail Elder Cohort
Three common definitions:1. Multiple chronic conditions2. Losing muscle strength3. Functional disability
All definitions overlap a lot,Practically, combine some of these: a. Age (or Medicare)b. Functional disabilityc. Serious chronic conditiond. Hospitalization or equivalent
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2. Required: Individual Care Plan
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Articulated Values Plan Implement
Outcomes
Goals Integration
Feedback Feedback
Evaluation of Quality
About Customized Service Plans
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Articulated Values Plan Implement
Outcomes T1
Articulated Values Plan Implement
Outcomes T2
TIME
Service Plans for Complex Chronic Illness
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URGENT NEEDS for CARE PLANS
▲Develop demand for multi-dimensional understanding of the situation, and person-centered care plans
▲Develop processes that regularly produce them
▲Develop feedback loops for real-time evaluation of merits
▲Develop quality measures that assess system performance
▲Use good care plans in system design
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What about an "Advance Care Plan?"
▲Natural to consider lifespan and dying as part of care planning
▲Include emergency plans like POLST
▲Designate surrogate decision-maker(s)
▲Document along with care plan
▲Update and feedback as for other plan elements
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3. Appropriate Services
▲Continuity, reliability, trustworthiness
▲Planning ahead
▲Caregiver assessment and support
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Encourage Geographic Concentration?
▲Services to homes can be more efficient if allowed to be geographically concentrated
▲Can utilize local strengths, solve local issues
▲(However - Must address risks of monopolies)
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Disaster for the Frail Elderly: A Root Cause
Inappropriate
Unreliable
Unmanaged
Wasteful “care”
Social Services• Funded as safety net• Under-measured• Many programs, many gaps
Medical Services• Open-ended funding• Inappropriate “standard” goals• Dysfunctional quality measures
No Integrator
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4. The Scope: A New “Rebalancing”
▲Has been from nursing home to community
▲Needs to be from medical services to social/environmental services
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Health-service and social-services expenditures for OECD countries, 2005, as % GDP
BMJ Qual Saf 2011;20:826e831.
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Health-service and social-services expenditures for OECD countries, 2005, as ratio
BMJ Qual Saf 2011;20:826e831.
US level
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Local level– not just state/federal (and provider)
▲Frail elders are tied to where they live
▲Local leadership responds to local factors
▲Localities can engender and use largely off-budget services
▲Localities can address environmental issues
▲Localities can address employer issues for caregivers
▲Having some local governance still requires having oversight and most financing at federal/state levels
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5. What will a local manager need?
▲Tools for monitoring – data, metrics
▲Skills in coalition-building and governance
▲Visibility, value to local residents
▲Funding – perhaps shared savings
▲Some authority to speak out, cajole, create incentives and costs of various sorts
▲A commitment to efficiency as well as quality
37
How could local management arise?
▲Care Transitions
▲Age-friendly cities and other urban planning
▲Local coalition building for healthy communities – CDC-engendered coalitions
▲Public health
▲Local aging authorities – commissions, offices
▲Area Agencies on Aging (and Administration for Community Living)
▲And more….
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If we had…
1. The Cohort - Services and processes tailored to frailty
2. The Services – Appropriate for frail elders
3. The Care plans – Negotiated for each frail elder
4. The Scope - Include long term supports and services
5. The local monitor- manager
THEN – My mother, and
Your mother,
would have…
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Some possibilities for action▲Help family caregivers to complain…loudly!
▲Require care plans for frail, disabled elders in conditions of participation, Meaningful Use 3, Duals demos, special needs plans
▲Learn to measure quality, institute feedback loops
▲Renew the Older Americans Act
▲Enable localities to develop monitors and management
▲Bring direct care workers under fair labor laws
▲Require Medicare providers to standardize processes and measures
▲Test a structured benefit for MediCaring at home
▲Test offering long-term care coverage at retirement
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What do you think?
What COULD you do?
What WILL you do?
41
We can have what we want and needWhen we are old and frail….
But only if we deliberately build that future!
42
“Unless someone like you
cares a whole awful lot,
Nothing is going to get better. It's not.”
― Dr. Seuss, The Lorax
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