Improving the Treatment and Transitions of Chronic Disease Care: Palliative Care, Extending Life

Transcription

1 Patient Centered Medical Home Health Home Behavioral Health Home Monthly Webinar Improving the Treatment and Transitions of Chronic Disease Care: Palliative Care, Extending Life Wednesday, July 27 th, :30 AM 8:15 AM Audio available: , Access Code

2 Today s Presenters Dr. Rebecca Kowaloff Medical Director of the Palliative Medicine Program at Southern Maine Health Care Dr. Kowaloff completed her undergraduate in History of Medicine at The University of Rochester. She attended Medical school at Touro College of Osteopathic Medicine in NYC and her completed her Internship and Residency in Internal Medicine at Maine Medical Center. Dr. Kowaloff is also a primary care physician. Heather DiYenno Palliative Care Program Manager at Southern Maine Medical Center Heather has extensive knowledge and experience working with people living with chronic illness. She previously worked as a case manager on a medical/surgical unit at Maine Medical Center for approximately 12 years. She holds a Bachelor's degree in Psychology from UNH and a Master's in Social Work from Boston College. Heather is originally from New Hampshire.

3 Disclosure Statement Presenters/Facilitators do not have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. 3

4 Important Webinar Notes Dial: Access Code: All lines have been muted To ask a question: Use the chatbox on the lower left-hand side of the screen Unmute your line - Press *7 State your name and Health Home team when speaking Mute your line again - Press *6 This call will be recorded and shared after the webinar UNMUTE *7 MUTE *6 4

5 Did you Hear? Dial: Access Code: UNMUTE MUTE You and your colleagues can earn Continuing Medical Education Credits! This Webinar is.75 CME Please complete the survey at the end of the webinar to receive your certificate of attendance. 5

6 Webinar Objectives Dial: Access Code: UNMUTE MUTE 1. Define Palliative Care and identify its place in the treatment of a chronic disease. 2. Identify a workflow for the primary care office. 3. Determine when a referral could be helpful and ensure communication occurs across this transition. 6

7 Rebecca Kowaloff, DO Medical Director, Palliative Medicine Program Southern Maine Health Care Primary Care Physician, Biddeford Internal Medicine Heather DiYenno, LCSW Palliative Care Program Manager Southern Maine Health Care Improving the Treatment and Transitions of Chronic Disease Care: Palliative Care, Extending Life

8 Learning Objectives O Define Palliative Care O Distinguish between Primary & Secondary Palliative Care O Triggers O Build the structure for Palliative Care in the Primary Care Office

9 Palliative Care A medical specialty that helps to control pain and other signs of a serious illness O Emotional, social, spiritual support Our goal: to keep anyone living with a lifelimiting illness as comfortable and functional as possible, so they can enjoy the best quality of life.

10 Hospice O Medicare-defined program of end of life care Palliative Care Hospice O Patients must be deemed by physician to have reasonable life expectancy of 6 months or less O Disease-specific guidelines O Must be willing to forgo curative intent/life prolonging therapies O Comfort-oriented therapies covered O Goal is comfort, maximizing quality of life, and staying at home

11 Palliative Care in Chronic Illness O Complexity of care: PC helps facilitate communication and coordination O Goals of care: Formulate an overarching plan for care that takes into account patient s values, wishes, and goals O Symptoms: Attentive to effects on comfort and quality of life and psychosocial experience of disease

12 Consider: O What are the patient s/family s goals for care? O Are treatment options matched to informed patientcentered goals? O Has the patient completed an Advance Directive? O Is the patient POLST-appropriate?

13 ACP Billing code O & O New January 1, 2016 O Can be billed multiple times O Helpful to document: O Time spent O POA, who was involved, given opportunity to decline O Document content of discussion O Why they are making the decision they re making O ACP documentation offered/filled out O Follow-up

14 Introducing Primary Palliative Care at SMHC O Provider/staff education at all sites O Role of Palliative Care: What can we do for you? O Triggers: identifying patients O Skills/scripts: SICP O Documentation: ACP guidelines O Systematic Approach O Community outreach O Pathways O Population Health O Team effort across the continuum

15 Palliative Care Triggers Disease specific Related to prognosis (surprise question: Would I be surprised if this patient were to die in the next 12 months? ) Acute change in condition/functional status Multiple medical conditions/admissions Functional decline Chronic home O 2

