Community-based Palliative Care Creating Robust Access to a Continuum of Supportive Care Martha L. Twaddle MD FACP FAAHPM HMDC SVP, Medical Excellence & Innovation JourneyCare CMO, Aspire Health Partners of Illinois Associate Professor of Medicine, Northwestern Feinberg School of Medicine Thursday, February 11, 2016
Join us for upcoming CAPC webinars and virtual office hours ➔ Webinar: – Palliative Care in the Neuro-ICU: The Crystal Ball of Prognosis Tuesday, February 16, 2016 from 12:00 — 1:00 PM ET Featured Presenter: Jennifer A. Frontera, MD – Development of an Outpatient Palliative and Supportive Care Nurse Practitioner Practice: Dos, Don’ts and Maybes Visit Tuesday, March 15, 2016 from 1:30 — 2:30 PM ET www.capc.org/ Featured Presenter: Darrell Owens, DNP providers/ webinars-and- virtual-office-hours/ ➔ Virtual Office Hours: – Planning for Community-Based Care with Jeanne Sheils Twohig, MPA February 16, 2016 at 11:00 a.m. ET – Building Effective Payer-Provider Partnerships with Tom Gualtieri-Reed, MBA & Kristofer Smith, MD February 16, 2016 at 3:00 p.m. ET – Palliative Care in the Home with Donna W. Stevens, BS February 18, 2016 at 1:00 p.m. ET – How to use CAPC Membership with Brynn Bowman, Director of Education February 19, 2016 at 2:00 p.m. ET 2
Objectives ➔ Review and discuss a conceptual framework for a continuum of supportive services with Community Based Palliative Care (CbPC) in a central role. ➔ Review Access Points where patients/families may naturally interface with Palliative Care support and examples of possible structure, function, and metrics of these access points. ➔ Reinforce the practical approaches to gap analysis, strategic partnerships and how to move forward in the ‘Community’.
Skate to where the puck is going …. Gretsky 4
Comprehensive Palliative Care (CPC) Center to Advance Palliative Care 2014 5
Medicare Definition of Palliative Care Palliative care means patient and family- centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice . 73 FR 32204, June 5, 2008 Medicare Hospice Conditions of Participation – Final Rule 6
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Integrated System of Care- Population Based Health The services and Manage Populations partnerships established Well = keep them well in an integrated system of Chronic = manage conditions care meet the needs of Well → Sick → Well the community throughout Well → Sick → the entire health and Palliative Care wellness continuum. Palliative Care Wellness Services: Wellness Center Diet and Nutrition Coaching Mammography Colonoscopy Psychiatry / “Sick” Psychology Women’s Center in hospital, facilities, Senior Center and home Chronic Well Buxton; Twaddle 2014 8
Caregiving Increases Mortality Risk Nurses Health Study : prospective study of 54,412 nurses ➔ Increased risk of MI or cardiac death: RR 1.8 if caregiving >9 hrs/wk for ill spouse Lee et al. Am J Prev Med 2003;24:113 Population based cohort study 400 in-home caregivers + 400 controls ➔ Increased risk of death: RR 1.6 among caregivers reporting emotional strain Schulz et al. JAMA 1999;282:2215. 9
Trajectory for Serious Advanced Illnesses High Hospital Home Rehab Health Repeat Function Death CbPC ( CHF, COPD often coupled with DM, ESRD etc ) Low Death usually follows Multiple hospitalizations disease exacerbation CPC Time frame – particularly targeting the last year of life. 10
Home-based Supportive Care High Hospital Home Home Rehab Health Health Function Hospice Care Home Health CbPC Death Low Death usually follows Multiple hospitalizations disease exacerbation CbPC Time frame – particularly targeting the last year or two of life. 11
Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers ➔ Gomes B et al. Cochrane Database of Systematic Reviews. 2013, Issue 6, Art No:CD007760 12
Results ➔ 23 studies (16 RCTs, 6 of high quality) of 35,561 participants and 4042 caregivers ➔ Palliative Care – Increased odds of dying at home – Reduced symptom burden 13
