Palliative Care 2020: Matching Care to Patient and Family Needs

Transcription

1 Palliative Care 2020: Matching Care to Patient and Family Needs Diane E. Meier, MD Director Center to Advance Palliative Care

2 Disclosures I have no disclosures to report.

3 Objectives 1. How is palliative care important to improving care of the most vulnerable? 2. How do we change the delivery system to improve access to quality palliative care for all persons with serious illness and their families?

4 Concentration of Spending Distribution of Total Medicare Beneficiaries and Spending, % 37% 63% Average per capita Medicare spending (FFS only): $8,554 Average per capita Medicare spending among top 10% (FFS only): $48,220 10% Total Number of FFS Beneficiaries: 37.5 million Total Medicare Spending: $417 billion 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, 2011.

5 Because of the concentration of risk (and spending), palliative care principles and practices are central to improving quality. Improved quality reduces cost.

6 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 a lot of acetaminophen. Admitted 4 times in 6 months for pain (2x), weight loss+falls, and altered mental status due to constipation. His family (83 year old wife) is overwhelmed.

7 Mr. B: Mr. B: I told the Dr. that I never wanted to go back to the hospital again. It s torture you have no control and can t do anything for yourself. And you get weaker and sicker. Every time I m in the hospital it feels like I ll never get out. 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 Dave Casarett

8 Concentration of Risk Functional Limitation Dementia Frailty Serious illness(es)

9 Most of Costliest 5% have Functional Limitations

10 The Modern Death Ritual: The ED and the ICU Half of older Americans visited ED in last month of life and 75% did so in their last 6 months of life. 90% of ED visits in those >65 due to symptom distress. 50% increase in ICU admissions from ED in people >85 years. Smith AK et al. Health Affairs 2012;31: Pines JM et al. JAGS 2013;61: Mullins et al. Acad Emerg Med 2013;20:

11 Dementia Drives Utilization Prospective Cohort of community dwelling older adults Dementia No Dementia Medicare SNF use 44.7% 11.4% Medicaid NH use 21% 1.4% Callahan et al. JAGS 2012;60: Hospital use 76.2% 51.2% Home health use 55.7% 27.3% Transitions

12 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:

13 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.

14 The 5% Highest risk, highest cost population: functional limitation, frailty, cognitive impairment +/- serious illness(es) What are the roles of primary care teams in improving care of this population?

15 What is Palliative Care? Specialized or generalist medical care for people with serious illness and their families Focused on improving quality of life as defined by patients and families. Provided by an interdisciplinary team that works with patients, families, and other healthcare professionals to provide an added layer of support. Appropriate at any age, for any diagnosis, at any stage in a serious illness, and provided together with curative and life-prolonging treatments. Definition from public opinion survey conducted by ACS CAN and CAPC

16 Conceptual Shift for Palliative Care

17 Don t ask what s the matter with me. Ask what matters to me. Palliative Care Teams Address 3 Domains 1. Physical, emotional, and spiritual distress 2. Patient-family-professional communication about achievable goals for care and the decision-making that follows 3. Coordinated, communicated, continuity of care and support for social and practical needs of both patients and families across settings

18 Palliative Care Language Endorsed by the Public Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.

19 Palliative Care Models Improve Value (Quality/Cost) 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

20 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

21 Access to Palliative Care Across the Continuum: The Future Provider Home Visits NH Services Hospital Consult Service Inpatient Unit Outpatient Specialty Clinics Outpatient PCP Clinics Cancer Center 21

22

23 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:

24 Palliative care in addition to usual oncology care allowed lung cancer patients to live almost 3 mos longer than those who got usual oncology care. Temel J, et al. NEJM 2010

25 Palliative Care at Home for the Chronically Ill Improves Quality, Markedly Reduces Cost RCT of Service Use Among Heart Failure, Chronic Obstructive Pulmonary Disease, or Cancer Patients While Enrolled in a Home Palliative Care Intervention or Receiving Usual Home Care, Usual Medicare home care 35.0 Palliative care intervention Home health visits Physician office visits ER visits Hospital days SNF days KP Study Brumley, R.D. et al. JAGS 2007

