Palliative Care within Iowa Health

A Value-Based Care Delivery Strategy.Brad Archer, M.D.Monique Reese, ARNP

Case: Mr. S

77yo male with chronic venous stasis edema. 3 admissions for various issues in past year. IHHC following for wounds on lower leg. Weight loss, weakness and multiple falls. Readmitted and inpatient PC consult. Unrecognized severe pulmonary hypertension. Hospice referral.

Issues

Fragmented care Episodic care Missed diagnosis Lack of care plan Excessive costs

Is This Uncommon?

Generally, less than 50% of patients with major chronic illness receive accepted treatments.

Less than 50% have satisfactory levels of disease control.

In a general patient population, 30 to 40% of discharge instructions aren’t completed.

Majority of Americans don’t feel that the chronically ill get good care.

5

“Moving into the next century, the most important breakthroughs will be in the form of clinical process innovation rather than clinical product improvement…the next big advances in health care will be the development of protocols for delivering patient care across health care settings over time.”

J.D. Kleinke, The Bleeding Edge

Delivering ValueDisease Management Continuum

Screening

Prevention

Primary Care Offices

Disease Case Management

Advanced Medical Team

Disease Registry

Risk Stratification Tool

Quality Indicators and Metrics

Hom

e H

ealth

Palliative Care

What is Palliative Care?

An active and multidisciplinary approach to care that works to relieve suffering and improve quality of life simultaneously with all other appropriate treatments for patients with advanced illness, and their families.

Iowa Health utilizes palliative care within an advanced disease management strategy.

Where is Palliative Care?

22% of all US hospitals have PC program 50% of all hospitals over 75 beds >90% started since 2000 >64% started since 2004 1,412 in 2007 No clear data on home care programs

Current system: Cure versus Care Model

Life Prolonging Care

Medicare

Hospice

Benefit

D

E

A

T

HDisease Progression-years

Diagnosis of serious illness

Death

The Place of Palliative Care in the Course of Illness

Life Prolonging TherapyLife Prolonging Therapy

Palliative CarePalliative Care Medicare Hospice Medicare Hospice BenefitBenefit

Individualized Medical Decision Making Benefits of standard diagnostic and

therapeutic interventions complicated by comorbid conditions and functional disability.

Personalized goals of care and quality of life assessment.

Care plan for each patient in palliative care.

A Proven Model:

Palliative Care employs the proven care delivery model used in Hospice to improve the quality of care delivered to patients earlier in the diagnosis of a serious, life threatening illness.

The impact of this model is recognized by the National Quality Forum and JCAHO as both organizations have adopted quality guidelines.

Core Elements of Quality PC :

Symptom management Patient and Family Centered Care Comprehensive Care Interdisciplinary team Communication Skill in the care of the dying and bereaved Continuity of care across settings

Care Delivery Model

SUPPORT: RN intervention failed to show outcomes impact. JAMA 1995; 274 (20)

Intensive MD clinic f/u did not reduce readmission or death. Arch Int Med 2007; 167(12)

PC saves hospitals $ but increases costs to hospice organization providing PC. Pall Sup Care 2004; 2(4)

So…important to have a team, “palliative care” approach but how to organize?

Models of Palliative Care

Model Combined consultative

service and inpatient unit Combined hospice and

palliative care programs Consultation service team Dedicated inpatient unit Hospice-based outpatient

consultation Hospice-based home pc Outpatient pc clinic

Associated Facility Hospital, nursing home Hospital, nursing home,

hospice Hospital, office, nursing

home, or home Hospital, nursing home,

inpatient hospice Outpatient settings Home Hospital or office

Iowa Health Palliative Care Physicians Clinical integration of specialty-focused

physicians at IHS. Statewide support system for providers. National standards. System goals. Local needs. Strong voice for improved patient care and

payment reform.

Palliative Care Delivery within IHS

IHHC Hospice and Palliative Care IHDM Palliative Care St. Luke’s CR Hospice and Palliative Care Trinity Regional Fort Dodge Hospice and

Palliative Care Trinity QC Hospice St Luke’s SC Hospice and Palliative Care

(community partnership)

Iowa Health Palliative Care

StatewideIHS Hospice/

Palliative Care Committee

IHS Fort DodgeHospice/PCCommittee

IHS Des MoinesHospice/PCCommittee

IHS WaterlooHospice/PCCommittee

IHS DubuqueHospice/PCCommittee

IHS Cedar RapidsHospice/PCCommittee

IHS Sioux CityHospice/PCCommittee

IHS Quad CitiesHospice/PCCommittee

Palliative Care Delivery Structure within IHDM: Inpatient Palliative Care consult service within

IHDM Home Palliative Care service within IHHC Home Hospice through IHHC Taylor House Inpatient Hospice Infusion and pharmacy services through IHHC Iowa Health Palliative Care Physicians

IH-Des Moines PC Structure

RN Manager/EthicsDirector

RN RN Pastoral Care

VPMA

MSW Manager/Hospice Manager

RN LSW ARNP

Director of Hospice and PC

IHDM IHHC

Medical Director

IHPCP

System Integration

Fragmented, episodic health care is the standard.

Coordination of care across system improves outcomes. Hospital, clinic, home care.

Coordination between providers and multiple disciplines.

Statewide collaboration.

Specialization

Board certification for physicians, nurses, social workers, chaplains.

