Raising the Bar: Palliative Care in Nursing Homes. No Disclosures. Learning Objectives 3/27/2017

Transcription

1 Raising the Bar: Palliative Care in Nursing Homes Diane E. Meier, MD Director, Center to Advance Palliative No Disclosures Learning Objectives By the end of the session, participants will be able to: Define palliative care principles and practices in long-term care settings and describe the difference between palliative care and hospice. Describe the benefits of implementing palliative care principles and practices for all facility residents and how integrating palliative care into nursing home facilities improves value by improving quality of care and reducing costs. Describe three examples of successful palliative care programs in skilled nursing facilities. Implement palliative care practices and principles in their facilities; by accessing palliative care tools, resources, and technical assistance 1

2 Who are we talking about? 2/3rds with moderatesevere dementia Frequent, burdensome transitions Untreated physical suffering >22% with: Substandard treatment Inadequate monitoring Failure or delay of needed care Advanced Dementia is a Terminal Disease CASCADE: Prospective study of 323 nursing home residents with advanced dementia from 22 nursing homes over 18 months 18 month mortality = 53% 41% pneumonia 6 month mortality 47% 53% febrile episode 6 month mortality 45% 86% eating problems 6 month mortality 39% Mitchell S L et al. N Engl J Med 2009;361: Sources of Suffering in Dementia Mitchell S L et al. N Engl J Med 2009;361:

3 Hospital Transfers Avoidable hospitalizations epitomize low value: inefficient, harmful, wasteful care Especially salient with hospital readmission penalties and new risk models Most importantly, a real burden for frail residents+ their families Burdensome Transitions in Last 90 Days of Life: 19% 474,829 nursing home decedents ( ) Burdensome Transition: Hospital transfer within 3 days of death, lack of nursing home continuity after hospitalization in last 90 days of life, multiple hospitalizations in last 90 days of life. 19% of decedents had a burdensome transition (range from 2.1% in Alaska to 38% in Louisiana) Burdensome transitions associated with: Increased risk of feeding tubes (rr=3.38) ICU admissions (rr=2.10) Stage IV pressure ulcers (rr=2.28) Late referrals to hospice (3 days prior to death) (rr=3.17) Burdensome Interventions in Nursing Home Residents in last 18 months of life Over last 18 months of life 34% treated with IV therapies 19% hospitalized 10% in ER 8% tube fed 22% referred to hospice Yet 96% of proxies stated that comfort should be the primary goal Mitchell S L et al. N Engl J Med 2009;361:

4 NH Palliative Care is Necessary High prevalence of serious illness, death in NHs: >40% of all adult deaths by 2030 High levels of physical suffering Extremely vulnerable population: cognitively + functionally impaired in underfunded, overregulated and inadequately staffed care setting Ranked lowest among the last places of care by family members (Teno et al JAMA 2004) What is Palliative Care? Specialized team care for people with serious illness and their families Focused on improving quality of life. Addresses pain, symptoms, stress of serious illness. 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 disease treatments. Conceptual Shift for Palliative Care Life Prolonging Care Medicare Hospice Benefit Not this Life Prolonging Care Palliative Care Hospice Care But this Dx Death 12 4

5 4 Successful Models 1. Contracted palliative care consultation services 2. Hospice care 3. Contracted hospice-based palliative care consultation services 4. Embedded nursing home palliative care Beyond hospice There are some patients for whom the hospice benefit will never be acceptable. Many residents not eligible for hospice because of uncertain prognosis Even in advanced dementia, the trajectory is uncertain Mitchell 2010 JAMA OIG, CMS penalties reluctance of hospice providers to enroll if prognosis uncertain very short hospice stays Bringing in external palliative care resources Palliative care consulting services Must be requested by nursing home provider MD/NP can bill Medicare Part B Financial model for NH palliative care of the near future anyone accepting $ risk such as ACOs, integrated health systems; managed care payers MLTC, MA, and hospitals (30 day readmission penalties etc.) 5