26 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 Primary outcome: a 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). Change in the composite score indicated a significant difference over time between the 2 groups (p =.013). Comart J et al. The Gerontologist 2012; dec 7. doi: /geront/gns154

27 RCT of Nurse-Led Telephonic Palliative Care Intervention N= 322 advanced cancer patients in rural NH+VT Improved quality of life and less depression (p=0.02) Trend towards reduced symptom intensity (p=0.06) No difference in utilization, (but v. low in both groups) Median survival: intervention group 14 months, control group 8.5 months, p = 0.14 Bakitas M et al. JAMA 2009;302(7):741-9

28 US Oncology: Pathways Include Palliative Care Clinical pathways specify: Number of regimens Exact drugs to use Goals of care discussion early The Checklist Approach. Advance medical directives and health agent appointment up front as standard of care. Use of homecare and hospice as standard of care. (In contrast, NCCN pathways allow 16 individual drugs in multiple combinations. No mention of non-chemo care until the end.)

29 U S Oncology pathways preserve survival, reduce cost by 35% in lung cancer. New guidelines have AMDs DPMA, hospice visit Less chemo More hospice Longer LOS For NSCLC, equal results, less toxicity, less cost. Chemo beyond 3 rd line off pathway. Neubauer M, et al. J Oncol Pract Jan;6(1):12-8.

30 U S Oncology pathways preserve survival, reduce cost by 34% in metastatic colon cancer. Table 1: Impact of pathways in colon cancer Overall survival (mos) Chemo Cost ($) Total Cost ($) Pathway , ,379-34% Nonpathway , ,020 P value 0.03 <0.001 <0.001 Hoverman R, et al. Am J Manag Care May;17 Suppl 5 Developing:SP45-52.

31 MA Full Risk PMPM contract with HealthCare Partners/DaVita 15%+margin. >700K patients Now instead of patients/day, Dr. Dougher sees 6-8.

32 Consequences of Late Referral to Palliative Care Serious Adverse Outcomes for Bereaved Caregivers: Compared to care at home with hospice, Care in ICU associated with 5X family risk of Post Traumatic Stress Disorder; and Care in hospital associated with 8.8X family risk of prolonged grief disorder Wright A et al. Place of death: Correlation with quality of life of patients with cancer and predictors of bereaved caregivers mental health. JCO 2010; Sept 13 epub ahead of print

33

34 Effect of Palliative Care on Hospital Costs

35

36 How Palliative Care Reduces Cost Improved resource use Reduced bottlenecks in high cost units Improved throughput and consistency The Conceptual Model: Dedicated medical team = Focus + Time = Decision Making / Clarity / Follow through

37 RESOURCES Key Characteristics of Effective Models 1: Targeting Demand Management DM/CM CCM-palliative care NEEDS

38 Jones et al. JAGS 2004;52

39 Gómez-Batiste X, et al. BMJ Supportive & Palliative Care 2012;0:1 9. doi: /bmjspcare

40 Targeting on the Front Lines Ask yourself: Does this patient have an advanced long term condition or a new dx of a serious illness or both? Would you be surprised if this patient died in the next 12 months? Does this patient have decreased function, progressive weight loss, >= 2 unplanned admissions in last 12 months, live in a NH or AL, or need more personal care at home? Does this patient have advanced cancer or heart, lung, kidney, liver, or cognitive failure?

41 Key Characteristic 2: Goal Setting Don t ask what s the matter with me; ask what matters to me! Ask the person and family, What is most important to you? Ultimately, good medicine is about doing right for the patient. For patients with MCC, severe disability, or limited life expectancy, any accounting of how well we re succeeding in providing care must above all consider patients preferred outcomes. Reuben and Tinetti NEJM 2012;366:777-9.

