Advocate Health Care Palliative Care Service Line

Advocate Health Care Palliative Care Service Line

Making the case for Palliative Care Approximately 90 million Americans are living with serious and life-threatening illness, and this number is expected to more than double over the next 25 years with the aging of the baby boomers. 1 in 4 patients report inadequate treatment of pain and shortness of breath. 1 in 3 families report inadequate emotional support. 1 in 3 patients report that they receive no education on how to treat their pain and other symptoms following a hospital stay. 1 in 3 patients are not provided with arrangements for follow-up care after hospital discharge. Source: CAPC Palliative Care FACTS AND STATS & CAPC Report Card

Why Palliative Care? Supports developing lifelong relationships with the patients and families we serve Right thing to do for patients and families Supports Physicians in a different way Improves Health Outcomes Total cost of care savings 3

What is Palliative Care? Facilitates coordination of PCP and Specialist treatment plans and aligns them with patient wishes/goals Initiates goals of care discussions Co-exists with curative measures Focuses on the relief of symptoms, pain and stress of a serious illness Offers an extra layer of support for patient and family Even if patients have chosen to continue with curative treatments 4

89% of appropriate patients are not in the last year of life Palliative Care Should begin early in the disease process to identify goals of care Variable life expectancy Curable, chronic, lifethreatening or terminal disease Concurrent with treatment for primary disease Hospice Care Life expectancy of 6 months or less End-of-life care Terminal diagnosis, Incurable disease Non-curative treatment only

Remember: ALL hospice patients receive palliative care, but NOT ALL palliative care patients are enrolled in hospice. Palliative medicine is not pre-hospice care.

Advocate s Palliative Care program covers a broad spectrum Any stage in acute or chronic illness Any setting Any length of need Can occur along with other treatments Can occur with curative treatments

Common Diseases and Symptoms Primary Diagnosis COPD CHF Cancer ESRD Advanced Dementia Symptoms SOB Nausea/Vomiting Constipation Confusion Poor PO intake Pain

Triggers for Advocate s Palliative Care Program Consider a palliative care evaluation when your patient meets any trigger: Needs assistance with goals of care discussions and advance care planning Has complex decisions to make regarding care that may require long conversations or multiple calls to the doctor s office Had uncontrolled symptoms and/or unacceptable levels of pain Has frequent hospitalizations and/or emergency room visits over a 30 day period Has a progressive disease where symptoms impact their quality of life (i.e., CHF, CAD, LVEF<25% Has progressive decline in functional status (i.e., Chronic care needs, ADL dependence, failure to thrive) Is considering tracheostomy or PEG tube placement Has a prolonged ICU stay w/o evidence of improvement Has unmet psychosocial or spiritual needs Requests a Palliative Care consult

Benefits to the Physician The Palliative Care team Partners with the Physician to: - Conserve Physician time by conducting family meetings. - Provide Physician support in resolving questions and conflicts between families/patients and other care providers. - Impart advice on managing complex physical, emotional, psychosocial and spiritual distress. - Facilitate coordination of care.

Advocate s Palliative Care Continuum Ambulatory Physician Office, Outpatient Specialty Clinic Acute Inpatient Services Community Based Hospice, Home Services, Extended Care Facilities 11

Advocate s Palliative Care Model Referral Sources Hospitals, PCPs, Specialists, ECMs and PAN SNF APNs refer patients to Palliative Care Team Advocate Health Care Receives dashboard and data on measures of success Initial Palliative Care Assessment A Palliative Care Team conducts goals of care discussion and a comprehensive assessment in hospital, clinic or patient s home/snf Palliative Care Team Daily huddle/weekly care team meetings led by the PC physician to review each patient s status Hospital, clinic, SNF or home visits from PC physician, APN, SW and Chaplain as needed Telephonic outreach to the patient and their family as needed Access to Gundersen Lutheran s Respecting Choices patient and family education materials Coordination with Advocate s ECM, HH, Hospice and PAN SNF programs AMG Beverly and Burbank Patients identified using claims data and outbound calls are used to schedule patients for PC appointment in clinic or if needed, in the home PC Team embedded in the clinics PCPs and Specialists Consulted on care plan changes and provides ongoing electronic communication including hand overs at discharge Helps PCP and Specialists manage patients with problems and symptoms that arise in advanced stages of a chronic disease