Focused clinical approach. Dedicated teams gain experience and

accelerate learning. Scale allows service delivery across

system. Hospital, clinic, home.

Who is a Palliative Care Patient?

Hospice/end of life “Terminal” disease process

Malignancy End-stage heart/lung/renal/hepatic Dementia Malnutrition/dehydration

Pain and symptom management Acute and chronic pain syndromes Dyspnea Delirium/dementia

What Happens to PC Patients After Discharge?

23% Nursing home with outpatient palliative Care 22% to a hospice house 12% die prior to discharge 12% Nursing home 10% Home with outpatient palliative care 7% Home 7% Nursing home with Hospice 6% Home with hospice

Why Palliative Care?

Symptom reduction Improved Quality of Life Improved hospital outcome measures Improved patient and family satisfaction Facilitate medical staff functions Reduced costs

Case JT Referred to IHHC in November 2007 65 y/0 Caucasian Male

Utilized entire Iowa Health System…IMMC, IMMC ER, IHP, IHHC, IHHH

Goal: Improve QOL, manage symptoms including chronic pain, prolong life, complete advance planning including living will, discuss health options thru out illness

PMH: CLL, CAD, HTN, PVD, T2DM, HF, Chronic Pain, Recurrent C-Diff

Hospitalizations 2007: 9 admissions, over 50% thru ER, average LOS

2 weeks, majority for HF exacerbations 2008: 4 admissions, 1 direct recurrent c-diff, 1 direct

for HF, 1 ER admit from cardiologist office for CP, 1 ER admit for confusion, average LOS 3-4 days

2009: 1 admission, direct for CHF/COPD exacerbation, LOS 2 days

Symptoms

• Dysnea • Pain• Edema• Cough,• Weakness,• Fatigue,

• Diarrhea,• Dysuria• loss of appetite• constipation• weight gain/loss• debility

Coordinated Care

Direct admissions Medication adjustments and education Labs Symptom management and education Disease education Advance planning Health options Home Care Placement with nursing, telehealth monitor,

Lifeline, infusion, HCA, PT, OT

Home Care

DietitiansPhysician

Insurance Payors

Hospice

Pharmacy

Community Resources

Faith Community

Retirement Centers

Nursing Facilities

Hospital

HME

Pediatrics

Infusion

Private Duty

Patient &Family

Model of Care

Outcome

Decreased inappropriate utilization of ER, decreased LOS, communication and collaboration throughout the continuum of care at IHS , peaceful death and…most important…improved quality of life for his last 2 1/2 years of life.

Mount Sinai Hospital, NYC: Improvement in Symptoms1997-2002: 2,219 palliative care consult service patients

Initial Evaluation Final Evaluation

Moderate

Severe

Mild

None

Pain

Nausea

Dyspnea

Palliative Care Financial Impact

Symptom management + goals of treatment + discharge plan =

Reduced LOS Appropriate utilization of outpatient

resources Reduced readmission rate Reduced total costs

IH-DM Inpatient

34% reduction in LOS LOS savings + cost reduction per day +

opportunity with available beds = Total savings $807,000 cost savings in year one $1,814,983 saved in year two $2,144,923 saved in year three

IHHC-DM Outpatient PC

33% conversion to hospice Majority utilize other home health services 64% hospital day reduction 62% hospital visit reduction 67% reduction in patient costs

Value Demonstrated

Hospitals save $274 to $374 per day per palliative care patient (Arch Int Med 2008;168).

Current PC impact of $1.2B/yr in U.S. Estimated $6B/yr possible (Health Affairs 2009)

Quality Improved-access, symptoms, satisfaction (J Am Geri Soc 2008;56).

High Value Service. Improved outcome per dollar of cost (JAMA 2008;300).

Value-Based Care Analysis

Standard IHS statewide data metrics Clinician-led clinical outcome parameters Internal rate of return calculation Align goals and resource commitment More appropriate reimbursement model

formation

Palliative Care Consult

Patient Tracking starts at time of consult.

Repeated Consults Tracked and Changes Monitored

Case Mrs.P:

Severe physical and cognitive impairment after a major embolic CVA.

Clear directives to son for life-sustaining measures based on religious beliefs.

Care planning at hospital with family. Close relationship developed with IHHC ARNP,

RN’s and other care providers. Patient lived another year at home. Avoided hospitalization.

Issues

Coordinated care Continuous care Complete medical work-up with accurate

diagnosis Clear individualized care plan Reduction in resource utilization and costs

Medicare Readmissions

Readmitted Patients Cost Billions. WSJ, April 1, 2009

Hospitals and fragmented nature of American healthcare system to blame. NYT, April 16, 2009

CMS pilot project announced to eliminate unnecessary hospital readmissions. A state quality improvement organization will monitor. MH, April 14, 2009

Aligned partners across the care continuum with parallel objectives accomplish this goal.

Health Care Payment Reform

Pay-for-performance most effective way to reduce health care costs. Commonwealth Fund, 2005.

Increasing numbers of programs link payment to performance. Annals Int Med, 2006.

Accountable Care Organization concept endorsed by the Robert Wood Johnson Foundation and the Brookings Institute.

Need for value-based partnerships within health care delivery systems.

IHS Vision and Mission Best Outcome for Every Patient Every Time

Can only be achieved through coordinated and integrated care.

Improving the health and well-being of the people we serve by providing the highest quality healthcare possible.

Responsibility for quality across the healthcare continuum.

Teamwork is NOT optional.