Palliative Care: Mission and Strategic Imperative. Sarah E. Hetue Hill, PhD Ascension Healthcare

Transcription

1 Palliative Care: Mission and Strategic Imperative Sarah E. Hetue Hill, PhD Ascension Healthcare

2 Ascension Palliative Care Definition Palliative Care is person-centered, holistic care delivered by an interdisciplinary team of professionals to provide an extra layer of support for patients affected by serious illness and their families. Palliative care can be provided concurrently with disease-modifying or curative treatment.

3 Ascension Palliative Care Model

4 Ascension Healthcare Palliative Care History System-wide Organizational Assessment in Palliative Care - Clinical Excellence Steering Committee endorsed proposal for Palliative Care Initiative Phase I of Initiative - Pilots Phase II of initiative- growth and spread: goal: spread leading practice palliative care in all acute goal: spread throughout continuum within all Health Ministries

5 Sample Achievements in our Programs Major accomplishments of individual acute care ministries: Patient/family satisfaction rate of PC patients at 4.7 out of 5 Pain well controlled w/in 48 hours 92% of the time, dyspnea well controlled w/in 48 hours 98% of the time Spiritual assessment w/in 24 hours 100% of the time 60% increase in completion of advance directives Major accomplishments of home health palliative care team: Increased median hospice LOS to 60 days versus 19 MLOS nationally 30 day readmission rate at 1% ; 60 day readmission at 3%.

6 Current State prior to 2013 Palliative Care Delivery at Acute Care >100 Beds 39% 4% 25% No palliative care delivery At least one person working on palliative care Interdisciplinary team in place 32% Interdisciplinary team in place in line with 2013 Scorecard/Joint Commission

7 Teams Not Adequately Staffed- Prior to 2013 Is Your Palliative Care Team Adequately Staffed? Yes 22% No 78%

8 Palliative Care Integrated Scorecard Measure: 2013 System Priority 2013 Integrated Scorecard and Short Term At-Risk Compensation Measures included Palliative Care Metrics To create baseline of high quality interdisciplinary teams, increase visibility and capacity, and take existing teams to next level

9 Post 2013 Scorecard Measure Palliative Care Delivery at Acute Care >100 Beds 8% Interdisciplinary team in place 92% Interdisciplinary team in place in line with 2013 Scorecard/Joint Commission

10 Palliative Care in the Midst of Health Care Reform From this: To this: Within context of health system initiatives: - Moving from Mission Imperative to Mission & Strategic Imperative - Quadruple Aim - Reducing Health Care Disparities

11 Palliative Care and the Quadruple Aim Improved Patient Outcomes (Population Health) Improved Patient Experience Improved Provider Experience Lower Costs

12 PC Contributes to our Quadruple Aim Improved Patient Experience Improves pain and symptoms that affect HCAHPS Increases patient and family satisfaction Focuses on individual experience to assure that personal needs, goals and preferences drive the clinical care and outcomes as illness progresses Creates a partnership among the individuals, their loved ones and the care team with a common goal of improving quality of care and quality of life

13 PC Contributes to our Quadruple Aim Improved Health Outcomes Increases length of life and quality of life for those who received consult vs those who did not Helps to mitigate pain and suffering of patients and families with serious illnesses Improves other symptoms that lead to suffering Decreases the proportion of people who die in hospitals and nursing homes who would prefer to die at home; assists in better health of families and loved ones

14 PC Contributes to our Quadruple Aim Lower Costs Studies continue to show palliative care impacts the following: Lower costs per day Shorter hospital LOS Shorter ICU LOS Fewer ICU admissions Reduced readmissions Fewer hospital admissions and inpatient deaths Fewer 30-day readmissions Reduced hospital mortality

15 PC Contributes to our Quadruple Aim Improved clinician experience Adds an extra layer of support for those physicians managing the care of persons with chronic/serious illness Assists with difficult conversation, addressing goals of care, symptom management for difficult to manage symptoms and for families in crisis Eases burden on staff, giving them something to offer patients and families that are suffering (moral distress)

16 Centers Model of Palliative Care Current State: -all patients not receiving primary PC -PC teams stretched thin -low penetration, high variability -too many late consults System Leadership for Palliative Care System Director, Palliative Care Regional Dyadic Leadership for Palliative Care Regional Director(s) of Palliative Care (operational lead and medical director) Resource Escalation Specialty palliative care teams Acute Care Outpatient Specialty PC consults in Home, SNF, LTC telehealth, other Palliative Care Fellowships Front Line staff with Primary Palliative Care Training Frontline clinicians and associates Frontline clinicians and associates Frontline clinicians and associates Future State: -high quality primary PC for everyone who benefits -Specialty Palliative Care for those with higher acuity -high penetration, low variability -consults earlier in illness trajectory 16 Proactive Integration

17 Outpatient Palliative Care Health System Based Practice Independent Practice Clinic Practice Community Practice Stand Alone Colocated Embedded Facility Visits (SNF, AL) Home- Visits

18 Palliative Care in Oncology

19 Palliative Care: Positive Outcomes For Patients with Cancer Increased patient satisfaction Improved quality of life Improved mood Decreased depression Increased median survival versus usual care For Caregivers Decreased anxiety Increased satisfaction Reduced symptom burden without increased grief for family caregivers after death

20 Palliative Care-Positive Outcomes for Caregivers Study Focus Method Conclusion Gysels et al, 2004 Improving PC in cancer patients The Methods Of Researching End of life Care Positive effect on CG burden, anxiety and satisfaction Wilson et al, 2004 Systemic review of EOL care Systematic review, intervention studies (randomized and nonrandomized designs) Positive effect on CG burden, anxiety and satisfaction 2003Resources for Enhancing Alzheimer's Caregiver Health (REACH) The effect of skill building on CG Meta-analysis Reduce CG burden Cochrane Review Effectiveness of homebased pc services Review of 23 studies of 37,500 patients and 4,000 family caregivers PC helps reduce symptom burden w/o increasing grief for family caregivers after death

21 Palliative Care-Positive Outcomes for Cancer Patients Trial Population Intervention Results- Pt satisfaction Gade et al Bakitas et al Temel et al 517 people surprise? 31% cancer 322 people ~1 yr prognosis 100% cancer 151 people 100% newly dx metastatic NSCLC Inpatient PC MDT consult Phone based PC by APN Outpatient PC >=monthly MD/APN and Inpt PC consult Increased satisfaction Results- QOL and survival Improved QOL Improved QOL Improved mood Improved QOL and mood, less depression, Longer median survival by ~3 mos Zimmerman et al 442 people 100% cancer 6mo-2yr prognosis Outpatient PC >=monthly Increased satisfaction Improved QOL

22 Ideal process to triage & identify patients for PC referral Screen patients, case finding is patient-centered Ensure ACP completion, full symptom assessment Consider referral to specialty PC for difficult/complex issues

23 Palliative care trajectory in HF

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25 Symptom Improvement of 3700 HF patients who received PC

26 American Heart Association Patients with cardiovascular disease should have access to continuous, coordinated, comprehensive, high quality palliative care given simultaneously with specialist care. ACC/AHA Guidelines June 26 7, 2018

27 Palliative Care: Primary versus Specialty Primary Palliative Care Basic skills & competencies required of all MD s & other health care professionals Specialty (Secondary) Palliative Care Provided by specialist consultant clinicians with additional training