PALLIATIVE CARE: State of the Art & Art of the State

Transcription

1 PALLIATIVE CARE: State of the Art & Art of the State Amberly Molosky, CHPCA Director of Palliative Care Banner Health Stacie Pinderhughes, MD Banner Good Samaritan Medical Center Learning Objectives: How did we get here? Palliative care in historical context. Where are we now? Palliave care at the tipping point. Where should we go? Palliave care for all in need. DISCLOSURE OF COMMERCIAL SUPPORT Amberly Molosky, CHPCA and Stacie Pinderhughes, MD do not have a significant financial interest or other relationship with manufacturer(s) of commercial product(s) and /or provider(s) of commercial services discussed in this presentation. the. 1

2 Palliative Care: State of the Art, Art of the State Stacie T. Pinderhughes, MD Medical Director Palliative Medicine Chair Division of Palliative Care Amberly Molosky Director Palliative Care Banner Health System Palliative care is about matching patients treatments to their goals Objectives How did we get here? Palliative care in historical context Where are we now? What works to improve quality for vulnerable older people Where should we go? Assuring palliative care for all in need the. 2

3 Middle Ages to the 1950 s Life expectancy years Hospices for travelers during crusades Churches created wards for poor and sick: 11 th 16 th Centuries Most deaths occurred at home Until about Life Expectancy in U.S. (2012) Median age of death is 78 years 75.7 for men, 80.8 for women Among survivors to age 65, median age at death is 84 years Among survivors to age 85, median age at death is 92 years Gain of 30+ years since 1900 US Census Bureau, Statistical Abstract of the United States, 2012 the. 3

4 20 th Century Responses to Longevity Expectation for a long life normalized Exponential growth in hospitals procedures medicines technology in association with health insurance NIH market forces Response to Medicalization of Serious Illness and Death Cicely Saunders: St. Christopher s Hospice, est Florence Wald: Connecticut Hospice, 1974 Elisabeth Kubler Ross listens to patients, publishes, On Death and Dying 1969 Grass roots, often faith based, volunteer hospice organizations Focus on cancer, not on chronic degenerative disorders of aging the. 4

5 Medicare Hospice Benefit 1982 A new Federal Benefit to provide payments Strengths: Marked improvement in access, focus on home, focus on family/survivors, lead to measurable and significant improvement in quality care for the dying Weaknesses: By law and design, is only for the dying with prognosis of < 6 mos. Who agree to forgo insurance coverage for disease modifying treatment lack of fit for chronic illness Consequences of the Medicare Hospice Benefit Reserved for brink of death care, 2012 median LOS 20 days and declining Utilization for chronically ill with unclear prognosis (e.g. dementia) framed as fraud and abuse. Hospice providers across the country are facing the catastrophic financial consequence of what would otherwise seem a positive development: their patients are living longer than expected. The refusal of patients to die according to actuarial schedules has led the federal government to demand that hospices repay hundreds of millions of dollars to Medicare. In Hospice Care, Longer Lives Mean Money Lost NYT What About People Who are Not Dying (Soon)? Care of the Seriously Ill in the U.S. The SUPPORT Study Controlled trial to improve care of seriously ill patients not getting Hospice Multicenter study funded by RWJ 9000 patients with serious chronic illness JAMA 1995:274: the. 5

6 Creation of the Burning Platform: Front Page News Late 1980 s SUPPORT data: < 50% MDs aware of their patient s wishes 38% spend > 10 days in ICU 50% had moderate severe pain more than half of last 3 days of life 40 60% reported mod severe pain after 1 week in hospital 55% families experience major burden The Present > 1,700 hospital palliative care teams in U.S., of highly variable quality, penetration, staffing outreach New medical and nursing subspecialty Highly variable undergraduate and graduate medical/nursing/social work education in palliative care Changing cognitive frame for palliative care in context of aging population, multi morbidity, and chronic disease the. 6

7 Growth of Palliative Care in U.S. Hospitals 2011 Snapshot Over the last ten years palliative care has been one of the fastest growing trends in health care. In fact, the number of palliative care teams within hospital settings has increased approximately 138%, from more than 600 in 2000 to more than 1500 today. # of Hospitals with Palliative Care Growth of Palliative Care Center to Advance Palliative Care Palliative Care Specialized medical care for people with serious illness Provides relief from symptoms Such as: pain/nausea/delirium Improves quality of life Provided by a team that works with the physician in charge to provide an extra layer of support Including: Doctors/nurses/social work/pharmd and other specialists Appropriate at any age and at any stage in serious illness Provided along with curative treatment Conceptual Shift for Palliative Care Permission from R. Sean Morrison, MD MSSM the. 7

