Creating Robust Access to a Continuum of Supportive Care Martha L. - - PowerPoint PPT Presentation
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
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
➔ 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 Tuesday, March 15, 2016 from 1:30—2:30 PM ET Featured Presenter: Darrell Owens, DNP ➔ 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
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Visit
www.capc.org/ providers/ webinars-and- virtual-office-hours/
➔ 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’.
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Center to Advance Palliative Care 2014
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73 FR 32204, June 5, 2008 Medicare Hospice Conditions of Participation – Final Rule 6
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“Sick” in hospital, facilities, and home Chronic Well
Palliative Care
Manage Populations Well = keep them well Chronic = manage conditions Well → Sick → Well Well → Sick → Palliative Care Wellness Services:
Coaching
Psychology
The services and partnerships established in an integrated system of care meet the needs of the community throughout the entire health and wellness continuum.
Buxton; Twaddle 2014
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➔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
➔Increased risk of death: RR 1.6 among caregivers
reporting emotional strain
Schulz et al. JAMA 1999;282:2215.
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Function Death
(CHF, COPD often coupled with DM, ESRD etc)
Low
Multiple hospitalizations Death usually follows disease exacerbation
High
Hospital Rehab Home Health Repeat
CPC Time frame – particularly targeting the last year of life.
CbPC
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Function Death Low
Multiple hospitalizations Death usually follows disease exacerbation
High
Hospital Rehab Home Health Home Health Home Health
Hospice Care CbPC
CbPC Time frame – particularly targeting the last year or two of life.
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➔ Gomes B et al. Cochrane Database of Systematic Reviews.
2013, Issue 6, Art No:CD007760
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➔ 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
➔ Change the culture of medicine to be patient-family centered –
– Anticipating needs of patients and families
– Deliver care that is meaningful and goal-driven
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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.
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➔ Pro-actively monitoring of patient well-being such as via
➔ 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.
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➔ Consultative Model – hospital based team
➔ Triggered by acute hospitalization, diagnosis, decline,
➔ Hospital culture and bylaws typically shape the team
➔ Ideal – the Naylor Transition Model for those being
➔ Financial – typically FFS/episodic unless bundled
➔Introduction to team-based model of care and
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➔ Stand alone or embedded in a specialty clinic ➔ Scheduled visits with flexibility for
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
– 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)
Temel JS et al. N Engl J Med 2010;363:733-742
Featuring Palliative Med / Advanced Illness Services Component
Specialty CM PC Expertise
Twaddell, Twaddle 2012
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Neighborhood: Home-based Primary & Palliative Care Population Health, PCMH@Home & PCMH@Home Neighbor
HEALTH STATUS STRATIFICATION
Data and Analytics
Low-Risk Patients
(Acute episodic care / routine health maint)
Medium-Risk Patients (Multiple chronic
diseases)
High-Risk Patients (Chronic disease unstable or changing / recently hospitalized) Home-based Primary Care (PCMH@Home)
Home-based Palliative Care (PCMH@Home Neighbor)
symptom burden or advanced disease
Patient Centered Medical Home Ambulatory Practice
Patient Outcomes Clinical Pathways
preventative services - Triage for same day care Specialty Services
High Intensity Care Management
Functional Limitations Multiple Chronic Conditions
HCN*
*HCN=healthcare navigator
Ritchie, Twaddle 2015
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➔Life is a rapid-cycle Quality Improvement
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Avoiding the non-beneficial cycle of repeated ED and hospital visits People should not have to earn support by suffering first
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➔ Continuation of Care from Inpatient setting:
– Continued GOC/Care Preferences discussions & Decisions – Symptom management
➔ Team:
– APRN/PA from hospital team – Care Manager (SW or Geriatrics CM) – Facility Med Director/Primary Care Physician – Specialty level PC Access – via APP and consulting Specialty physician. – Chaplaincy from Facility
➔ Initial Assessment triggered by Risk or Event
– Thorough Assessment
– PPS typically <60% - possibility for improvement?
