Building an Integrated Team-

Based Community Palliative

Program

Nancy Guinn, M.D.

Medical Director, Home and Transition Services

Presbyterian Healthcare System

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Join us for upcoming CAPC

webinars and virtual office hours

➔ Webinar:

– Identifying the Right Patients or Specialty Palliative Care:

Thursday, November 17, 2016 | 1:30 - 2:30 pm ET

➔ Virtual Office Hours:

– Pediatric Palliative Care with Sarah Friebert: Wednesday, October 12, 2016 |

4:00 pm ET

– Billing for Community-Based Palliative Care with Anne Monroe, MHA:

Monday, October 17, 2016 | 12:00 pm ET

– Building Effective Payer-Provider Partnerships with Tom Gualtieri-Reed,

MBA and Kristofer Smith, MD, MPP: Tuesday, October 18, 2016 2:00 pm ET

– Palliative Care Models in the Community with John Morris, MD, FAAHPM:

Tuesday, October 18, 2016 | 3:00 pm ET

– Ask a Program Leader with Andrew Esch, MD, MBA: Wednesday, October

18, 2016 | 2:00 pm ET

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Visit

www.capc.org/providers/

webinars-and-virtual-office-

hours/

Building an Integrated Team-

Based Community Palliative

Program

Nancy Guinn, M.D.

Medical Director, Home and Transition Services

Presbyterian Healthcare System

3

Objectives

➔At the conclusion of this seminar, the learner

will be able to:

– List two measurements that keep health plan

CEOs up at night

– Identify how home-based palliative care programs

can address these issues

– Describe one value-based way to pay for

palliative care

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5 Confidential |

Presbyterian HealthCare Largest not-for-profit healthcare system in New Mexico

Serving one in three New Mexicans

755,387 unique customers (March 2016)

11,000 employees New Mexico’s largest private employer

108 years in New Mexico

Health Plan

Delivery System

Medical Group

6 Confidential |

Focus on Values-based Care

Health Plan started in 1986

Medicare Advantage Plan since 1998

• Largest Medicare Advantage Plan in the state

In New Mexico

• One in three covered by Medicaid

• Ranked 51st in nation for percentage of residents receiving health insurance through an employer

• More Medicare and Medicaid lives and fewer commercial lives than other health insurance markets

Triple Aim is centerpiece of care model at Presbyterian

Accountable for the total cost of care

Approximately 470,000 members statewide

7 Confidential |

Presbyterian

Delivery System

and Medical Group

8 hospitals in 7 communities; opening a new medical center in Santa Fe in 2018

800 employed providers

9,000 contracted providers

30+ Multi-specialty clinic sites

1.8 million visits in 2015

All Primary Care Sites are PCMH

Presbyterian Home and

Transition Services

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Hospice Physicians

House Calls

Hospital at

Hom

e

Palliative Care

Inpatient

Clinic

Home

Complete Care:

An Advanced Illness

Management

Program

Advance Care Planning

Health Risk Assessments

Presbyterian Home and Transition

Services

Inpatient

Palliative Care House Calls

and

Home Palliative

Team

Restructure Inpatient

Palliative Team to

remove focus on

FFS providers

2008 2013 2015

Office

Palliative Care

Complete

Care

2005 2010 2014

Hospital at Home

Inpatient Palliative Services

➔ Started in 2005

➔ Demonstrated decrease in variable costs after consultation in

2007-2008

➔ 2014: Developed multi-disciplinary approach using equal

ratios of social work and medical providers

➔ 2,000 consults/year in 3 Albuquerque hospitals/SNF

– 30 day readmission rate tracked monthly: 5-8%

– 75% of patients complete Advance Directive within 30 days

➔ Available 7 days a week

➔ Team: 3 APRNs, 1 MD, 3 Social Workers, 1 Chaplain, 2 RN’s

➔ Integrated with Inpatient Hospice Team

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Community-based Office

Palliative Care

➔ Office/Clinic Pilot in 2012-2013

– Demonstrated dramatically reduced total cost of care for patients

seen in clinic

➔ Expanded to 5 primary care and 2 oncology clinics

➔ Continues to demonstrate:

– Low hospitalization rate (<8%)

– Advance Directives (80% within 30 days of initial visit)

– High percentage of patients receive hospice care prior to death

➔ Clinic: 1 NP, assistance from 2 MDs

– Integrated with Oncology, Social Work, and Psychology

– Integrated with Home Palliative Team

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Community-based Home

Palliative Care

➔ Housed in Home Health agency

– Sees primarily Presbyterian Health Plan patients

– ADC 150-200 patients (about 1/3 of agency census)

➔ Team trained in Palliative Care

– Integrated with House Calls, Home Palliative Care providers, strong

social work component

➔ Hospital Readmission rate is always 8% or lower for this complex

population.

➔ Home visits by 1 NP, with assistance from 3 MD’s

➔ Full-time Social Worker (as well as House Calls SW team)

➔ Team of RN’s from home health agency (therapists also)

➔ Just adding Chaplain

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House Calls

➔ Founded in 2010 from Hospital at Home

➔ “Mobile” Patient-Centered Medical Home

➔ Team based approach

– MD/NP/Social Worker/Support staff

– Offers Primary Care, Urgent Care, Hospital at Home

➔ Tracks all Hospitalization/ED rates

– (3-8% of total census monthly)

➔ Tracks standard primary care measures: vaccination rates

– (100% given/offered)

➔ Presence of Advance Directive (MOST)

– (75% of patients)

➔ 72 hour follow up following hospitalization (100%)

– Now tracking 48 hours follow up and follow up after ED visits

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• Heart Failure

• COPD/Emphysema

• Pneumonia

• Cellulitis

• Deep Vein Thrombosis

• Stable PE

• Nausea/Vomiting

• Dehydration

• Complicated UTI

Patient Population A Patient’s Day Outcomes

• Daily Physician visit

• Daily Nurse visit (min)

• ECG’s, lab x-rays

• Home Health Aide twice

daily

• Medications/Medical

Equipment Provided

• Emergency visits as

needed (rare)

100% Core Measures (Heart Failure &

Pneumonia)

.05% Falls

3.2 Average LOS

2.47% 30 day

Readmissions

7.4% 90 Day

Readmissions

Hospital at Home

Complete Care

➔ Piloted 2015 – focused on 5% of Presbyterian

Medicare Advantage members with most serious

illness burden

– Needs assessment: responsible for 64% of costs

➔Will have enrolled 600 members by close of 2016.