8 Because of the Concentration of Risk and Spending, Palliative Care Principles and Practices are Central to Improving Quality and Reducing Cost Concentration of Spending Distribution of Total Medicare Beneficiaries and Spending, % 10% Total Number of FFS Beneficiaries: 37.5 million 37% 63% Total Medicare Spending: $417 billion Average per capita Medicare spending (FFS only): $8,554 Average per capita Medicare spending among top 10% (FFS only): $48,220 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, Mr.B An 88 year old man with mild dementia admitted via the ED for management of back pain due to spinal stenosis and arthritis. Pain is 8/10 on admission, for which he is taking 5 gm of acetaminophen/day. Admitted 3 times in 2 months for pain (2x), weight loss+falls, and altered mental status due to constipation. His family (83 year old wife) is overwhelmed. the. 8

9 Mr. B: Mr. B: Don t take me there! Please! Mrs. B: He hates being in the hospital, but what could I do? The pain was terrible and I couldn t reach the doctor. I couldn t even move him myself, so I called the ambulance. It was the only thing I could do. Modified from and with thanks to Diane Meier Concentration of Risk Functional Limitation Dementia Frailty Serious Illness(es) Adapted from CAPC.org the. 9

10 The Modern Death Ritual: The Emergency Department Half of older Americans visited ED in last month of life and 75% did so in their last 6 months of life. Smith AK et al. Health Affairs 2012;31: Adapted from CAPC.org Dementia Drives Utilization Prospective Cohort of community dwelling older adults Callahan et al. JAGS 2012;60: Dementia Medicare SNF use 44.7% 11.4% Medicaid NH use 21% 1.4% Hospital use 76.2% 51.2% Home health use 55.7% 27.3% Transitions No Dementia Dementia and Total Spend 2010: $215 billion/yr By comparison: heart disease $102 billion; cancer $77 billion 2040 estimates> $375 billion/yr Hurd MD et al. NEJM 2013;368: the. 10

11 In case you are not already worried The Future of Dementia Hospitalizations and Long Term Services+Supports 10 fold growth in dementia related hospitalizations projected between 2000 and 2050 to >7 million. Zilberberg and Tija. Arch Int Med 2011;171: fold increase in need for formal LTSS between now and 2050, from 9 to 27 million. Lynn and Satyarthi. Arch Int Med 2011;171:1852. Surprise! Home and Community Based Services are High Value Improves quality: Staying home is concordant with people s goals. Reduces spending: Based on 25 State reports, costs of Home and Community Based Long Term Care Services are less than 1/3 rd the cost of Nursing Home care. Study: Having meals delivered to home reduces need for nursing home 10/14/2013 HealthDay News A study published today in Health Affairs found if all 48 contiguous states increased by 1% the number of elderly who got meals delivered to their homes, it would prevent 1,722 people on Medicaid from needing nursing home care. The Brown University study found lower Medicaid costs would more than offset the cost of providing the meals. the. 11

12 Social Supports and Impact on Healthcare Utilization Provision of public housing to the homeless leads to marked decrease in healthcare services utilization. Larimer et al. JAMA 2009;301: Improving Care of this Population Requires Application of What We Already Know Highest risk, highest cost population are those with functional limitation, lack of social supports, frailty, cognitive impairment +/ serious illness(es). What works to improve care of this population? Palliative and Geriatric Care Models Improve Value Quality improves Symptoms Quality of life Length of life Family satisfaction Family bereavement outcomes MD satisfaction Care matched to patient centered goals Costs reduced Hospital costs decrease Need for hospital, ICU, ED decreased 30 day readmissions decreased Hospitality mortality decreased Labs, imaging, pharmaceuticals reduced Adapted from CAPC.org the. 12

13 GRACE Integrated (capitated) care for low income seniors w/ MCC, mostly dual eligibles In home APN+SW assessment and care plan RCT of 951 seniors <200% poverty level Quality: improved QOL, high MD satisfaction Cost: Decreased ED, hospital, readmissions. $1500 PMPY savings Counsell SR et al. JAGS 2009;57:1420. Bielaszka DuVernay C. HA 2011;30: the. 13

