The Changing Landscape of Palliative Care

Transcription

1 The Changing Landscape of Palliative Care KAHPC 17th Annual Conference August 2015 Brian Jones Joe Rotella Elizabeth Wessels Turner West Kay Williams

2 Why Home-based Palliative Care? Turner West, MPH, MTS Hospice of the Bluegrass

3 What is Palliative Care What is Palliative Care? What is Community-Based Palliative Care? Distinguishing Palliative Care Vis-à-vis Hospice Care? Vis-à-vis Case Management?

4 What is Palliative Care Center to Advance Palliative Care Marketing Study Palliative care, also known as palliative medicine, is specialized medical care for people living with serious illness. It focuses on providing relief from the symptoms and stress of a serious illness whatever the diagnosis. The goal is to improve quality of life for both the patient and the family.

5 What is Palliative Care Center to Advance Palliative Care Marketing Study Palliative care is provided by a team of palliative care doctors, nurses and other specialists who work together with a patient s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.

6 Growth of Palliative Care in U.S. Hospitals

7 What is Community Based Palliative Care?

8 Why Community-Based Palliative Care?

9 Key Characteristics of CommunityBased Palliative Care

10 Innovation Opportunities Joe Rotella, MD, MBA, HMDC, FAAHPM American Academy of Hospice and Palliative Medicine

11 A time for new models of care Affordable Care Act is marching on Value-based purchasing (VBP), risk-sharing models Public quality reporting CMS Innovation Center demonstrations Triple aim Better health outcomes for populations Better experience for patients Better value for payers

12 Palliative care is part of the solution Hospice and palliative care hold keys to highvalue care for sickest patients Advance care planning and patient-centered care Pain and symptom management Psychosocial, spiritual and practical support Support for families and caregivers Care where the patient lives 24/7 availability for crisis intervention Coordination of all aspects of care

13 CMS Innovation Center programs Accountable Care Episode-based Payment Initiatives Primary Care Transformation Medicaid and CHIP Population Initiatives Medicare/Medicaid Initiatives Initiatives to Accelerate Testing of New Payment and Service Models Initiatives to Speed Adoption of Best Practices

14 Accountable care Pioneer, Advanced Payment, Next Generation ACOs Rural Hospital, ESRD, PACE, Nursing Home VPB demos What ACOs, demos are active in your service area? How can you help them improve outcomes and cut costs for patients with serious illness? Get a seat at the table, learn where they are feeling the most pain, and offer a solution

15 Episode-based payments Comprehensive Care for Joint Replacement Oncology Care Model 4 Models of bundled payments for acute hospital and post-acute care Retrospective, pay for acute only Retrospective, pay for both acute and post-acute Retrospective, pay for post-acute only Prospective, pay for acute only

16 Primary care transformation Patient-centered medical homes in Federally Qualified Health Centers Independence at Home (home-based primary care for those with multiple chronic conditions) Multi-payer Advanced Primary Care Practice (CMS joins multi-payer primary care initiatives currently conducted within states)

17 Dual-eligible initiatives Financial Alignment Initiative for Medicare/Medicaid Enrollees Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents

18 Accelerate new payment and service models Frontier Community Health Integration Community-based Care Transitions Medicare Care Choices Model State Innovation Models Health Care Payment Learning and Action Network

19 Other payers are playing too Commercial insurance Medicare Advantage Managed Medicaid Self-insured employee health groups

20 Thinking about innovation G Pisano, Harvard Business Review, June 2015

21 New business models Fee for service Per diem Shared savings Shared bundled payments Pay for performance (quality, utilization) CMS demonstration payments Non-traditional payers

22 New service models Expanded medical providers (NPs and PAs) Community health workers Volunteers Call centers Telehealth Post-acute care episodes Crisis intervention Patient empowerment

23 Sources of start up capital Retained earnings, endowments Donors Advance payments Grants Investors Loans

24 Key differentiators Who? (payers, patients, partners, providers) Where? (site of care, service area) How provide care? (visits, calls, virtual platforms) How generate revenue? How license? (hospice, facility, practice) How measure performance? How grow?

