Advance Care Planning Facilitate Patient Care & Improve Your Bottom Line Judy Citko Thomas, JD Lael Conway Duncan, MD
CCCC Statewide collaboration of organizations healthcare providers consumers regulatory agencies Improving palliative care Promoting high-quality, compassionate care for the seriously-ill
Life Expectancy Centers for Disease Control [Internet]. Atlanta, GA: National Centers for Health Statistics. Available from: http://www.cdc.gov/nchs/.
Leading Causes of Death in the U.S. Centers for Disease Control [Internet]. Hyattsville, MD: Leading Causes of Death; 2010. Available from: http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm.
Deaths in Acute Care Settings are Down; Intensive Care at the End of Life is Increasing Change in End-of-Life Care for Medicare Beneficiaries: Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009 Teno JM JAMA. 2013 February 6.
Increasing Healthcare Transitions at End of Life Change in End-of-Life Care for Medicare Beneficiaries: Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009 Teno JM JAMA. 2013 February 6.
Californians Think Planning for Serious Illness and End of Life Is Important Think recording wishes is important 82% Wishes for care Recorded in some form: 23% CHCF 2012 data, The Final Chapter
Most Patients Do Not Discuss End-of-Life Wishes with Family Source: Californians Attitudes Toward End-of-Life Issues, Lake Research Partners, 2011. Statewide Survey of 1,669 adult Californians, including 393 respondents who have lost a loved one in the past 12 months. Copyright 2012, California HealthCare Foundation.
Percent of Patients Admitted to ICU/CCU during the Hospitalization in which Death Occurred California vs. U.S., 1996 2007 25.0% 20.0% 15.0% 10.0% CA US 17.5% 17.1% 19.9% 20.8% 17.8% 17.7% 22.5% 18.5% California was second only to New Jersey in the percentage of patients admitted to ICU/CCU during the hospitalization in which death occurred. 5.0% 0.0% 1996 2000 2004 2007 Source: The Dartmouth Atlas of Health Care, Percent of Decedents Admitted to ICU/CCU during the hospitalization in which death occurred, by gender. Accessed December 19, 2011, http:// www.dartmouthatlas.org/data/ table.aspx?ind=127. Source: The Dartmouth Institute for Health Policy and Clinical Practice, The Dartmouth Atlas of Health Care, Percent of Decedents Admitted to ICU/CCU during the Hospitalization in which Death Occurred, California. Accessed December 12, 2011. http://www.dartmouthatlas.org/data/table.aspx? ind=127&tf=8&ch=32&loc=6&loct=2&addn=ind-127_ch-30_tf-10&fmt=152
Patients Spending Seven or More Days in ICU/ CCU during the Last Six Months of Life California vs. U.S., 1996 2007 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% CA US 21.9% 19.0% 16.1% 12.5% 16.8% 14.1% 11.9% 10.0% 1996 2000 2004 2007 The percentage of chronically ill Californians spending seven or more days in intensive care units (including both highand intermediateintensity beds) almost doubled between 1996 and 2007, and is almost a third higher than the national average. Source: The Dartmouth Institute for Health Policy and Clinical Practice, The Dartmouth Atlas of Health Care, Percent of Decedents Spending 7 or More Days in ICU/CCU during the Last 6 Months of Life, California. Accessed December 12, 2011. http://www.dartmouthatlas.org/data/ table.aspx?ind=129&tf=8&ch=32&loc=6&loct=2&addn=ind-129_ch-30_tf-10&fmt=154
Most Patients Do Not Record Their Wishes for Care or Discuss Options with Providers 20-25% of Americans record their wishes for care in serious illness or at end of life in an Advance Directive 42% of people discuss their care preference with family Data: CHCF 2012 Final Chapter
Quality of Care at the End of life Inadequate emotional support 50% Not enough information 30% Inadequate physician communication 24% Inadequate attention to pain 24% Inadequate attention to dyspnea 22% Teno, J.M., Clarridge, B.R., Casey, V., Welch, L.C., Wetle, T., et al. (2004) Family perspectives on end-of-life care at the last place of care. JAMA, 291, 88-93.Wright AA Associations between end of-life discussions, patient mental health, medical care near death, caregiver and bereavement adjustment. JAMA 2008; 300 (14) 1665-1673.