14 Hospital at Home Quality: Improved patient satisfaction Reduced 6 month mortality by 38% (Cochrane) Cost: Total spend reduced by 19% Mediated by reducing both LOS and clinical testing Cryer L et al HA 2012;31: ; Shepperd S. CMAJ 2009;180: Palliative Care Improves Quality in Office Setting Randomized trial simultaneous standard cancer care with palliative care co management from diagnosis versus control group receiving standard cancer care only: Improved quality of life Reduced major depression Reduced aggressiveness (less chemo < 14d before death, more likely to get hospice, less likely to be hospitalized in last month) Improved survival (11.6 mos. vs 8.9 mos., p<0.02) Temel et al. Early palliative care for patients with non small cell lung cancer NEJM2010;363: the. 14

15 Palliative Care in the Nursing Home Retrospective case control study comparing care processes in 125 end stage dementia patients receiving palliative care consultations ( ) to 125 historical controls (2006) receiving usual care Single facility (Hebrew Rehabilitation) in Boston Data source: MDS Composite outcome based on utilization patterns, depression, and pain and other clinical Indicators, and change on this composite score (and the individual outcomes) over a 1 year period. Results: Residents receiving palliative care consultation had fewer ED visits (p<.001) and less depression (P=.03). Significant difference over time between the 2 groups (p =.013). Comart J et al. The Gerontologist 2012; dec 7. doi: /geront/gns154 Palliative Care in National Context Quality is poor: US ranks 40 th in quality indices worldwide, >100,000 deaths per year from preventable hospital errors, 48 million uninsured, healthcare #1 cause of personal bankruptcy Cost is unsustainable: Healthcare is bankrupting the United States The Future of Palliative Care Not enough to have access to palliative care in hospitals Most illness occurs at home and in communities Home palliative care needed without regard to prognosis or goals of care Goal= insure access to palliative care across all settings and stages of illness the. 15

16 Goal 1: All patients and families will know to request palliative care in the setting of serious illness Palliative Care Hits the High Notes Better health. Better care. Lower Cost Key Messages: Palliative care sees the person beyond the cancer treatment. Palliative care is all about treating the patient as well as the disease. It s a big shift in focus for health care delivery and it works. What can I do? TAKE ACTION! ASCAN Capitol Hill ad campaign 2012 the. 16

17 For Patients & Families GetPalliativeCare.org Hospital Provider directory What it is and how to get it Patient and family resources Goal 2: All healthcare professionals will have the knowledge and skills to provide palliative care Why is it so bad? One reason is deficiencies in medical education 74% of residencies in U.S. offer no training in end of life care 83% of residencies offer no hospice rotation 41% of medical students have never witnessed an attending talking with a dying person or his family and 35% never discussed the care of a dying patient with a teaching attending Billings & Block JAMA 1997;278:733 the. 17

18 Workforce: the Major Barrier to Access Oncologists: 1 for every 145 patients with new cancer diagnosis Cardiologists: 1 for every 71 heart attack victims Palliative Medicine: 1 for every 1,300 people with serious illness Workforce Priorities Increase number of fellowship programs, fellows in training, and funding Develop mid career board certification track Promote generalist level palliative care through undergraduate, graduate and mid career training Goal 3: All healthcare institutions will be able to support and deliver high quality palliative care the. 18

19 Towards Delivery of High Quality Palliative Care Strategic partnerships towards key policy priorities Regulation, accreditation Quality measures linked to payment incentives TJC Palliative Care Certification Certification for Palliative Care emphasizes: A formal, organized, inpatient palliative care program led by an interdisciplinary team whose members possess the requisite expertise in palliative care. A special focus on patient and family engagement. Processes which support the coordination of care and communication among all care settings and providers. Access via Quality Measurement Linked to Payment Payment increasingly linked to quality outcomes National Quality Forum under contract with CMS for palliative care measures use them now and be ready Next step is integration in Value Based Purchasing the. 19

20 Access to Palliative Care Across Continuum: The Future (Present) and Future The future is here now. It s just not very evenly distributed William Gibson The Economist, 2003 Special Thanks Dr. Diane Meier, Director of Center to Advance Palliative Care Banner Health Palliative Care Team AZ Geriatrics Society Some slides adapted from CAPC.org with permission the. 20