Design, Results, and Implementation of a Whole Person Intervention for Late Life Care Steven Schroeder, MD

Creating a Whole Person Intervention for Patients with Serious Illness and their Caregivers Eric Anderson, MD

DISCLOSURE We have no relevant commercial relationships to disclose.

Symposium Agenda I. Introduction II. Design and intervention III. Research IV. Implementation 5 minutes 20 minutes 20 minutes 20 minutes --------------- Questions & Discussion 25 minutes 4

Usual Care http://www.startribune.com

Serious Illness Today CHALLENGE VALUE Fragmentation What Matters 6

Navigating Serious Illness Episodes of Care LifeCourse Time (2-3 years) 7

Key Questions Is it possible to deliver supportive/palliative care for patients and their families, living at home with serious illness? Can we do this with a community health worker? 8

Design And Listening Sessions 243 patients, caregivers, and others Design principles: Whole person support A relationship based on storytelling Individualized planning Collaboration and coordination among care teams Normalizing difficult conversations 9

LifeCourse Core Components Care Guide 1 Whole Person 2 What Matters 3 Family & Community 4 10 1 Schellinger, S. 2016, AJHPM. Building new teams 2 Anderson, E. et al. 2017, AJHPM. Expanding the Palliative Care Domains 3 Schellinger, S. et al. 2017, AJHPM. Self-Defined Goals 4 Anderson, E. 2017, AJHPM. It has changed my life.

What is LifeCourse?

How Did We Find Mosezel? Approach to Patient Identification and Enrollment Electronic Health Record Enrolled Patients & Families 13

Patient Identification And Enrollment The Goal: All patients with serious illness who could die in the next 2-3 years Criteria: 1. A diagnosis of serious illness in an advanced stage 2. Modified Charlson comorbidity score 4 3. RN chart review algorithm 14

How Did We Find Jason And Judi? Education Bachelor s degree Skills Communication Serious illness experience Knowing or caring for someone with serious illness 15

LifeCourse CHW (Care Guide) Training Non-expert delivery of supportive/palliative care using defined questions sets 1 and patient-rated assessments Advance care planning Communication and collaboration 16 1. Clinical Practice Guidelines for Quality Palliative Care, National Consensus Project for Quality Palliative Care

How Do Care Guides Structure Their Work? Physical Family/Caregiver Visit #1 Visit #2 Visit #3 Visit #4 Visit #5 Visit #6 Ongoing Domain Question Sets Psychological Cultural Ethical Social Financial/Legal Spiritual Legacy & Bereavement End of Life Assessment Tools ACP ESAS PPS Who s At Your Table? Advance Care Planning 17

How do Care Guides structure their work? Physical Family/Caregiver Visit #1 Visit #2 Visit #3 Visit #4 Visit #5 Visit #6 Ongoing Domain Question Sets Psychological Cultural Ethical Social Financial/Legal Spiritual Legacy & Bereavement End of Life Assessment Tools ACP ESAS PPS Who s At Your Table? Advance Care Planning 18

LifeCourse Presentations at IAGG IAGG World Congress of Gerontology and Geriatrics https://www.iagg2017.org/ July 24, 2017 July 25, 2017 Abstract : Effect of a Person-Centered Intervention on Patient Experience With Care in Serious Chronic Illness Abstract : Improving Quality of Life for Late Life Patients: Key Findings From LifeCourse Intervention Session: Palliative Care for Older Adults Presenter: Nate Shippee Time: 2:00 PM - 3:30 PM Abstract : Speaking From the Heart: The Changing Goals of Heart Failure Patients in the Last Years of Life Session: Care Preferences at End of Life Presenter: Sandy Schellinger Time: 4:00 PM - 5:30 PM Session : Quality of Life and Well-Being: International Perspectives Presenter: Tetyana Shippee Time: 8:00 AM - 9:30 AM Abstract : Health Care Utilization Outcomes for Patients Enrolled in a Late Life Care Intervention Session: Unique Perspectives in Understanding End of Life Care Experiences Presenter: Anne Betzner Time: 2:00 PM - 3:30 PM 19