6 Impact of Palliative Care Consultation 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 Consultation in the NH Miller SC et al. JAGS 2016: 19 September 2016 DOI: /jgs NHs in NC+RI, propensity score matched retrospective cohort Days between Death and Initial Palliative Care Visit Hospitalization in last 7 days of life With Palliative Care Consultation Hospitalization in last 7 days of life Without Palliative Care Consultation < 7 days 21% 36% 8 30 days 11% 22% days 13% 21% days 7% 23% 17 Increases in Nursing Home Hospice From 1999 to 2006, the rates of hospice use more than doubled Mean lengths of stay also doubled Hospice is the dominant current model of palliative care in the nursing home Miller

7 October 7, 2014 Higher facility level penetration of hospice reduces hospitalization risk for both hospice and non-hospice users. Embedded NH palliative care: Alternative Payment Models enable Delivery of Palliative Care in the Skilled Nursing Home 20 Care elements for effective SNF (palliative) care Expert symptom management and patient (and family) centered support Not just pain, Not just physical symptoms, requires expertise in the social, emotional and spiritual dimensions of patient (and family) experience Expert disease management (with other providers) Very complex patients with multiple chronic conditions; Need to adjust medications and care plan to patient goals, function, age, etc. Goals of care clarification and care planning Not a document; Not a transaction; Requires skilled ongoing communication often with multiple stakeholders Nursing home engagement and care coordination Commitment and ability to develop care plan with nursing home; Contingency planning; Ongoing availability for expected changes in condition 7

8 Payment Models to Enable Embedded Palliative Care in the Nursing Home 1.Contract with Payer Institutional Special Needs Plan Other Medicare Advantage plan contracts Institutional Special Needs Plan (I-SNP) Medicare Advantage program designed for long-stay nursing home patients: Adds a specially trained nurse practitioner with special training in: Symptom management Goals of care communication and advance care planning Geriatric and complex care team National network of expert medical directors for education and support Works with the long term care team for coordinated care planning Contract with SNF allows for patients to be changed to skilled without a hospitalization In place > 25 years Currently > 50,000 patients in >1900 nursing homes in 35 states Example: CarePlus Nurse practitioner s role in skilled nursing home Evaluates the patient and creates personalized health care plan Bridges the gap between the staff, medical director and primary care physician Educates facility staff on specific patient needs Serves as first point of contact if patient s condition changes Visits patient routinely and in urgent situations Complex Care Management 8

9 CarePlus Nursing Home Program Results 1.49% reduction in ED visits 2.60% reduction in hospitalization 3.48% reduction in total costs 4.$9,000 in savings per member per month What we have learned- 1. Improvement in palliative care in the SNF is an urgent need 2. Specialized skills and care team are required for effective care 3. New payment models can support embedded NH palliative care services Improved quality Reductions in readmissions support hospital partners Reduction in hospitalizations, ED visits and total costs support value based programs such as Medicare Advantage Palliative Care supported by new NH Regulations 9

10 Palliative Care in LTC = Truly the Perfect Fit Person- Centered Goals Opportunity for meaningful family/resident discussions Care-plan addressing symptom management Interdisciplinary team External Barriers to Palliative Care, some real, some perceived Requirements of Participation Regs in NHs (and myths about regs) Misconception that palliative care and skilled care cannot co-exist Current quality measures focused on functional improvement and safety above all Proposed value-based payment measures fail to begin with person-specific goals Short-stay residents with multiple transitions NHs are punished for natural progression of disease: CMS NH Quality Initiative Current NH quality measurements do not allow for a different set of metrics for end of life care. Measures include % with: 1. Increased ADL dependency 2. Moderate-severe pain 3. Restraints 4. Most of time in bed or chair 5. Decreased ability to move 6. UTI 7. Increased depression-anxiety 8. Weight loss 9. Pressure sores 10. Bowel-bladder incontinence and use of indwelling catheters For post acute stay SNF residents (many of whom have prognosis <6m): 1. Delirium 2. Pain 3. Pressure sores 10