➔ ACP and logistics – who is the decision-maker?
– “What is the 3 AM plan?”
➔ Bundled payments, Shared Savings, Risk. Less so - PeMPM,.
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➔ Team: – APRN/PA – Care Manager (SW or Geriatrics CM) – Primary Care Physician – Specialty level PC Access – via APP and consulting HPM physician. – Chaplain – collaboration with primary Spiritual Care or provide. ➔ Initial Assessment triggered by Risk or Event – Thorough Assessment
– GOC/Care Preferences discussions & Decisions – Symptom management – PPS typically <70%. ➔ ACP and logistics – who is the decision-maker? – “What is the 3 AM plan?” ➔ Bundled payments, PeMPM, Shared Savings, Risk.
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➔ In private homes –strong primary care competencies are critical.
The Primary & Palliative Care Model becomes essential.
➔ Collaboration with Home Health – they leave, we stay (and we
episodically ask them back)
➔ Wound Care expertise ➔ High SW involvement & Behavioral Health ➔ Homemaker and CNA need is often high ➔ Coordination of Community resources. ➔ 24/7 responsiveness. ➔ Timely ‘reports’ to referring/co-managing professionals, including Health
Plans
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Triggered by ‘event’ vs. risk stratification
➔ Team
– Primary Care Physician – with specialty trained APRN, SW, Chaplaincy – Specialty level PC Access – via APRN and consulting Specialty HPM physician. – Care Manager – RN, SW, Geriatrics
➔ Thorough Assessment –
– Medical, psychosocial, spiritual. – Functional, nutritional, safety.
➔ Not required to be ‘homebound’ but documented medical necessity
depending on payment mechanism.
– PPS typically <50%.
➔ ACP and practical logistics – who is the decision-maker, where do
they live?
– “What is the 3 AM plan?”
➔ Increasingly: PeMPM, Shared Savings, Risk
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➔ Medication reconciliation, justification, safety, and management. ➔ Tele-health (ex: tele-monitoring, Video-visits, TapCloud….) ➔ Metrics & Outcomes
– Frequency of care team initiating calls vs. patient (proactive) – Symptom assessment & management – Falls assessment, Safety, Nutrition – ACP discussed, completed – ED/Hospitalization use – Engagement – Satisfaction – especially Caregiver – Hospice conversion for those eligible
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Population Health, PCMH@Home and PCMH@Home Neighbor: Home-based Primary Care and Palliative Care
HEALTH STATUS STRATIFICATION
Data and Analytics
Low-Risk Patients
(Acute episodic care / routine health maint)
Medium-Risk Patients (Multiple chronic
diseases)
High-Risk Patients (Chronic disease unstable or changing / recently hospitalized)
Home-based Primary Care (PCMH@Home)
Home-based Palliative Care (PCMH@Home Neighbor)
burden or advanced disease
Patient Centered Medical Home Ambulatory Practice
Patient Outcomes Clinical Pathways
preventative services - Triage for same day care Specialty Services
High Intensity Care Management
Functional Limitations Multiple Chronic Conditions
HCN*
*HCN=healthcare navigator
Ritchie, Twaddle 2015
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➔ Improve quality of life for patients and their
including pain, anxiety, depression, fatigue, and loss of appetite.
room utilization
Groh G, et al. J Palliat Med. 2013 Ornstein K et al. J Palliat Med. 2013
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➔ Patients who receive outpatient palliative care or
➔ Patients discharged to hospice care have a
Hospice – Hospital Partnerships Journal of Palliative Medicine, September 2014 e
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➔Knowledge of home-based care and
➔Expert IDT, seasoned in home-based care
➔Community-based, integrated into other
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➔ Different operational needs and processes. ➔ Different payment mechanisms. ➔ Financial tensions – what is the ROI? ➔ Perspective and expertise of Providers.
– Competencies and scope of practice of the team.