1 Clarifying Question? 20

Key Questions Addressed Is it possible to deliver supportive/ palliative care for patients and their families, living with serious illness? Can we do this with a community health worker? Yes Yes 21

Key Questions Addressed Is it possible to deliver supportive/ palliative care for patients and their families, living with serious illness? Can we do this with a community health worker? Yes Yes Does it make a difference? 22

Utilization, Quality of Life, and Care Experience of Patients in LifeCourse Heather R. Britt, MPH, PhD

DISCLOSURE We have no relevant commercial relationships to disclose.

Study Design A quasi-experimental study, non-equivalent group design was used to test effectiveness of the LifeCourse intervention. Patients diagnosed with a serious chronic illness participated in intervention or usual care comparison groups (N=450 and 453, respectively). Both groups completed quarterly data collection assessments, starting at baseline and continuing through the end of life. 3

Outcomes Patient Quality of Life 1 Experience 2 System ED Visits Inpatient Days ACP Completed Hospice Days ICU Days Total Cost of Care 4 1 FACIT-PAL (Functional Assessment of Chronic Illness Therapy - Palliative Care) 2 LifeCourse Experience tool

Measures Quality of Life: FACIT-PAL (Functional Assessment of Chronic Illness Therapy - Palliative Care) Healthcare Utilization: Advance care planning completion, hospice utilization and hospital utilization (ED, ICU, and inpatient stays) collected via electronic health record Total Cost of Care: Calculated via claims data for patients covered by risk-based contracts Payer control patients were selected using propensity scores based on demographics and pre-period enrollment expenditures. 5

Baseline Characteristics LifeCourse n = 450 Usual Care n = 453 P-value Age in years, M (SD) 78.1 ± 12 74.3 ± 12.5 <.001 Female, % 51% 51% 0.817 Caucasian, % 95% 95% 0.982 Living with partner, % 45% 49% 0.170 College educated, % 39% 36% 0.338 Living at home, % 74% 91% <.001 Primary Diagnosis, % Heart failure 57% 69% <.001 Cancer 16% 17% Dementia 27% 14% Comorbidity index, M (SD) 4.5 ± 2.2 4.6 ± 1.9 0.311 Physical Wellbeing, M (SD) 20.1 ± 5.6 19.6 ± 6.2 0.177 6

LifeCourse Patients Maintain Quality of Life Longer 140 138 Patients' Quality of Life* Quality of Life Score 136 134 132 130 128 126 124 122 120 0 3 6 9 12 15 18 21 24 27 30 Months in LifeCourse 7 *This figure shows trend lines or the average change in quality of life over time.. Of critical importance is the fact that LifeCourse patients were, on average, older and sicker than usual care patients, making the effect of LifeCourse on quality of life even more striking.

LifeCourse Significantly Associated with Better Care Team Experience Patients' Care Team Experience* 47 Care Team Experience Score 46 45 44 43 Usual Care 42 0 3 6 9 12 15 18 21 24 27 30 Months in LifeCourse 8 *This figure shows trend lines or the average change in quality of life over time. It is also important to note that LifeCourse patients were slightly older and sicker than usual care patients, as a whole. Additionally, the care team experience for usual care and LifeCourse participants was tested statistically and is not different.