11 Case Study: Palliative Care for Skilled Resident 68 yr old male, moderately obese, type II DM, heart disease and post open heart surgery for aortic aneurysm and valve replacement. Developed post-op wound infection and sternal osteomyelitis. Pt is anxious, in pain, often SOB and nauseated. In SNF for wound care and IV abx. How would you care plan his service needs? How would you address the palliative care needs? What resources would be helpful? What other conditions might you see benefiting from palliative care during their skilled service? CMS will increase both the number and type of quality measures used in the Five-Star Quality Rating System future measures will include claims-based data on re-hospitalization. Using Regulations to Support Palliative Care 30-day readmission for short stay Resource use measure for short stay Pain control as publicly reported measure Resident and family satisfaction Document alignment of care plan with person-specific goals 11

12 Palliative Care as a Quality Assurance Performance Improvement (QAPI) Process Improvement Plan (PIP) Reduced pain Reduced hospital transfers QAPI Process Improvement Plan (PIP) requires resident/family input, and engagement of all staff PIP focuses on palliative care training for direct care worker, and nursing staff Track data and outcomes creates GREAT framework to sell your program within your system. Developing a Business Plan Track number of residents with serious illness, and the number who return to hospital/icu/ed for symptom management Calculate development/staff costs for your proposed palliative care model Work with hospital medical/nursing team to develop glide paths across settings that focus on determining goals, aligns care plan with goals, and sets up NH as preferred partner for health system Who Wins? 12

13 Policy Work to be Done Quality measures that do not merely focus on improvement Quality measures that capture personcentered goals as the top priority Payment model increasing reimbursement for complex and palliative care and less incentive for high level rehab What can you do? In Sub Acute Rehab, seek external palliative care consultation from either hospices or health systems nearby, or identify and train an internal team; work with local MA plans to develop an I-SNP In LTC, same as above, plus strengthen hospice integration, contracts 38 13

14 CAPC s Online Clinical Curriculum for All Frontline Clinicians Clinical courses for all disciplines and all specialties Recognition strategies: Designation in Pain Management & Communication Skills CE Credits for MD, PA, RN, APRN, social work, case managers Case-based, interactive Compatible on computers, tablets and smartphones Comprehensive reporting on course completions 40 CAPC Online Curriculum Safe + Effective Pain Management Comprehen sive Pain Assessment Monitoring for Efficacy, Side Effects Substance Use Disorder Matching the Drug Class to the Pain Converting from Short- Acting to Long-Acting Opioids Patient Factors Influencing Prescribing Opioid Conversions Assessing Risk of Substance Use Disorder Advanced Conversions and Opioid Side Effects Opioid Trials: Design, Efficacy and Safety Special Populations and Patient- Controlled Analgesia Prescribing an Opioid Managing Patients at Risk for Substance Use Disorder Prescribing Short-Acting Opioids: 4 Cases Pain Management: Putting it All Together Communication Skills Delivering Serious News 41 Discussing Prognosis Clarifying Goals of Care Advance Care Planning Running a Family Meeting 2016 Clinical Curriculum Symptom Management Shortness of Breath Constipation Nausea & Vomiting Anxiety Depression Whole-Person Care Care Coordination Disease Trajectories Congestive Heart Failure (CHF) 42 Assessing & Supporting the Family Caregiver Chronic Obstructive Pulmonary Disease (COPD) Dementia 14

15 Resources Meier DE et al. Raising the standard: Palliative care in nursing homes. Carlson M et al Strategies and innovative models for delivering palliative care in nursing homes. JAMDA 12-(2):91-8: Feb 2011 Ersek M, Stevenson D. Integrating palliative care into nursing homes. Meier DE. Tomorrow s nursing homes must integrate palliative care. Mead R. The sense of an ending: An Arizona nursing home offers new ways to care for people with dementia Join capc.org for tools training and technical assistance on implementation of palliative care services in the nursing home. THANK YOU!! diane.meier@mssm.edu 15