25 Give your innovation a chance Use separate staff from routine operations Build culture of learning and rapid adaptation Have a reasonable business plan Have milestones Know break-even points and how much capital you can burn Get full buy-in of governance and senior leaders

26 New Palliative Care Models at Hospice of the Bluegrass Turner West, MPH, MTS Hospice of Bluegrass

27 CBPC at Hospice of the Bluegrass Settings Outpatient Clinic (1999) Early Adopter of community-based palliative care Nursing Homes (2004) Solo practitioner model Home Based Palliative Care Rare, but not unprecedented under clinic operations

28 CBPC at Hospice of the Bluegrass Current CBPC at Hospice of the Bluegrass Reopening clinic at Baptist Health Lexington Serve patients in Baptist Health system from oncology, cardiology, pulmonology, internal medicine Hospice of the Bluegrass physicians 24/7 Call 2 clinics per week

29 CBPC at Hospice of the Bluegrass Delivering high quality, interdisciplinary, CBPC in a manner that is financially sustainable is difficult. Collaborations with a health care payer Partnership with a hospital or health system Grant Funding Philanthropic Support Operate at a loss as part of mission or as a strategic initiative to be well positioned to compete in a health care delivery system focusing on value.

30 At Home Support A Model for Advanced Illness Management Elizabeth Wessels, LCSW Care Guide Partners/Hosparus Ewessels@careguidepartners.org

31 At Home Support Model Overview Copyright Support. Reproduction by permission only. 31

32 The Missing Piece Stage 1 Stage 2 Stage 3 Care Gap Terminal Mourning Stage 4 CHRONIC DISEASE 2 20 Years SERIOUSLY ILL Months HOSPICE 6 Mos. or Less GRIEF SUPPORT MAYBE Tier 3A 5 % Population 50% Cost Copyright Support. Reproduction by permission only. 32

33 The Case Of Sally An example Tier 3A Patient: 55 years old Limited Caregiver Assistance COPD diagnosis Arthritic High Blood Pressure Congestive Heart Failure Type 2 Diabetes Smoker Oxygen Dependent Cannot manage her medications Experiencing loss of independence Requires ADL assistance Lacks knowledge of disease process Lonely/Depressed Limited Financial Means Frequent visitor to ER Copyright Support. Reproduction by permission only. 33

34 Interdisciplinary Clinical Program Design PCP RN MSW Patient Family Assistant Volunteer Consulted on and approves the plan of care Notified of any significant changes in patient status Writes orders for any changes in plan of care (i.e. medication, DME, etc.) Skilled nursing interventions Medication reconciliation Pain and symptom management Teaching patient about disease condition Assessment of social and emotional factors Coordination of community resources Assistance with legal/financial issues Advanced care planning ADL/IADL support Light housekeeping Personal care Intermittent respite Assists with light housekeeping duties Provides caregiver respite Provides for companionship visits with the patient and family Copyright Support. Reproduction by permission only. 34

35 Hospital Admissions 23% 2014 Results (Preliminary) 2013 = 28% 4.57 Overall Score Outcomes ER Utilization 35% 2014 Results (Preliminary) 2013 = 19% Hospital Readmissions 30% 2013 Results 2014 Results TBD 2014 Q3 YTD Savings Savings Per Patient Day Cost Savings Source: At Home Support Payer Claims DataCopyright Support. Reproduction by permission only. $91.92 $9.8M 35

36 Palliative Care Models at St. Elizabeth Hospice Brian Jones, DHSc, MS, CHPCA St. Elizabeth Hospice

37 Palliative Initiatives Brian Jones, DHSc, MS, CHPCA Director of Hospice and Palliative Care Programs

38 About St. Elizabeth Healthcare NKY, 400k population base (facilities in SE Indiana and Cincinnati) St. Physicians (97 primary care and specialty office locations) 6 facility system (1,200 licensed beds) No other acute care providers in NKY geographic area Around 7,300 employees 38

39 Palliative Care 39 Palliative/Hospice Fellowship Program SEP Palliative Program in LTC facilities St. Elizabeth Homecare Palliative Program Palliative Inpatient consult service Palliative Outpatient clinic Palliative care triggers in acute care EMR SEP/SEH Chronic Disease Management programs. SEP Advance Care Planning and EMR triggers.

40 Medicare Care Choices Model at Lourdes Hospice Kay Williams, MSW Lourdes Hospice/ Mercy Health

41 Good news no treatment costs

42 Bad news 90% pay cut

43 Panel Discussion What are your questions for our panelists? Brian Jones Joe Rotella Elizabeth Wessels Turner West Kay Williams