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Transformational Palliative Care:
Matching What We Do To Our Patient’s Needs
Diane E. Meier, MDDepartment of Geriatrics and Palliative Medicine
Icahn School of Medicine at Mount SinaiDirector, Center to Advance Palliative Care
www.getpalliativecare.org
No Disclosures
Objectives
• The case for palliative medicine
• What works to improve quality and reduce costs for vulnerable populations?
• Limitations of our taxonomy and professional tribalism
• How to face outwards towards needs of:– Our patients, their families– Policy makers, payers, health system
leadership
Concentration of SpendingDistribution of Total Medicare Beneficiaries and Spending, 2011
10%
63%
37%
90%
Total Number of FFS Beneficiaries: 37.5 million
Total Medicare Spending: $417 billion
Average per capita Medicare spending (FFS only): $8,554
Average per capita Medicare spending among
top 10% (FFS only): $48,220
NOTE: FFS is fee-for-service. Includes noninstitutionalized and institutionalized Medicare fee-for-service beneficiaries, excluding Medicare managed care enrollees. SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost & Use file, 2011.
Because of the Concentration of Risk and Spending,
Palliative Care Principles and Practices are Central to Improving Quality and
Reducing Cost
Mr.B• An 88 year old man with mild
dementia admitted via the ED for management of back pain due
to spinal stenosis and arthritis. • Pain is 8/10 on admission, for
which he is taking 5 gm of acetaminophen/day.
• Admitted 3 times in 2 months for pain (2x), weight loss+falls, and altered mental status due to constipation.
• His family (83 year old wife) is overwhelmed.
Mr. B:• Mr. B: “Don’t take me to the
hospital! Please!”• Mrs. B: “He hates being in the
hospital, but what could I do? The pain was terrible and I couldn’t reach the doctor. I couldn’t even move him myself, so I called the ambulance. It was the only thing I could do.”
Modified from and with thanks to Dave Casarett
Concentration of Risk
• Functional Limitation
• Dementia
• Frailty
• Serious illness(es)
Most of Costliest 5% have Functional Limitations
http://www.cahpf.org/docuserfiles/georgetown_trnsfrming_care.pdf
The Modern Death Ritual: The Emergency Department
Half of older Americans visited ED in last month of life and 75% did so in their last 6 months of life.
Smith AK et al. Health Affairs 2012;31:1277-85.
Dementia Drives UtilizationProspective
Cohort of community dwelling older adults
Callahan et al. JAGS 2012;60:813-20.
Dementia No Dementia
Medicare SNF use 44.7% 11.4%
Medicaid NH use 21% 1.4%
Hospital use 76.2% 51.2%
Home health use 55.7% 27.3%
Transitions 11.2 3.8
Dementia and Total Spend
• 2010: $215 billion/yr
• By comparison: heart disease $102 billion; cancer $77 billion
• 2040 estimates> $375 billion/yr
Hurd MD et al. NEJM 2013;368:1326-34.
In case you are not already worried…The Future of Dementia Hospitalizations
and Long Term Services+Supports
10 fold growth in dementia related hospitalizations projected between 2000 and 2050 to >7 million.
Zilberberg and Tija. Arch Int Med 2011;171:1850.
3 fold increase in need for formal LTSS between now and 2050, from 9 to 27 million.
Lynn and Satyarthi. Arch Int Med 2011;171:1852.
Why? Low Ratio of Social to Health Service Expenditures in U.S.
for Organization for Economic Co-operation and Development (OECD) countries, 2005.
Bradley E H et al. BMJ Qual Saf 2011;20:826-831
Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.
Surprise! Home and Community Based Services are High Value
• Improves quality: Staying home is concordant with people’s goals.
• Reduces spending: Based on 25 State reports, costs of Home and Community Based LTC Services less than 1/3rd the cost of Nursing Home care.
•Highest risk, highest cost population are those with functional limitation, frailty, cognitive impairment +/- serious illness(es)
•What are our roles in improving care of this population?
This Requires Expertise
What is Palliative Care?• Specialized medical care for people with serious illness and their families• Focused on improving quality of life as defined by patients and families.• Provided by an interdisciplinary team that works with patients, families, and
other healthcare professionals to provide an added layer of support.• Appropriate at any age, for any diagnosis, at any stage in a serious illness,
and provided together with curative and life-prolonging treatments.