42 Goals for Care Survey of Senior Center and AL subjects, n=357, dementia excluded, no data on function Asked to rank order what s most important: Overall, independence ranked highest (76% rank it most important) followed by pain and symptom relief, with staying alive last. Fried et al. Arch Int Med 2011;171:1854

43

44 Impact of Goal Setting through Advance Care Planning Prospective data on >3000 Medicare beneficiaries (linked HRS, claims, and NDI) Advance directives associated with lower Medicare spending, lower hospital death rate, and higher hospice use in medium-high Medicare spending regions of the U.S. Nicholas et al. JAMA 2011;306:

45 Key Characteristic 3: Can We Deliver on People s Goals? Not When Families are Home Alone 40 billion hours unpaid care/yr by 42 million caregivers worth $450 billion/yr Providing skilled care Increased morbidity/mortality/ban kruptcy aarp.org/ppi

46 Optimistic Baby Boomers say Get Ready, Kids! 70% of those who have never received long term care say they can rely on family in time of need as they age, (compared to 55% of those who have received it). The Scan Foundation/NORC/AP April 2013 To.pbs.org/15TQh2B

47 Why? Low Ratio of Social to Health Service Expenditures in U.S. for Organization for Economic Co-operation and Development (OECD) countries, Bradley E H et al. BMJ Qual Saf 2011;20: Copyright BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.

48 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 LTC Services less than 1/3 rd the cost of Nursing Home care.

49 Families Need Help if We Are to Honor People s Goals Mobilizing long term services and supports is key to helping people stay home and out of hospitals. Predictors of success: 24/7 phone access; high-touch consistent and personalized care relationships; focus on social and behavioral health determinants; coordinated integration of social supports with medical services. This is our job.

50 Payers Are Already Bringing the Care Home

51 Exemplar: BCBS MI The Missing Piece Solution Thank you Dottie Deremo! Chronic Disease Management Advanced Illness Management Hospice Care 6 mos yrs mos

52 a wholly owned subsidiary of Hospice of Michigan Payer: BCBS Michigan Providers: ACOs,Employers in SE Michigan Improves Quality Outcomes Supports Stressed Family Caregivers Saves 30% Net Total Health Care Costs for Tier 3 patients demonstrated by 3 rd party independent research 52

53 How? System Redesign Telesupport 24/7/365 Outcomes Analytics Predictive Modeling Analytics ER & Hospital Transition Coaches AIM Home Services 24/7/365 53

54 Key Characteristic 4: Pain and Symptoms Pain of moderate or greater severity that is often troubling is reported by 46% of older adults in their last 4 months of life and is worst among those with arthritis. 90% ED visits >65 years are due to symptoms. Smith AK et al. Ann Intern Med 2010;153: Pines JM et al. JAGS 2013;61:12-17.

55 It s Not Only Pain: Symptom Burden of Community Dwelling Older Adults with Serious Illness Percent of patients reporting symptom Ltd Activity Fatigue * * Discomfort *75% or more reported symptom as bothersome * * SOB Pain Lack Well Being Appetite * Insomnia * Weakness Depression Anxiety Walke L et al, JPSM, 2006 *

56 Key Characteristic 5: Dynamic Nature of Risk Early advance care planning + communication on what to expect + treatment options + access. As illness progresses, ability to titrate dose intensity of services. Morrison and Meier. N Engl J Med 2004;350(25):

57 Integrate Palliative Care into New Delivery and Payment Models Adding palliative care targeted to the highest risk populations to the specifications for ACOs, bundles, PCMHs is key to their success at improving quality and reducing cost.

58 Major Health Systems/ACOs Get It Making multimillion dollar investments in palliative care integration across settings: Partners Health System/ Harvard Medical School U. of Pittsburgh Health System Duke U. Health System North Shore-LIJ Health System OSF Health System Iowa Health System Ohio Health System Sharp Health System Banner Health System

59 Transforming 21 st Century Care of Serious Illness Gomez-Batiste et al.2012 Change from: Change to: Terminal Advanced Chronic Prognosis weeks-month..prognosis months to years Cancer..All chronic progressive diseases Disease..Condition (frailty, fn l dep, MCC) Mortality.Prevalence Cure vs. Care Synchronous shared care Disease OR palliation..disease AND palliation Prognosis as criterion..need as criterion Reactive.Screening, Preventive Specialist Palliative/Geriatric Care Everywhere Institutional.Community No regional planning.public health approach Fragmented care Integrated care

60 (Present) and Future The future is here now. It s just not very evenly distributed. William Gibson The Economist, 2003