Palliative Care and Hospice in an Accountable Care Model Key Strategies to a Successful Integrated Delivery System Monique Reese DNP, ARNP, FNP-C, ACHPN Lori Bishop RN, CHPN Objectives Describe the formation and utilization of palliative care and hospice within an integrated delivery system Discuss strategies for use of metrics to support value of palliative care and hospice in an ACO model Demonstrate the impact of expanding these services across the care continuum. 1
Case Study PC Opportunities and Impact Healthcare Reform Focus Better Care for Individuals TRIPLE AIM Better Health for Populations Lower Cost 2
Health Care Reform: Game Changing Options Hospice Concurrent Care Pilots (2012) Medicare Independence at Home demos Accountable Care Organizations (shared savings 2012) Bundled payments pilots (2013) Innovations Center (2011) What is an ACO? Whether the payer is Medicaid, Medicare, Wellmark or other insurance: ACO goals are universal Better care Higher quality More value ACO clinical programs are universal Specific programs for target population and specific person, depending upon needs Iowa Health System 6 3
What an ACO is Not An HMO or Managed Care Third-party organizations that contract directly with health care providers to offer care to a defined group of patients Per Member Per Month (PMPM) fees to assume all risk/gain with limited quality or success Focus on cost with limited on quality or performance measures Lower cost by denying care and ratcheting down utilization Iowa Health System 7 Why Do We Need ACOs? Current care delivery is episodic and fragmented Many patients lack a primary care provider Patients are accessing primary care via ED visits No care coordination results in duplicative services and heightened health care costs Behavioral health is not integrated t with medical care Patients and providers are frustrated Iowa Health System 8 4
22 6 Social Workers 5 Physical Therapists Current State: A year in the Life of a Patient 19 13 Meds 5 Hospital Admissions i 6 Weeks SNF Care 37 Nurses Clinic Visits 4 Occupational 2 Therapists Nursing Homes 6 Community Referrals 2 5 Source: Johns Hopkins, RWJ 2010 (G Anderson) Home Care Agencies Months of Home Care 16 Physicians Iowa Health System 9 ACOs Transform Care Delivery FFS View: Acute, episodic care focuses on non-compliant patients ACO View: Holistic, patientcentered care shifts focus from non- p compliant patients to root causes of delivery system failures 5
But what about health care costs? Iowa Health System 11 Exponential Growth 6
Why Palliative Care? U.S. is spending much more for older ages Source: Fischbeck, Paul. US Europe Comparisons of Health Risk for Specific Gender Age Groups. Carnegie Mellon University; September, 2009. Iowa Health System 13 90 80 70 60 50 40 30 20 10 0 Total ED Visits & Hospitalizations 10 - Oct 11 -Nov 12-6 -5-4 -3-2 -1 1 2 3 4 5 6 PreConsult PostConsult -Dec 1 - Jan 2 -Feb 3 -Mar 4 -Apr 5 - May 6 - Jun 7 - Jul 8 - Aug 9 - Sep 7
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Palliative Care Definition Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain and stress of a serious illness whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient s other doctors to provide an extra layer of support. Palliative care is appropriate at any and at any stage in a serious illness, and can be provided together with curative treatment. 9
RELATIONSHIP TO HOSPICE Hospice is a subset of Palliative Care focused on end of life care. All Hospice care is palliative but not all Palliative Care is Hospice. Palliative Care Hospice < 6 mos. to live Comfort care only Palliative Care Expertise Primary PC All providers Secondary PC Specialty 10
Components of Fully Integrated PC Program Inpatient consultation service (acute, ICU, ED) Outpatient practice (Home care, clinic, LTC) Geographical inpatient unit (could be inpatient unit and/or hospice house) *JOURNAL OF PALLIATIVE MEDICINE Volume 11, Number 9, 2008 Mary Ann Liebert, Inc. DOI:10.1089/jpm.2008.0149 IHS Model of Palliative Care Delivery Systems-based approach An organized, deliberate approach to the identification, assessment, and management of a complex clinical problem; including checklists (triggers), treatment algorithms, provider education, quality improvement initiatives, and changes in delivery and payment models. 11
Program Model Provider led (Palliative Medicine) Dyad Leadership One program/one team across all sites of service Blended: Consultative/Co- management/care Coordination 12
Intensity of Service OPPC Home Care Hospice 16.0 14.0 12.0 10.0 8.0 6.0 4.0 20 2.0 0.0 Acute PC Consultation Rate National Average is 4 10% A B D F H UPH 13
100 90 80 70 60 50 40 30 20 10 0 Acute & Community PC % Discharged to Hospice A B D E F H UPH 25 DISCHARGE TO HOME HEALTH CARE 20 15 10 AcuteUPHC Comm HC 5 0 A B C D E F UPH 14
The Purpose of Measurement External and Internal quality assessment Demonstrate value Research/Exploratory - Quality Improvement Initiatives Identify your Stakeholders Patients and families Community partners Health System leaders Physicians and clinics Hospital leaders and clinicians Home care and hospice CMS, CMMI, MedPac, legislators, etc. 15
Metric Domains Operational Customer Satisfaction Metrics Financial Clinical Metric Definitions Considerations Reporting frequency Timeframe Overall Criteria Database (manual entry) vs. data pull Database Elements HIPPA! 16
Metric Definition Components Source Measure Numerator Denominator Definitions Inclusions and Exclusions Additional Clarification Hospice ALOS for PC Referrals 140 120 100 80 60 40 20 0 A B C D Acute Community Total 17
Financial Metric 600,000 500,000 400,000 300,000 200,000 Approximately 40 50% of billable is received Billed Received 100,000 0 Acute Community 7.00 600 6.00 5.00 4.00 3.00 2.00 1.00 Pain Score Initial & Post Consult 0.00 A B D F H UPH 18
Hospice Customer Satisfaction (FEHC) Overall Rating (G1) Composite Score Iowa Health System 37 PC Expansion Opportunities Emergency Room Clinic Long Term Care Telemedicine 19
Best Outcome For Every Patient Every Time Right Patient Identify appropriate patients Ensure timely referral Right Time Right Service Coordinate Care National Recognition 20