Practicing patient centered medicine in the 4th quarter Bob Arnold MD 2016 Learning Goals: To define the difference between goals and strategy To describe a goal focused method of talking with patients and families (REMAP) To name two programs for providing palliative care to patients at home Input from E Weinstein and D White REMAP: Discussing Goals of Care Reframe Reframe Expect emotion Map out what s important Align with patient values Plan treatment to match values Given this news, it seems like a good time to talk about what to do now We re in a different place than before We re at a point where more treatments are unlikely to make you feel better and they may make you worse Goals of Care Conversations: Delivering Serious News 3 Goals of Care Conversations: Delivering Serious News 4 2. Expect emotion: respond empathically 2. Expect emotion: respond empathically Bad news emotions Emotion brain shut down cognition I can see you are really concerned... Tell me more about that... I can see how much you love your son Is it ok for us to talk about what this means?
FAQ What if they do not agree the current plan is not working Is it they do not understand? Is it they are too emotional? If they can not give up the goal, can they hold it AND plan for what if it does not work Prognostic awareness Can not hear Can hear and do not believe Believe in head not heart Believe and hope wrong Transitioning to mapping: Stepping back Need to separate from strategy Can we step back and think about what you are hoping for and that will let us come up with the right choice for you? There are different options. To find the right one for you. 3. Map out the future Have you ever written a living will? Have you ever thought what if things do not go the way you want? Have ever had to face any issues like this for your family? 3. Map out the future Given this situation, what s most important? As you think about the future, what concerns you? What kind of things do you enjoy doing? Keep going to the well Often the first answer is To live longer! Acknowledge I hear you and Ask what else? Ask what if this was unlikely?
FAQ hoping for a miracle Join with the miracle I hope we get one too See if they can expand their hope portfolio What else can you hope for? Can they consider what if a miracle does not happen? FAQ Surrogate discussion Avoid want What would your dad think if he was sitting hear and could hear what we are saying? Attend to the emotion he is a fighter 4. Align with values As I listen, it sounds like what s important is... I think we can help you do xx... By planning ahead, we can avoid things like... 5. Plan treatments that match values Here are things we can do now... For this situation, here are some things that would help What do you think? Assent vs consent 5. Plan treatments that match values Are they ready to hear a plan? Am I ready to give a recommendation Do I know enough of the medicine? Are the teams on the same page? FAQ Show your work Focus on what can be achieved Focus on their ability to meet new goals Make clear recc about what can not be achieved and do not offer
Best Worst Talking about the future when uncertain Most likely What if the family members disagree with each other? Elicit everyone s views in a nonjudgmental manner Empathize with how hard the situation is Do not take sides Try to focus the conversation on what the patient would have wanted Fulfilling the promise A home-based supportive and care management program that provides advanced care planning, articulation, and communication of individual goals of care, with a focus on symptom management, comfort, and decision making processes in collaboration with the Member and their PCP. Target Population: This program is designed for members with serious or advanced illness, and is designed to optimize their quality of life as they continue to cope with the complications and treatment of their illness. Home-based care teams (RN, SW) provided in collaboration with CRNP home visits where appropriate Goals of Care conversation and Advanced Care Planning, including POLST Defined and documented interventions based on Goals of Care Provided outside of the skilled home health and homebound requirements 22 Kaiser Sutter Labson MC, et al. Innovative Models of home-based palliative care. The Cleveland Clinic of Journal of Medicine 2013: e-s30-es35. Labson MC, et al. Innovative Models of home-based palliative care. The Cleveland Clinic of Journal of Medicine 2013: e-s30-es35. 23 24
25 Member Criteria: -Age > 21 -All Lines of Business -2 or more co-morbid conditions, or Metastatic Cancer -Incremental implementation and expansion based on CRNP geographical coverage Program Referral Criteria: To ascertain appropriateness for, Physicians or Providers shall provide attestation confirming that the Member has an advanced, serious illness and has at least one of the following diagnoses or experiences: - Congestive Heart Failure - Liver Failure - Coronary Artery Disease - Dementia / Alzheimer s Disease - Chronic Obstructive Pulmonary Disease - Parkinson s Disease - Renal Failure / ESRD - Metastatic Cancer - 3+ ED/Urg in the past 12 months - 3+ IP Admits in the last 12 months - 2, or more, ICU Stays within the same hospitalization - Palliative Care / Supportive Services Encounter - Deferred Hospice - Dis-enrolled from hospice secondary due to non-progression of disease - End stage disease but not a candidate for transplant - LTAC Stay within the past year 26 Approval through Insurance Services Division clinical review for program enrollment 10 visits per lifetime (any combination of services) Place of Service = Home with fee-for-service reimbursement structure RN, SW CRNP as appropriate No Member cost-sharing Does not require face-to-face encounter Enhanced Clinical Consultants Medical Director Oversight and Clinical Support Dr. Namita Ahuja Insurance Services Division Clinical Pharmacist Interdisciplinary Team Review Ambulatory palliative care Cancer Cardiology Nephrology Geriatics HIV