Sharp HealthCare Hospice and Palliative Care

Transcription

1 Sharp HealthCare Hospice and Palliative Care The Continuum for Advanced Illness and End Stage Disease Management (AAC) Daniel R. Hoefer, MD CMO, Outpatient Palliative Care and Hospice Suzi K. Johnson, MPH, RN Vice President Sharp HealthCare Hospice and Palliative Care

2 Principles of Transitions 1. Proactive Disease Management 2. Proactive Psychosocial Management 3. Accurate description of what the health care industry can provide

3 27% of patients with incurable terminal disease believed they could have been cured Unresectionable non-small-cell lung cancer 54% AIDS 32% CHF 22% ALS 16% COPD 12% Daniel P Sulamsy, OFM, MD, PhD, et al, The Accuracy of Substituted Judgment in Patients with Terminal Diagnoses, April 1998, Annals of Internal Medicine, Vol 128(8), PP

4 Medicare Cost in Matched Hospice and Non-Hospice Cohorts Bruce Pyeson FSA, MAAA et al, Journal of Pain and Symptom Management, May 2004, Vol 28(3) pp

5 Comparing Hospice and Non-Hospice Patient Survival Among Patients Who Die Within a Three Year Window Steven Connor PhD, et al, Journal of Pain and Symptom Management, March 2007, Vol (3) pp

6 Mean Survival Increased by 29 days for patients who chose hospice over non-hospice care: CHF Lung Cancer Pancreatic Cancer Colon Cancer Breast Cancer Prostate Cancer = + 81 days = + 39 days = + 21 days = + 33 days = + 12 days = + 4 days

7 Birth of the Concept for the Transitions Program 1. Medicare is based on an archaic model of health management 2. Professional Experience and Evidenced Based Hospice Care

8 4 Pillars of Transitions Transitions - Extending the evidenced based benefits of Hospice Care to patients at an earlier point in their healthcare. 1. Comprehensive in-home patient and family education about their disease process; proactive medical management 2. Evidence-based Prognostication 3. Professional Proactive Management of the Caregiver 4. Advance Health Care Planning

9 1. In Home Proactive Disease Management a. Do not need to be home bound b. Do not need a Medicare Part A skilled requirement

10 2. Evidenced-Based Medical Prognostication doctors 2. Estimates on 468 terminally ill patients 3. Mean patient survival 24 days 4. Considered accurate if estimate within 33% for any give patient 5. 20% of the time accurate 1. 80% of the time inaccurate 2. 63% over-optimistic 6. The average over-optimistic estimate was off by 530% British Medical Journal; Extent and Determinants of Error in Doctors Prognoses in Terminally Ill patients; Prospective Cohort Study; Vol 320(7233), 19 Feb 2000 pp

11 The Clinical Consequences of Institutionalized Over-optimism a. Increases the risk that treatment decisions by patients, families and healthcare providers are NOT consistent with reality b. Leaves patients and families emotionally unready for inevitable outcomes c. Increase risk that providers will lose credibility

12 3. Professional Evidence-Based Care for the Caregiver Evidenced-based medicine - Hospice care is associated with an absolute reduction in death rates in the caregiver at 18 months post death of the patient of 0.5% (1 in 200) Nicholas Christakis, et al, The Health Impact of Health care on families: a Matched Cohort Study of Hospice Use by Decedents and Mortality Outcomes in Surviving, Widowed Spouses, Social Science and Medicine 2003, vol57 pp

13 4. Advance Health Care Planning Evidenced-based medicine shows that AHCDs (which would include POLST) do not consistently match the health care desired by the patient with the care received by the patient

14 Problems with Advance Health Care Directives 1. They are not disease specific 2. They are too vague or contradictory to be interpreted in the context of the care which is being provided Resolve Moral Conflict Proactively

15 What Transitions does not do 1. We do not prevent or discourage the patient from seeing their cardiologists or PCPs 2. We do not prevent or discourage state-of-the-art cardiology therapies or interventions 3. We do not discourage hospitalizations 4. We do not "take over" the medical management of the patient