Definition from public opinion survey conducted by ACS CAN and CAPC http://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdf
Conceptual Shift for Palliative Care: Both-And, not Either-Or
Medicare Medicare Hospice Hospice BenefitBenefit
Life Prolonging CareLife Prolonging Care OldOld
Palliative CarePalliative Care
Bereavement
Hospice CareHospice CareLife ProlongingLife Prolonging
CareCareNewNew
Dx Death
18
Palliative Care Models Improve Value
Quality improves– Symptoms– Quality of life– Length of life– Family satisfaction– Family bereavement
outcomes– MD satisfaction– Care matched to
patient centered goals
Costs reduced– Hospital costs decrease– Need for hospital, ICU,
ED decreased– 30 day readmissions
decreased– Hospitality mortality
decreased– Labs, imaging,
pharmaceuticals reduced
Key Characteristics of Effective Models 1: Targeting
Demand Management DM/CM CCM-palliative care
RE
SO
UR
CE
S
NEEDS
Jones et al. JAGS 2004;52
Gómez-Batiste X, et al. BMJ Supportive & Palliative Care 2012;0:1–9. doi:10.1136/bmjspcare-2012-000211
Ask yourself:
•Does this patient have an advanced long term condition or a new dx of a serious illness or both?•Would you be surprised if this patient died in the next 12 months?•Does this patient have decreased function, progressive weight loss, >= 2 unplanned admissions in last 12 months, live in a NH or AL, or need help at home?•Does this patient have advanced cancer or heart, lung, kidney, liver, or cognitive failure?
Targeting on the Front Lines
Key Characteristic 2: Goal Setting
• “Don’t ask what’s the matter with me; ask what matters to me!”
• Ask the person and family, “What is most important to you?”
• “Ultimately, good medicine is about doing right for the patient. For patients with multiple conditions, severe disability, or limited life expectancy, any accounting of how well we’re succeeding in providing care must above all consider patients’ preferred outcomes.”
Reuben and Tinetti NEJM 2012;366:777-9.
Priorities for Care
Survey of Senior Center and AL subjects, n=357, dementia excluded, no data on function
Asked to rank order what’s most important:
Overall, independence ranked highest (76% rank it most important) followed by pain and symptom relief, with staying alive last.
Fried et al. Arch Int Med 2011;171:1854
Recent E-mail from a Geriatrician
“I have a particular interest in goals of care and how best to convey this dialogue across the continuum. For the last 18 months I have spearheaded the Community Based Care Transitions Program in New Haven….Many of the readmissions are related to unaddressed palliative care needs (surprise surprise)…I’m interested in how we can develop policies to ensure providers are discussing goals of care and not just a menu of possible interventions.”
Impact of Goal Setting through Advance Care Planning
• Prospective data on >3000 Medicare beneficiaries 1998-2007 (linked HRS, claims, and NDI)
• Advance directives associated with lower Medicare spending, lower hospital death rate, and higher hospice use in medium-high Medicare spending regions of the U.S.
Nicholas et al. JAMA 2011;306:1447-53.
Key Characteristic 3: Can We Deliver on People’s Goals? Not When
Families are Home Alone
• 40 billion hours unpaid care/yr by 42 million caregivers worth $450 billion/yr
• Providing “skilled” care• Increased
morbidity/mortality/bankruptcy
aarp.org/ppi
http://www.nextstepincare.org/
Optimistic Baby Boomers say “Get Ready, Kids!”
70% of those who have never received long term care believe they can rely solely on family in time of need as they age.
The Scan Foundation/NORC/AP April 2013
To.pbs.org/15TQh2B http://www.apnorc.org/projects/Pages/long-term-care-perceptions-experiences-and-attitudes-among-americans-40-or-older.aspx
Families Need Help if We Are to Honor People’s Goals
• Mobilizing long term services and supports is key to helping people stay home and out of hospitals.
• Predictors of model success: 24/7 phone access; high-touch consistent and personalized care relationships; focus on social and behavioral health determinants; coordinated integration of social supports with medical services.
Payers Are Already Bringing the Care Home
www.theatlantic.com 02.25.13 MA Full Risk PMPM contract with HealthCare Partners/DaVita 15%+margin. >700K patients“Now
instead of 30-40 patients/day, Dr. Dougher sees 6-8.”