Palliative Care at Home Implemented a palliative care home based program for homebound patients with progressive, chronic illness Launched in Q4 2011 630 patients admitted in 2014 Team model of care includes, MD, APN, Social Worker, Chaplain Augments the patient s primary care physician Teams complete Advanced Care Planning with patient and surrogate MD s/apn s trained on coding. Current MRA coding for the MA-palliative care patient avg. 1.83 Providing SNF Palliative Care for ACO patients in PAN Network with SNF APNs 13

Palliative Medicine Team Provides Care At Home Focuses on 3 primary care physician needs: Coordination of Care Advance Care Planning Symptom Control

Coordination of Care Palliative Medicine team communicates with Primary Care Physician, SNF MD/APN and specialists to set a plan of care and achieve patient s goals.

Advanced Care Planning Five Wishes POA for HC DNR POLST Patient/Family Meetings for Goals of Care Planning

Examples of Commonly Treated Symptoms SOB Nausea/Vomiting Constipation Confusion Poor PO intake Pain

Home Based PM Services Offered LPN services (Palliative Care Coordinator) for intake, phone triage and coordination of services APN services for symptom management and Advance Care Planning Social work services for psycho-social concerns and resources Chaplain services for spiritual support Massage Therapy

APN Processes Goals of Care Establish reason for consult (goals of care, symptom control and/or coordination of care) Obtain a copy of any documents and send to Primary Physician Upload ACP documents into Clinicare after obtained/completed APN to have ACP and POA discussions Pain or Symptom Control If a new medication is started, plan for daily follow up to ensure that the new medication was effective or that there were no adverse effects Serve as advisor to patient and family on how to manage complex symptoms Coordination of Care/ Communication Establish plan for coordination of care/communication with: Patient/family Primary Physician (Progress note available in clinicare, sent to primary physician) Specialists Home Health (change in medication, patient status, hospitalization, hospice or death) Palliative Medicine IDT Palliative Medicine IDT Physician SW LPN *Visit frequency is patient dependent

Communication to Physician APN establishes communication plan with PCP and involved specialists after first visit. Notes are available in Allscripts Clinicare and can be tasked to AMG Physicians. If the physician is not AMG, notes are faxed to the physicians office.

Documentation If seeing patient for Palliative Medicine need and with an order (patient will be on PM Census). V66.7 in diagnostic codes at the end Change billing area to Palliative Care Advocatecare or Palliative Care Managed Care Document 1157f and 1158f for ACP discussions Document Palliative Medicine Needs in A/P ACP Coordination of Care Symptom Control

Palliative Medicine at Home All Payers Year # of Admits 2011 5 2012 188 2013 487 2014 630 2015 318

Palliative Medicine at Home-Program Statistics Average Length of Stay on PM = 150.7 days Payers = AMG Formally AHC 49.44% Commercial 13.75% Medicaid 0.19% Medicare 39.22% Mix of AMG & APP physician patients

Palliative Medicine at Home- Metrics August 2015 All Payers Metric Baseline Goal Result % of PM patients transitioned to Hospice % of PM Patients discharged due to death Average length of Stay PM patients on Hospice YTD-All cause none 20% 44.21 % none NA 7.5 % 36.7 55 days 65.90 days AD/ACP conversation % Less than 1% 100% Discussion 50% Completion % of Discharged patients with Pain documentation (quarterly) * Updated 9/1/15 91% Discussion 89% Completion None 50% 2013 YTD 8.3% 2014 YTD 58% 2015 YTD 94% *

Challenges Significant psycho social issues Availability of behavioral health services in the home Staffing turnover Training for new APN is 2-3 years Transitioning back to primary care opioid prescriptions

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