➔ Cultural dissonance with the goals of care. ➔ Corporate Practice of Medicine.
contract with Providers in a physician practice structure (or PCMH)
– typically do not or cannot contract directly with a hospice agency to provide HBPC – need separation.
Emerging evidence
➔ Increased Patient/family engagement and satisfaction –
“personalized medical care”
➔ Reduction in non-beneficial utilization of ED & Hospital and
associated burden.
➔ Proactive care management
– Fewer urgent visits prompted by patient/family distress. – Increase in ‘out-going’ pt-healthcare team interactions.
➔ Increase in Goals of Care discussions and securing of
ACP.
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➔ Improvement in Quality of Life, Goal-aligned care ➔ Impact on Survival ➔ Impact on caregiver stress and quality of life (present &
future health)
➔ Decrease non-beneficial care: Chemotherapy, ICU in last
14 days of life.
➔ Increased ALOS in hospice, median LOS in hospice. ➔ Death in the preferred setting
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➔ Increased Health system “loyalty” ➔ Enhanced Quality and decreased ‘waste’ ➔ Decreased unnecessary (non-beneficial) utilization
➔ Enhanced efficiencies in delivering pro-active,
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➔ “Feet on the Street” care delivery that is need driven to high
risk patients/families. Optimizing Care Management.
➔ Population Health:
– Transparency and increased understanding of overall cost throughout the continuum. (costs displacement to home) – Creation of sustainable systems of care through re-engineering the care delivery patterns.
➔ Re-allocation of ‘savings’ to unit of care and to patient/family
benefit, thus enhancing sustainability of supportive care continuum.
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“Sick” Chronic Well
Manage Populations Well = keep them well Chronic = manage conditions Well → Sick → Well Well → Sick → Palliative Care
Wellness Services:
Coaching
The services and partnerships established in an integrated system of care meet the needs of the community throughout the entire health and wellness continuum.
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Scherer
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➔ Who? – identify a discrete ‘population’ where we could launch
a pilot?
➔ Where? Where do we want to start – and which settings will
we connect in the continuum?
➔ With Whom?
– Which Physician practice is super fun to work with and willing to innovate?? – Which Home Health agency might partner – identify high risk patients that we could support with CbPC?
➔ How will we do this? How will we know we’re successful?
(measure!)
➔ How will this be sustained – what is the financial
underpinning?
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➔
CAPC Online courses:
– Course 501: INTRODUCTION TO PALLIATIVE CARE IN THE COMMUNITY – Course 502: NEEDS ASSESSMENT: ENSURING SUCCESSFUL COMMUNITY-BASED PALLIATIVE CARE – Course 503A: OFFICE-BASED PALLIATIVE CARE PROGRAM DESIGN – COMING SOON: Course 503B: HOME-BASED PALLIATIVE CARE PROGRAM DESIGN – Course 504: BUILDING THE BUSINESS PLAN FOR YOUR COMMUNITY-BASED PALLIATIVE CARE PROGRAM
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Technical Assistance:
– IPAL OP (outpatient toolkit) - https://central.capc.org/eco_player.php?id=116 – Community Based Palliative Care module - https://central.capc.org/eco_player.php?id=270 – Home-Based module - https://central.capc.org/eco_player.php?id=44 – Long Term Care module - https://central.capc.org/eco_player.php?id=87&cid=278&pid=278 – Office Based module - https://central.capc.org/eco_player.php?id=103&cid=278&pid=278
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2016 CAPC National Seminar (CbPc is a major theme for this year’s Seminar!)
– Pre-Con Boot Camp focusing on Palliative Care in Community Settings: Home, Office/Clinic and Long Term Care – When: October 26–29, 2016 – Where: Rosen Centre Hotel - Orlando, FL
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➔ For a calendar of CAPC events, including upcoming
– https://www.capc.org/providers/webinars-and-virtual-office-hours/
➔ Today’s webinar recording can be found in CAPC
Central under ‘Webinars: Community Based
– https://central.capc.org/eco_player.php?id=186
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