Key Characteristic 4: Pain and Symptoms –
Disabling pain and other symptoms reduce independence and quality of life.HRS- representative sample of 4703 community dwelling older adults 1994-2006
Pain of moderate or greater severity that is ”often troubling” is reported by 46% of older adults in their last 4 months of life and is worst among those with arthritis.
Smith AK et al. Ann Intern Med 2010;153:563-569
It’s Not Only Pain: Symptom Burden of Community Dwelling
Older Adults with Serious Illness
Walke L et al, JPSM, 2006
* **
**
* *
*75% or more reported symptom as bothersome
Key Characteristic 5: Dynamic Nature of Risk
• Early advance care planning + communication on what to expect + treatment options + access.
• As illness progresses, ability to titrate dose intensity of services. Morrison and Meier. N Engl J Med 2004;350(25):2582-90.
Taxonomies and Their Discontents
• Balkanized health system: Hospital, office, NH, AL, home, PACE, LTACH, hospice…
• Balkanized disciplines: IM, FM, geriatrics, palliative care, cardiology, oncology, nephrology, CCM, hospitalists, SNFists…
• Lots of evidence-based “best practices” based on small scale programs.
• Competitive, struggling, isolated, ineffective at meeting population needs.
We Are Confusing Our Audiences
-Policy makers and payers and hospitals and health systems are asking: Who has the best impact on LOS? On 30 day readmissions? On hospital mortality? On HCAHPS? On total (payer) spend? For which patient population? In which settings? Does anyone pay for this? How can I believe your cost avoidance arguments? How do I choose?
-Patients and families: HELP!!
What to Do? Implement, Scale
• Our challenge is broad implementation of what’s already been shown to work in small scale programs.
• Scaling and diffusion of innovation via technical assistance, training, and social marketing.
• Be at the table or be on the menu: Drive policy change
What do systems, payers, colleagues and people and their families need?
1. Clear, Simple Technical Assistance for
– System integration design– Model(s) selection and matching to
population needs– Implementation, quality, and
standardization– Risk stratification and targeting– Evaluation
Care Management
Move Inpatients Through the System Safely and Efficiently:
ACE/HELPNICHE
Palliative Care
Provide patient-centered,
coordinated care: PCMH (GRACE,
Guided Care), Medical house
calls, ACOs
Keep some patients with acute illness
out of the hospital:
Hospital at Home
Prevent Readmission:
Care Transitions Programs
www.med-ic.org
What do systems, payers, colleagues and people and their families need?
2. Workforce Training•Not even close to enough clinicians with specialty training to meet the needs•Therefore, our role is to:
– Train generalists and help communities to step up
– Provide subspecialty consultation for the most complex
– Improve evidence base through research
What do systems, payers, colleagues and people and their families need?
3. Public and constituency awareness through social marketing and PR: We need to create a positive public vision of the good to drive demand and access and to help leaders to know about, and then implement models.
Treating the person beyond the disease.
Transforming 21st Century Care of Serious Illness Gomez-Batiste et al.2012
Change from: Change to:
Terminal ……………………………………Advanced Chronic
Prognosis weeks-month…………………..Prognosis months to years
Cancer ……………………………………..All chronic progressive diseases
Disease……………………………………..Condition (frailty, fn’l dep, MCC)
Mortality…………………………………….Prevalence
Cure vs. Care………………………………Synchronous shared care
Disease OR palliation……………………..Disease AND palliation
Prognosis as criterion……………………..Need as criterion
Reactive…………………………………….Screening, Preventive
Specialist……………………………………Palliative/Geriatric Care Everywhere
Institutional………………………………….Community
No regional planning……………………….Public health approach
Fragmented care……………………………Integrated care
(Present) and Future
“The future is here now. It’s just not very evenly distributed.”
William Gibson
The Economist, 2003
Upcoming AudioconferenceBuilding the Future of Home-Based Palliative Care•Thursday September 19, 2013•1:30 – 2:30 PM EST•https://www.capc.org/products/audio-conferences/2013-09-19/•Learn from a CMS Innovation Grantee on integration of home palliative care within a Home Health Agency
National Seminar Nov. 7- 9 in Dallas:
Palliative Care Across the Continuum
• http://www.capc.org/capc-resources/capc-seminars/dallas-2013/seminar-overview
• Early bird rate until September 25.
• Highly interactive seminar presenting best practices from front-line innovators in care of the sickest and costliest 5% of patients.