16 Results from June 2007 to December Referrals 109 Admissions 26 Referrals to Hospice 94 Not Admitted

17 Transitions Program SRS

18 94% reduction in ER visits and Hospitalizations

19 CHF Can you see it? Nov 2006 Feb 2007 May 2007 June 2008 Dec 2008 May 2009 Dec 2009 Mar 2010 Dec 2010 Jan 2011 BUN Creatinine HGB BNP ADL defecit

20 Fried, Linda P., et al, Frailty In Older Adults: Evidence of a Phenotype, 2001 Journal of Gerontology, Vol 56A(3), M146-M156

21 Issues Important in the Management of a Pre-terminal Aging Population: 1. Mobility Deficit 2. Transportation Deficit 3. Financial Restraint 4. Social Support/Family Deficit 5. Cognitive Deficit 6. Compliance Deficit 7. Change in Goals of Care

22 Pt # Patient Charges Pre-Transitions Pre- Transitions Hospital/ER Visits Patient Charges During Transitions Hospital/ER Visits During Transitions Title Cost Differential 1 $59, $ $58, $5, $2, $3, $8, $7, $ $ $2, $2, $6, $2, $3, $1, $1, $ $ $ $ $6, $ $5, $ $ $ $ $ $ $ $ $ $4, $1, $2, $21, $2, $19, $ $5, $5, $ $1, $1, $ $1, $1, $ $ $ $1, $3, $2, $5, $1, $3, Transitions Program SRS ** Grayed cell charges include Hospital/Lab/ MD claims while on Transitions Calculations based on: 1. Data for 60 patients provided by SRS Managed Care 2. MCA charges for all Diagnoses pre & during Transitions 20 $ $ $ Totals $330, $168, $161,979.15

23 Comparative Data 76% reduction in ER visits and hospitalizations

24 Discharge Data 80% go to Hospice 20% die on service

25 Paradigm Shift #1 Historically 63% of CHF patients died in the hospital (2005) Three Hospital Deaths on Transitions Cardiac Cath COPD Cardiac Arrest

26 Paradigm Shift #2 Historical average hospitalizations for CHF during the last year of life 3.5 Average number of CHF admissions for Transitions patients is < 1 during the last year of life

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28 71.5% reduction in cost CHF ICD-9 as primary reason for admission

29 Pt # Patient Charges Pre- Transitions Pre- Transitions Hospital/ER Visits Patient Charges During Transitions Hospital/ER Visits During Transitions Cost Differential 1 $59, $ $58, $5, $2, $3, $8, $7, $ $ $2, $2, $6, $2, $3, $1, $1, $ $ $ $ $6, $ $5, $ $ $ $ $ $ $ $ $ $4, $1, $2, $21, $2, $19, $ $5, $5, $ $1, $1, $ $1, $1, $ $ $ $1, $3, $2, $5, $1, $3, Transitions Program SRS ** Grayed cell charges include Hospital/Lab/ MD claims while on Transitions Calculations based on: 1. Data for 60 patients provided by SRS Managed Care 2. MCA charges for all Diagnoses pre & during Transitions 20 $ $ $ Totals $330, $168, $161,979.15

30 50% Cost Reduction CHF ICD-9 as primary or secondary reason for admission

31 Outcomes The patients live longer and better The caregivers live better and survive The families are happier with the care provided Cardiologists and PCPs still provide state-of-the-art Cardiology care Care provided is increasingly consistent with the goals of care of the patient Cost effective

32 Transitions Admissions Admissions to Transitions FY '07 FY '08 FY '09 FY '10 FY'11

33 Emergency Room and Hospital Visits Hospitalizations/ED Visits

34 Hospice Transitions Transfers to Hospice FY '07 FY '08 FY '09 FY'10 FY'11

35 Hospice Total Admissions - Heart Failure FY '06 FY '07 FY '08 FY '09 FY '10 FY'11

36 Hospice Length of Stay Heart Failure ALOS MLOS FY '07 FY '08 FY '09 FY'10 FY'11

37 Patient Family Satisfaction Transitions FY2011 Percent VERY satisfied CHF COPD Dementi a 1. The extent to which you were taught to manage your medications and symptoms related to your diagnosis 2. The education you received regarding contacting the Transitions team at any time for assistance in managing your symptoms 3. The assistance you received with long term care planning and advanced directives Overall 76% 75% 88% 79% 75% 88% 90% 82% 81% 86% 88% 84% 4. Improvement in your quality of life 69% 57% 89% 72% 5. Assistance received from the nurse or medical social worker when problems occurred 6. Likelihood of recommending the Sharp Transitions Program to others for managing advanced chronic illness 69% 75% 82% 74% 78% 100% 91% 86%