16 Primary Palliative Care O MA Coordinate all out of office triage and assist with ACP O LCSW Provide continuity in patient and family counseling services O Care Manager Coordination of care transitions across health care settings including home visits if necessary O Office Care Coordinators- risk stratification and referrals O Physician Serious Illness Care Program (SICP), med management, home visits O Community Partners- assists our patients with advance directives

17 How do we do it? O Triggers in the EMR O ACP pre-visit planning O Surprise Question O 9Ps O Trained facilitators O ACP O POLST

18 Reminder Letter

19 SMAA Card Sometimes it s easier to communicate with your dog than your family. Let us help you start the conversation. Southern Maine Health Care is partnering with Southern Maine Agency on Aging to provide FREE Advance Care Planning assistance. A trained Advanced Care Planning facilitator will call you to set up an appointment. You can call (207) with any questions.

20 Specialist Palliative Care O Difficult symptom management cases O Particularly challenging conversations, family issues, patient suffering, ethical dilemmas O Follow patients for long trajectory of chronic illness

21 Palliative care evaluation o Are there distressing physical/psychological symptoms? o Are there significant social/spiritual concerns affecting daily life? o Does the patient/family understand the current illness, prognostic trajectory, and treatment options? o Elicit illness trajectory: What were you able to do 6 months ago? o Assess values: What does quality of life mean to you? o Assess goals and wishes for the future o Uncover fears and worries

22 Serious Illness Conversation Program

23 Specialty Palliative Care: Outpatient Consultation O Referral process O Oncology shared visits O Patient Assessment: identify needs O Team members: O LCSW O Chaplain

24

25

26 Benefits of Palliative Care O Treatment of pain and other symptoms O Coordination of care O Help navigating the medical system O Avoidance of unnecessary treatments and/or hospitalizations O Assistance making necessary plans O Help with fulfilling patient s wishes (Ellis Fischel Cancer Ctr. Univ. Missouri H C)

27 Health System Benefits O Decrease hospital LOS, ICU admission rates, and aggressive (and costly) medical care near the end of life. O Better understanding of illness, prognosis, and limits of aggressive measures, and often opt for less-aggressive treatment O Higher and earlier hospice admissions save future hospital admissions O In ACO model, can dramatically increase shared savings

28 References 1. Riley GF and Lubitz JD. Long-term trends in Medicare payments in the last year of life. Health Serv Res 2010;45: Trends in Inpatient Hospital Deaths: National Hospital Discharge Survey, Whitford K, Shah N, Moriarty J. Impact of a Palliative Care Consult Service. Am J Hospice and Pall Med 2014; 31(2): May P, Garrido M, Cassel JB, et al. Prospective Cohort Study of Hospital Palliative Care Teams for Inpatients with Advanced Cancer: Earlier Consultation is Associated with Larger Cost-Saving Effect 5. Morrison RS, Penrod J, Cassel JB et al. Cost Savings Associated with US Hospital Palliative Care Consultation Programs. Arch Int Med 2008;168:

29 Practice Sharing! Dial: Access Code: UNMUTE MUTE Tammy C. Dickey, Eastern Maine Medical Center 29

30 Practice Sharing! Dial: Access Code: UNMUTE MUTE Resources Resources for Palliative Care in a Primary Care Setting (Hanley) Everybody Dies: A Guide to Making Hard Conversations a Little Bit Easier (Hanley) Before I Die Wall: Last Years: 30

31 Practice Sharing! Dial: Access Code: UNMUTE MUTE Denise Breer & Josie Poulin, Winthrop Family Medicine 31

32 THANK YOU!

33 Want to share with your team? Dial: Access Code: UNMUTE MUTE Webinar recordings available online or via podcast within 48 hours following live webinar New to podcasting? Learn how to access our podcasts via our website ( Next PCMH/HH Webinar! Wednesday, August 24 th, :30 8:15 a.m. Annual Wellness Visit: Door to Geriatrics Care 33

34 Save the Date Dial: Access Code: UNMUTE MUTE September 29 th Learning Session For, Primary Care Health Homes, Behavioral Health Homes, & Community Care Teams Augusta Civic Center Opportunities to Connect and Network in you region! Learn strategies and approaches to improve the care for the people you serve! 34

35 New Monthly Audio Podcast Stories of Real People Making Health Care Better

36 Materials & More Info on our Website! 36

37 Contact Info/Questions for PCMH/Health Home Practices Dial: Access Code: UNMUTE MUTE General Questions: Practice Facilitators: Amanda Banister: Rachel Charette: Paula Eaton: Chelsea Edwards: Josh Farr: Mary Beyer (BHH): 37