Catalyzing Patient Quality of Life Preferences into Medical Care Choices

Helen D. Blank, PhDApril 2010

Situation Assessment – Industry Observations • Significant body of research documenting the low quality and high cost of care during advanced illness

Quality Studies

Cost Studies– Dartmouth Atlas of Health Care– Medical Care Inconsistent With Patients’ Treatment Goals: Association with 1-year Medicare Resource Use and Survival (Teno, Journal

American Geriatric Society, 2002)– Health Care Costs in the Last Week of Life Association with End-of-Life

Conversations (Zhang, Archives of Internal Medicine, 2009)– Patient and Family Centered Outcomes at the End of Life (Teno, JAMA, 2004)– Opportunities to Improve the Quality of Care for Advanced Illness (Krakauer, Health Affairs, 2009)

– Patient and Family Centered Outcomes at the End of Life (Teno, JAMA, 2004)– Trends in the Aggressiveness of Cancer Care Near the End of Life (Earle, JCO, 2004)– Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death & Caregiver

Bereavement (Wright, JAMA, 2008)– Beyond Information Exploring Patients’ Preferences (Epstein, JAMA, 2009)– Discussions With Physicians About Hospice Among Patients With Metastatic Lung Cancer

(Huskamp, Archives of Internal Medicine, 2009)– Family Perspectives on End-of-Life Care at the Last Place of Care (Teno, JAMA, 2004)

Note: For discussion purposes advanced illness is defined as a member health situation which will likely result in death over the course of the next twelve months.

• Physicians don’t uniformly have the training, time, and financial incentive to effectively

implement shared decision making during advanced illness– Structural changes to delivery system over the long term are required to address these deficiencies

• Payers have historically addressed the issue through medical utilization and case management strategies often creating a battle of economic interests

– Covered benefit determination then peer review for necessity

– Care coordination & monitoring to optimize implementation efficiency of largely inefficient care decisions

– Ignores the fact that patients have intrinsic but often unexpressed quality of life preferences that favor less aggressive curative treatment options than the status quo.

• Patients don’t currently recognize the need, have the knowledge, or possess the confidence to participate in, let alone drive, care decision making processes in order to effectuate their quality of life preferences

Situation Assessment – Industry Observations

“The data – and my clinical experience – suggest that when patients and doctors spendthe time to talk about their values and goals and the likely outcomes of proposed treatments most – but not all – will opt against a trial of all life-prolonging technologiesavailable.” Dr. Sean Morrison, Director NPCRC

Vital Decisions SAB Member

Our Solution & Value Proposition

To catalyze the intrinsic but often unexpressed patient quality of life preferences into care decision making in order to increase the efficiency and quality of care

Medical Ethics• Goal Setting• QoL Issues• Cultural or Personal Values

Advanced IllnessCounseling• Understanding& Acceptance• Behavioral Change• Communication• Advocacy Skills

Conventional Advance Care Planning• Weighing Treatment Options • Pain Issues • Documentation e.g. ADs• Hospice & Palliative Care

Exp

ert Staff

Experience Base

Proprietary MethodologiesN

eutr

alit

y

Providing Skilled Navigation Through Areas That Others are Reluctant to Explore

Vital Decisions Living Well Program Goal & Strategy

To create patients and families who proactively participate in their care by identifying, communicating and incorporating their quality of life priorities into current and future care decisions

Create an Informed Patient

Identify Quality of Life Priorities

Integrate Prioritiesinto Care Decisions

Develop Plan,Communicate & Revise

• Current Medical Situation• Future Medical Situation Scenarios

• Current and Future Quality of Life & Care Decisions/Alternatives• Transition Points

• Independence, Interactivity, Comfort• Current & Future

• Care Decisions that Support Priority Achievement• Current & Future

• Ensure Effectuation of Priorities Throughout Illness Progression• Integrate with Family & Providers

• Communication Vehicles &Support

Create an Active Patient• Stage Based Behavioral Change Strategies and Activities Embedded in Process• Proprietary Methodology Developed in Conjunction with Prochaska for Advanced Illness Population• Active on Current & Future Scenarios

Vital Decisions Living Well Program Process Overview

Scripts and Branching Logic (Conversation Flow)

Tools & Decision Aids for Patient & Counselor

Counseling Workflow Automation Patient P

rofile

EngagementMedical &QoL Assessment

ID of Priorities & Integration With Medical Choices

ReadinessTo ActAssessment

FollowUp

Call Lo

g

Patient A

ction Plan

AC

P D

ocs

Deliverables

Process Modules (conducted over multiple sessions, typically three-five)

Tools

Communi-cation &Revision

Decisionmaking(Current& Future)

Behavioral Stage Action Strategies Plans & Follow-Up

Educational Materials for Patient

Identification

Vital Decisions Living Well Program Process Overview

EngagementMedical &QoL Assessment

ID of Priorities & Integration With Medical Choices

ReadinessTo ActAssessment

FollowUp

Process Modules (conducted over multiple sessions, typically three-five)

Communi-cation &Revision

Decisionmaking(Current& Future)

Behavioral Stage Action Strategies Plans & Follow-Up

Identification

Motivational Interviewing Based Techniques

Page 14

Study Results

Appreciation of the Program

Choice of Care Survey (N=101)

32

41.7

19

14

24.6

14.5

% patients Averagedays onhospice

Median dayson hospice

Hospiceresulting fromprogramparticipation

Hospice notresulting fromprogram

• reduced intensity of service (increased hospice use)

• a trend toward longer hospice duration for patients referred as a result of the program

• a high level of participant satisfaction• counselee perceptions of improved decision

making capabilities • higher satisfaction levels in those who chose

hospice as a result of the program vs. those who chose hospice for other reasons

RESULTS

METHODS

160 Original Counselees•completed between 09/07 and 06/08 •terminal or advanced illness •commercial and managed Medicare•large national healthcare plan

101 ‘Choice of CareSurveys’ Completed

independent group surveyedthis cohort for satisfaction

42 reached/59 not reached

35 ‘Satisfaction’ Surveys completed with original counselee

measured hospice use resulting from program participation, determined by counselee (58%) or Case Manager (38%)

measured appreciation of the program as well as perceived personal effectiveness in healthcare decision making following participation

• Counselees would appreciate the program and perceive it to be in their best interests.

• Counselees would perceive increased personal effectiveness in making good medical decisions.

• Counselees would tend to choose a lower intensity of care, specifically hospice services.

RESEARCH HYPOTHESES

0102030405060708090

100

Well-inform

ed before?

Better in

formed? *

Improved MD communicatio

n? *

Better u

nderstand choices?*

Making best decisions?

Ensure plans were carried out?

%

Hospice(N=12)

Non-hospice(N=23)

0

10

20

30

40

50

60

70

80

90

100

Providecomfort?

Recommend?

%Hospice (N=12)

Non-Hospice (N=23)

Perceived Program Effectiveness

* significant at P< .05

RESULTS (CONTINUED)

CONCLUSIONS

PARTNERSHIP BETWEEN VITAL DECISIONS AND CASE MANAGEMENT

•successful co-management of over 5000 cases

•case managers refer using a clear set of researched end-of-life prompts combined with clinical judgment

•Vital Decisions’ expertise in patient centered, end-of-life issues is a unique resource for case managers

Satisfaction Survey

Effects of the “Living Well” Program included…