LifeCourse Patients with Lower Physical Wellbeing Have Fewer ED Visits. 9 P value =.05

And Fewer Inpatient Days P value =.05 10

LifeCourse Promotes ACP Completion and Earlier Enrollment in Hospice Completed Advanced Directives Days Enrolled in Hospice 78% 59% 34 days 15 days LifeCourse Usual Care LifeCourse Usual Care 32% 127% p < 0.001 p = 0.018 11

Total Cost of Care Propensity Score Matching Patient Characteristics Before and After Propensity Score Matching 13 Matched Payer Control (N = 406) LifeCourse (N = 125) Age 77 ± 13 78 ± 10 Prescriptions 10 ± 8 11 ± 10 Follow-up period 386 ± 289 376 ± 249 Male 45% 44% Caucasian 96% 95% Married 40% 38% Died during follow-up 41% 42% Principal diagnosis Cancer 24% 14% Cardiovascular 36% 51% Dementia 11% 22% Other 29% 13%

LifeCourse Decreases Total Cost of Care Adjusted Monthly Costs LifeCourse Patients Usual Care Patients Per Patient Per Month Savings $2,525 $3,484 $959 * Patients were matched on demographic and health factors, as well as pre-enrollment costs. The number of patients included in this analysis was 125. Likely due to the small number of patients for whom we had access to their data, the findings are not statistically significant. Payback Ratio 8:1 14

1 Clarifying Question? 16

Key Questions Addressed Does it make a difference? Yes 17

Key Questions Addressed Does it make a difference? Yes Can LifeCourse be implemented successfully? Is LifeCourse adaptable to new settings? 18

lifecoursemn.org

LifeCourse Beyond Research: Learning Through Implementation and Evaluation Paige Bingham, MBA

DISCLOSURE We have no relevant commercial relationships to disclose.

LifeCourse Beyond Research Allina Health Care Management NorthPoint Givens Brain Tumor Center Minneapolis Heart Institute Allina Health Primary Care Allina Health Specialty Community Health Center (not affiliated with Allina Health) Allina Health Palliative Care Abbott Northwestern General Medicine Associates 3

Spreading LifeCourse Choosing Implementation Partners 3-Step Implementation Process Modifications from Research to Practice Site Variations Evaluation Framework Future Plans 4

Reaching Patients Primary Care Clinic Abbott Northwestern General Medicine Associates NorthPoint Health and Wellness Center Patient Profile Older, frail adults Medical Home serving low income, African-American, Hispanic & Hmong Specialty Care Coordinated Care Minneapolis Heart Institute Givens Brain Tumor Center Care Management Community-based Palliative Care (Implementing Fall 2017) Advanced heart failure & transplant Brain tumor At-risk for readmission High-risk ACO population Hospice graduates 5

Gaining Leadership Support Leadership Endorsement Champion 6

Integrating LifeCourse Existing Site Team Trained Care Guide 7

LifeCourse Implementation Process 3 6 Month Setup Timeframe 8

Step 1: Site Management Training Engage site team - Identify site champions - Gain buy-in from site team Hire care guides Conduct 6 implementation meetings - Review LifeCourse processes - Customize workflows - Tailor EHR documentation 9

Step 2: Care Guide Training Palliative care domains 1 LifeCourse visit framework Advance care planning Communication/collaboration Lay healthcare worker role and scope Professional boundaries Electronic health record 10 Footnote: 1. Clinical Practice Guidelines for Quality Palliative Care, National Consensus Project for Quality Palliative Care

Step 3: Continuing Support & Evaluation Precepting - Assess care guide competency Consultative support - For care guides on pt issues - For site team regarding implementation issues Process and outcome evaluation - Framework design, measures, and support 11

12 Modifications Research to Practice

Modified Core Assessments Visit #1 Visit #2 Visit #3 Visit #4 Visit #5 Visit #6 Ongoing Physical Family/Caregiver Domain Question Sets Psychological Cultural Ethical Social Financial/Legal Spiritual Legacy & Bereavement End of Life Assessment Tools ACP PROMIS-10 ESAS PPS Who s At Your Table? Advance Care Planning 13

14 Modified Patient Identification

Patient Identification and Referral Site Variations Dashboard Driven.Provider Driven Care Management General Medicine Heart Institute NorthPoint FQHC Brain Tumor Center 15

Clinicians on Care Team Site Variations Multidisciplinary..Provider-Nurse Care Management Heart Institute Brain Cancer Center NorthPoint FQHC General Medicine 16

