Program Development for Safety Net Institutions

Catherine Deamant, MDDirector, Palliative Care Services

Cook County Health and Hospitals System

Coleman Fellowship WorkshopSeptember 7, 2013

We Bring HealthCARE to Your Community

Definition of Safety Net Institution

• Provides significant level of care to low-income, uninsured, and vulnerable populations.– Not dependent upon public vs. non-profit– Core safety net providers: mission to have “open door” to

all regardless of ability to pay (high uninsured, Medicaid, vulnerable)

• High risk for fragmented care, inadequate community support & high symptom burden

Palliative Care in Safety Net Setting

• Goals of palliative care are same as all hospitals:– Provide high quality interdisciplinary care to improve

quality of life for patients with serious illness throughout the continuum of care with respect and dignity.

• Justifications for palliative care are same for all hospitals:– Cost savings – Patient/family satisfaction– Quality metrics

Palliative Care in Safety Net Setting

• Know who you serve• Demonstrate credibility• Identify unique opportunities

Know who you serve: Patients & Families

• Lack of access to care means late diagnosis– 40% diagnosed with advanced illness within 3 months of

hospitalization (20% on the index admission)

• Culturally diverse:– 30% Limited English proficiency

• 60% uninsured at time of admission– Fear of financial burden

• 8% advanced liver disease (national-2%)– Limited social support

• Young population– Average age-58 years

Demonstrate credibility with patients

• Address the barriers to quality end of life care through palliative care interventions– Develop relationship with interpreter services– Educate on advance directive as form of empowerment– Address misconceptions of hospice care– Respect wishes for site of death-home is not always a goal

• Trust:– PC consult for hospice referral– Build relationship; avoid abandonment

• Facilitate goal of return to home country– Must be patient’s goal, not institution’s

Impact on Disparities: End of Life Decisions

Outcome Variable Overall PCC Primary team

Completed a Durable Power of Attorney for Health Care

126/141 (89%)

118 (94%)

8 (6%)

DNR Status 153/173(88%)

101 (66%)

52 (34%)

Hospice Enrollment 134/147 (91%)

37% died inpatient hospice

173 African-American patients with Cancer seen by PC

Know who you serve: Providers

• Emotionally challenging to care for very young patients who are dying with limited resources– Support primary team – Strategies to reduce burnout (especially for PC team)

• Majority of consultations for goals of care• Develop hospital-hospice relationship who will share

the mission (unless hospital has own hospice)– Be comprehensive in your PC role (address issues of

prognosis and resuscitation before referral) – Serve as attending physician– Provide medications for transfer home

Hospital Deaths seen by PC

Measurement 2009 2012 Nat’l

% of deaths with PC consult (any LOS)

71/190 (37%) 166/327 (51%) 13%

% of deaths with PC consult (LOS <2 days)

6/62 (10%) 14/83 (17%)

% of deaths with PC consult (LOS >2 days)

65/128 (51%) 149/244 (61%)

Know who you serve: Administration• Palliative care can facilitate more effective utilization

of scarce hospital resources– Assist in care planning for chronic, complex patients– Long Stay Committee; Case Management Rounds; Ethics– Identify options for right setting of care

• Healthcare Reform– Patient-Centered Medical Home-Priority for ambulatory

palliative care – High hospital occupancy rate (challenge for inpatient unit)

• Educational Mission– Fellowship; Resident Rotation; Medical Student Rotation

CCHHS Palliative Care Impact

JSH Rush UIC Mercy U of C Sinai

% of Deaths with ICU Admission 10 26 25 20 24 28

% of Deaths in Hospital 29 35 33 25 34 44

Hospice Enrollment 45 40 40 51 45 23

Hospice Days(per decedent) 20 11 14 14 15 7

http://www.dartmouthatlas.org, 2003-2007

Lowest death rates associated with ICU admissionSecond lowest hospital deathsSecond highest hospice enrollmentHighest length of stay in hospice care

Among Medicare Decedents:

2012 Statistics: Ambulatory PCCost savings-$840,000-1.2 million

Cost Analysis Factors Cost savings/revenue

Hospital Costs Total per day $3,426

Total inpt cost $7637-11,063

Potential Cost-avoidance

Total cost savings (110 pts) $840,070-1,216,930

Potential Revenue generation

Revenue in outpatient $48,290

2012: Total number of paracentesis performed-110 home or clinicAssumptions: Hospitalization for paracentesis is 2-3 days with admit thru ED Charge code-49082 at $439