Overarching goals ➔ With active knowledge of diagnoses, medications, and anticipated course of illness – proactively monitor and care manage patients to avoid crises and suffering that drive non-beneficial utilization. ➔ Drive/incentivize patient-healthcare interactions that are care directed (value), not activity or volume directed, thereby decreasing costs and aligning expenditures with meaningful (beneficial) care . ➔ Develop and analyze coordination of care and patient engagement and its impact on patient, family, and health- system’s outcomes . ➔ Change the culture of medicine to be patient-family centered – – Anticipating needs of patients and families • not waiting for “asks” or crises – Deliver care that is meaningful and goal-driven 14
Pragmatic Goals: Establish a sustainable, scalable integrated model of Comprehensive Palliative Care (Supportive care) across sites of care: ➔ Identify/develop ‘Access Points’ and provide consistent, timely, systematized response. ➔ Routinize risk stratification of patients needing specialty level supportive services and PC care-management – aligning intensity and site of care with patient needs and goals. ➔ Embed or create access to Specialist level Palliative Care within the Access Points – Effectively integrate home-based specialty supportive care services as a seamless continuum to PCMH. 15
Pragmatic Goals: ➔ Pro-actively monitoring of patient well-being such as via web-based programs – dynamic ‘risk’ stratification (ex telemedicine) ➔ Proactively provide timely information and data to stakeholders (PMDs, treating Specialists, Community Partners, Payors) ➔ Educate - Further the development and consistency of primary (generalist & champion) palliative care competencies among treating physicians and their care teams.
Access Points 17
Access point - Hospital 18
Access Point - Hospital ➔ Consultative Model – hospital based team (Physician, APRN/PA, SW, Chaplain) ➔ Triggered by acute hospitalization, diagnosis, decline, anticipated poor outcomes or death in hospital ➔ Hospital culture and bylaws typically shape the team structure and function. ➔ Ideal – the Naylor Transition Model for those being discharged – APRN/PA who sees pt/family in the hospital sees them in next site of care. ➔ Financial – typically FFS/episodic unless bundled
Access Point - Hospital ➔ Introduction to team-based model of care and integrated care – – Assessment of the bio-psychosocial-spiritual needs – Symptom assessment and management. – Family meetings – Initiation /furthering/completion of ACP discussions How do we make sure that there is continuity?
Access point - Ambulatory 21
Access Point – Ambulatory ➔ Stand alone or embedded in a specialty clinic ➔ Scheduled visits with flexibility for impromptu/’ urgents or right on time ’ ( particularly when integrated in specialty clinics ) ➔ Physician, Nurse, SW, APP ➔ Referred by physicians or self-referred. ➔ Initial assessment/consultation with pt/family ➔ Clinical scenario – Typically patient PPS >60% ➔ One time or scheduled follow-up (transition clinics) ➔ Payment: Typically FFS/episodic payment 22
Access Point – Ambulatory Consultation Process Metrics & Outcomes: • Comprehensive Assessments completed – Bio-psychosocial-spiritual ➔ Introduction to team-based model of care ➔ Initiation or furthering of ACP discussions ➔ Examples of Metrics & Outcomes: – Written +/- verbal communication to consulting professional(s) & stakeholders – Time from request to fulfillment – ACP conversation occurred/completed – Conversion to hospice for eligible patients – Medication review and interaction analysis performed – PQRS – Patient/family satisfaction – Referring professional satisfaction – Utilization patterns (ED, Hospital)
Early Palliative Care for Patients with Metastatic Non-Small Cell Lung Cancer Temel JS et al. N Engl J Med 2010;363:733-742
Patient-Centered Medical Home Coordinated Care Model Featuring Palliative Med / Advanced Illness Services Component Specialty CM PC Expertise Twaddell, Twaddle 2012 25
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