Staffing Care Guides Site Variations Existing Care Guides vs. Hiring New Care Guides Existing Hired New Care Management NorthPoint FQHC Heart Institute Brain Tumor Center General Medicine 17

Geographic Distance Site Variation 25 miles Radius Near Far NorthPoint FQHC General Medicine Care Management Heart Institute Brain Tumor Center 18

Payment Site Variations Type of Payment Payment Source Revenue Sites Full Risk Medicare Advantage $ Capitated Allina/Aetna (in process) Shared Savings CMS NextGen $ Reconciled Care Management Accountable Care Org Care Coordination $ PMPM Care Management FFS per Visit Medicaid PCMH $40/visit NorthPoint Philanthropy Family Foundation $50,000/yr Givens 19

Evaluation Plan Goal: Assess fidelity and understand factors that influence implementation and outcomes Cross-site evaluation underway Observational process & outcome evaluation 20

Evaluation Questions Evaluation Framework How does each site perform on evaluation measures? How do key site features appear to influence performance? Process Measures Differentiating site features Patients served Sessions delivered Outcome Measures Quality of Life Utilization ED visits, Inpatient days, ICU stays, Hospices LOS, Palliative care use 21 Source: EHR Data; Interviews with site staff, LifeCourse staff

Preliminary Evaluation Results Number Served by Site (n=255) 87 43 33 36 56 Heart Institute Brain Cancer NorthPoint General Medicine Care Management 22

Successes Expanded reach to diverse populations Allina uptake Whole person approach Spotlight for Employee Giving Campaign Affirmation from outside Outside influencers carrying the message Papers and Presentations accepted Recognition (e.g. Joint Commission) 23

Challenges and Opportunities Financial sustainability Dosing around frequency and length Clarity on role during hospice Ideal panel size Opportunities for TeleHealth Supportive messaging 24

25 Messaging

Next Steps Supporting access to late life care for individuals and families Spreading LifeCourse nationally: Health systems and plans Community health centers (urban and rural) 26

Key Questions Addressed Can LifeCourse be implemented successfully? Is LifeCourse adaptable to new settings? Yes Yes 28

lifecoursemn.org

Appendix

How is LifeCourse Different? LifeCourse A longitudinal relationship, offering support through the last several years of life A continuum-based approach that follows the patient across settings Balances medical and nonmedical focus, to promote a whole person approach Trained lay healthcare workers, called care guides, as primary contact Other Supportive Care Programs Time limited, many are 30-90 days and focused on a point in time such as posthospitalization Typically condition related, i.e. heart failure Medically focused on improving specific outcome measures RN or SW as primary contact Visits are in-person Contact is primarily telephonic 31 Supports a generalist approach to palliative care that does not require specialty training Supports a medical model of care requiring clinical training

Core Questions, Example Physical Question Set, Visit 1: What do you understand about your current condition? Would you describe your condition as curable, stable, treatable, in remission, progressive or something else? How would you describe your current care plan? What symptoms do you experience or are most bothersome? How has living with [your illness] changed your life? 32

Core Tools PROMIS-10+1 Quality of Life assessment ESAS (Edmonton Symptom Assessment System) Self-report tool designed to assist in assessment of symptoms PPS (Palliative Performance Scale) Helps assess functional performance and decline over the course of an illness Who s At Your Table? An exercise that can be used to better understand a patient s social network. 33

NorthPoint Implementation Comprehensive community health care center in the heart of North Minneapolis since 1968. - Federally Qualified Health Center - Full spectrum of medical, dental, behavioral health and human services 34

Who NorthPoint Serves Ethnicity/Race Black/AfrAm 52% Hispanic 26% Asian 12% White 7% > 1 race 3% Nat Am 1% Language: 31% of patients with a primary language other than English 35

Who NorthPoint Serves Annual Median Income * $65,033 $60,828 $30,081 $26,751 $22,148 $21,508 State of MN Hennepin County 55411 55429 55412 55430 * ACS 5-Year Estimate 2010-2015 36