Institute of Medicine Findings Multiple transitions in care near EOL Demand for family caregiving is increasing Palliative care is associated with a higher quality of life Palliative care and hospice patients may live longer Timely referral to palliative care insufficient
Institute of Medicine Findings Most near EOL cannot make HC decisions ACP and medical orders are needed to ensure that choices are honored Default of acute care for all unacceptable Clinician patient conversations about EOL care goals and preferences are necessary to avoid unwanted treatment
IOM Recommendations Clinicians need to initiate conversations about EOL care choices Incentives, quality standards, and system support are needed Improved clinician communication skills and more frequent and productive clinician patient conversations are needed
IOM Recommendations Health care delivery organizations and others should encourage advance care planning and informed choice based on the needs and values of individuals Professional standards should be developed for clinician patient communication and ACP
Early access to information will help people plan and make healthcare choices that suit them best. Avoid planning under pressure.
Major Trends Make ACP Attractive Advances in medical care Healthcare reform Consumer interest
Population Medicine & the Future of Care Using ACP to REFOCUS Care
ACP: Realistic Goals Knowing patient goals and providing most appropriate care: Treatments that match wishes and prognosis Reduction in patient/caregiver stress Greater patient/family satisfaction Reduction in burdensome treatments The right care for the right patients. Efficacy of Advance Care Planning: A Systematic Review and Meta-Analysis Houben JAMDA 2014, Association Between Physician Orders for Life-Sustaining Treatment for Scope of Treatment and In-Hospital Death in Oregon, Fromme J Am Geriatric Society, 2014
Caring about the Patient Experience
Creating Advance Care Planning Systems
Advance Care Planning 2014 Case Studies in ACP Hospice, Community and Healthcare Settings
San Jose County: Hospice of the Valley Community Life program: Outreach and education on EOL care, life transitions, ACP, estate / financial planning, and more. ACP program Planning for Your Future: Advance Care Planning Basics of ACP, free community workshops Training for ACP facilitators National Healthcare Decisions Day events Let s Start the Conversation Together
Santa Cruz County: Community ACP Activities Make Your Wishes Known Program working with community educators, physicians and other care providers to promote completion of AHCD Training healthcare professionals, community groups & local businesses about the importance of ACP ACP information phone line Community presentations in situ Disseminates referral cards about ACP & AD Conducts outreach to faith communities on ACP
Marin County: Hospice by the Bay Community outreach and education grew out of local POLST coalition housed at HBTB. Highly popular panel discussions in local settings in Marin and Sonoma. Free NHCDD events on April 16 for AD and POLST completion. Ongoing POLST / ACP meetings. Local education events.
Innovation in the Healthcare Setting: SHARP Essential elements and activities: Design unique AD Develop curriculum Create referral process Train dedicated facilitators Begin Transitions Program Volunteer training and program Lead by Example employee program Provide resources
NHPCO and ACP Supports and promotes ACP CaringInfo.org website Resources Assistance and information for individuals and organizations
How ACP achieves goals Patients and families better prepared Avoid excessive transitions in care Managed-care dollars could be saved Help for acute care: Better control over readmissions Improved management of ICU beds
How ACP achieves goals Opportunity for active choice of PC or Hospice Better utilization of practices of Palliative Care Earlier appropriate implementation of Hospice Care Patients wishes honored
Coalition for Compassionate Care of California CoalitionCCC.org (916) 489-2222 / info@coalitionccc.org Facebook.com/CoalitionCCC Twitter: @CoalitionCCC