➔Uses alliance with health plan to fund non-

reimbursed services in the home, including DME,

in-home foot care, urgent RN and community

paramedic care

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Complete Care

➔ Accept the most complex patients from our health

system

➔RN in-home case management

➔ “One number to call” 24/7

➔ Integrate with Palliative and House Calls

– Community paramedic program

➔ Track numerous outcomes including every ED

visit, hospitalization, falls, any urgent visits,

enrollment in hospice

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Complete Care

➔Tracks total cost of care:

– Initial reports show savings of $700-$1000 PMPM

➔Readmission and hospitalization rate 50% of

predicted in this population

➔85% of patients who die do so at home by

their choice

➔Hospice average LOS: 59 days

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Urgent Visits (Complete Care and House Calls)

Other Savings:

• Post-acute care cost avoidance (commonly 40-60%)

• Complication cost avoidance (falls, hospital acquired infections,

delirium, ADL decline)

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Cost Avoidance: Jan 2015-June 2016

Ambulance, Emergency Room and Hospital Savings: 553 Urgent Home Visits with 372 directly avoiding an ED Visit

Costs % Use Pt Count Cost Avoidance

Average ED Cost $700 100% 372 $260,400

Average AAS Transport cost $300 90% 335 $100,440

Average hospitalization cost $8,000 90% 335 $2,680,000

Total $3,040,840

Advance Care Planning

➔ Supports and manages the state POLST project

➔ Integrated with New Mexico “Conversation

Project”

➔Monthly reports on scanned AD’s throughout our

system – by clinic, hospital, provider

➔ Training in every PHS setting on having

conversations with patients

➔Creating trained volunteer ACP Facilitators to

support all providers

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Integration in Presbyterian

Healthcare

Palliative Care

Health Plan: Manage Complex Patients

Hospital:

Readmissions, Post-acute

Care

PCMH: Care for Complex

Patients, assist with difficult

conversations

Patients and Families: Help in the Home and Clinic

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Integration from the Patient’s

perspective

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Patient

House Calls Provider

and Social Worker

Home Palliative Provider

Home Palliative

RN

Complete Care

Hospice MD

Community Paramedic

They may only

see 2 or 3 of

these team

members in

their home

Patients for Programs are

identified by:

➔Direct referrals from case managers in

clinics, health plan, hospital

➔Diagnoses (lung cancer in Oncology)

➔Intake staff in Home Health

➔Annual Health and Wellness Assessments

➔Epic Registries

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Registry

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Operations

➔Each team/service has a lead provider

➔Manager of Practice Operations

• Pairs with lead provider

• Scheduling, recruitment, help with technology

• Tracks outcomes, assists with meetings

➔Complete Care has a Program Manager

• Oversees all RN case managers

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Tools to Help:

From Progress Note to Report

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Tools to help: ACP notes

Communication

➔ Shared Electronic Medical Record with all services

➔ Team Patient-Centered Meetings:

– Home Palliative IDT with all services present

– Inpatient Palliative Team with Outpatient and Hospice

represented

– Complete Care Meets with House Calls Social Work Team

– Monthly Clinical/Educational Case Conference with all

present

– Monthly meeting with Geriatric Psychiatrist

➔ Teams also have monthly operational meetings

➔ Update emails to all providers for the entire service

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How are teams are blended

1. House Calls offers ongoing medical care for Home Palliative

patients

2. Palliative providers offer consultative services for House

Calls patients

3. Palliative Clinic patients are often referred for Home services

4. Hospice providers are available for Home Palliative Consults

5. House Calls and Complete Care serve patients together

6. Night nurses for Hospice cover House Calls, Palliative,

Complete Care patients

7. Complete Care RN’s assist with all clinical phone calls for

House Calls patients 28

Which providers are right for

this work?

➔Primary Care providers

➔Hospice providers and social workers

➔APN’s with acute care training

➔Search for comfort working independently

➔Don’t be afraid to train for gaps

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Palliative Care’s Value

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Positioned as essential in a system of care for fragile and complex patients

Community-based Palliative

Care can be an answer to your

system’s concerns:

➔ Readmission concerns in hospitals

(Track readmission rates for your patients)

➔ Health Plan concerns about rising costs

(Work with identified complex and costly patients)

(Demonstrate patients remaining in the home)

➔ Patient hopes for improved continuity and navigation,

a better experience of care

(Demonstrate success on Patient Surveys)

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Palliative Care can be an answer

to:

➔ Increased use of specialty and emergency services

(Track percent of patients seen with certain diagnoses)

(Track percent of patients who visit ED before/after PC)

➔ Specialty certifications such as Commission on Cancer

(Volunteer to assist other departments with clear

documentation of palliative services)

➔ As you survey your environment, what needs do you

find?

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Palliative Care’s Value

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Positioned as essential in a system of care for fragile and complex patients

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