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39 Transitions - Dementia Launched July 1, 2009

40 4 Pillars of Transitions In home proactive disease management Evidenced based medical prognostication Care for the caregiver Advanced healthcare planning

41 Standard of Care versus Evidenced-Based Medicine Perceived benefit of feeding tubes by physicians 195 returned surveys from 500 physicians in the AMA master file Decreased aspiration pneumonia (76.4%) Improves pressure ulcer healing (74.%) Increases survival (61.4%) Improves nutritional status (93.7%) Improves functional status (27.1%) Most physicians felt that feeding tubes were standard of care in advanced dementia and 62% underestimated the 1 month mortality rate (actual rate is 20% to 40%. Is there any medical evidence that mortality decreases by hospitalizing demented patients with pneumonia? Joseph Shega, MD, et al, Barriers to limiting the Practice of Feeding tube Placement in Advanced Dementia, Journal of Palliative Medicine, vol.1, Nov. 6, 2003, pp

42 Standard of Care versus Evidenced-Based Medicine Cont d Robert Thompson, DO, et al, Hospitalization and Mortality Rates for Nursing Home acquired Pneumonia, The Journal of Family Practice, April 1999vol.48(4) (Acute mortality rates the same) Terri Fried, MD, et al, Whether to Transfer? Factors Associated with Hospitalization and Outcome of Elderly Long-Term Care Patients with Pneumonia, J. Gen Intern Med, 1995, vol. 10, pp (Acute mortality rates the same) Terri Fried, MD, et al, Short-Term Functional Outcomes of Long-term Care Residents with Pneumonia Treated With and Without Hospitalization, JAGS, March 1997, vol.45(3), pp (Acute mortality rates the same) However, at two months, the patients transferred to the hospital had increased mortality rates than those not transferred and markedly decreased functional decline compared to those not transferred.. The worst functional loss was seen for those who were independent or mildly demented at baseline. Robert R Muder, MD, et al, Pneumonia in a Long-term Care Facility: A Prospective Study of Outcome, 1996, Arch Intern Med, vol.156, pp (Acute mortality rates the same) David R Mehr, MD, MS, Risk Factors for Mortality in Lower Respiratory Infections in Nursing Home Patients, 1992, J Fam Pract vol.34, pp (Acute mortality was slightly higher for hospitalized patients)

43 Iatrogenic Consequences of Hospitalization 1. Infections 2. Falls and Trauma 3. Delirium 4. Treatment errors

44 Predictive Model For Delirium Criteria: (1 point for each) 1. Hearing or visual deficit 2. Severe Illness 3. Cognitive Impairment (MMSE < 24) 4. BUN/Cr ratio > 18 0 points 9% risk 1-2 points 23% risk 3-4 points 83% risk Inouye, Sharon K, MD, et al, A Predictive Model for Delirium in Hospitalized Elderly Patients Based on Admission Characteristics, 1999, Ann Intern Med, vol.119, pp474-81

45 Standard of Care versus Evidenced- Based Medicine Delirium is always reversible FALSE Delirium is associated with permanent: Mental Decline Physical decline Markedly increased mortality Increased Institutionalization Prolonged Hospitalization

46 Standard of Care versus Evidenced Based-Medicine Cont d Delirium accounts for 49% of all hospital days in hospitalized older patients Inouye, Sharon K, MD, Delirium in Older Persons, NEJM, 2006, vol.354(11), PP Demented Patients are at 500% the risk of developing Delirium Cole, Martin G, MD, FRCP, Delirium in Elderly Patients, 2004, J Ger Psychiatry, vol.12(1), pp.7-21

47 My Mother was Never the Same Understanding that delirium is not necessarily reversible mandates a revised medical and ethical standard when recommending treatments to the at risk population

48 The minimum we should know... Delirium is NOT always reversible Delirium is induced by the treatments we provide Dementia increases the risk of developing delirium by 500% 60-70% of hospital cases of delirium are NOT preventable