High costbut low health 1 The Determinants of a Health Population - - PDF document

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Advanced Disease Coordination

Jeff Thompson, MD Chief Executive Officer

The constant complaint…

High cost…but low health

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The Determinants of a Health Population

Health Care 20% Social and Economic 40% Healthy Behavior 30%

Physical Environment 10%

But the U.S. spends 80% of resources here And 20% in all other areas combined

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To begin, we must…

Admit and recognize that patient/family

• utcomes are not as good as they might

be…that we might do better. Face the Brutal Facts – Jim Collins

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Lack of Advance Care Planning Results In…

• Great moral and emotional distress for families

and providers.

• Demands heavy time commitments for health

professionals to work through decisions.

• Creates conflicts among health professionals.
• Uses significant health resources while decisions

were sorted out.

• Leaves everyone with moral uncertainty about

the choices made.

A few early observations…

• Simply getting patients to fill out statutory

documents like living wills would not help.

• Simply telling health professionals that they

should talk to patients or they should document patient plans would not work.

• Stressing these two processes would not

improve the system.

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Four Key Components of Good Advance Care Planning Systems

• Community engagement
• Professional education and skills training
• A system that honors wishes
• Continuous quality improvement

Advanced Disease Coordination Attributes

NOT focused on limitation of treatment, but is focused on:

• Helping patient and family understand chronic

illness

• Helping guide subsequent care from an

informed vantage point

• Accompanying and supporting patient, family

and staff through subsequent journey

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Last Steps

ACP: Establish a specific plan of care expressed in medical

• rders using the POLST

paradigm. Adults whom it would not be a surprise if they died in the next 12 months.

Next Steps (DS‐ACP)

ACP: Determine what goals

• f treatment should be

followed if complications result in “bad” outcomes. Adults with progressive, life‐limiting illness, suffering frequent complications

First Steps

ACP: Create POAHC and consider when a serious neurological injury would change goals

• f treatment.

Healthy adults between ages 55 and 65.

Stages of Advance Care Planning Over the Life Time of Adults

Study by Fried, Bradley, Towle and Allore (2002)

Three factors that influence treatment decision making

• 1. treatment burden
• 2. treatment outcome
• 3. the likelihood of the outcome

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For the Patient

“The discussion, not the list [written plan], was what matter most…it was that simple – and that complicated.” A statement made about Gundersen’s advance care planning work by Atul Gawande, MD in “Letting Go” The New Yorker, August 2, 2010.

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“One of the most intractable...politically charged…third rail issues…put a screeching half to the much needed public conversation.”

How to Die In America: Welcome to La Crosse, WI Forbes, 9/23/14

Authors include:

AARP Aetna Center to Advanced Palliative Care Dartmouth National Palliative Care Research Center Senator Warner, D‐Va Secretary Leavitt, R‐Ut Sutter Health

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“We all die. A fundamental question is do we want to have a say in how we live.”

—Jeffrey Thompson, MD

Having Your Own Say

Institute of Medicine 2014 Report: Current State

• Who have made their wishes

clear?

• Do clinicians follow patients’

previously expressed wishes?

• Does Advance Care Planning

affect patient or caregiver

• utcomes?
• Does Advance Care Planning

affect healthcare costs?

Dying In America: Improving Quality and Honoring Individual Preferences Near the End of Life, Institute of Medicine (2014, pgs 3‐8 to 3‐18)

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Institute of Medicine 2014 Report: Model Advance Care Planning Initiatives

• Electronic Health Record
• POLST
• Respecting Choices

Dying In America: Improving Quality and Honoring Individual Preferences Near the End of Life, Institute of Medicine (2014, pgs 3‐42 to 3‐52)

Gundersen Health System Model for End‐of‐Life Care

• Person/patient‐ and family‐centered care
• Advance care planning
• Care coordination
• Palliative
• Hospice
• Organ & tissue donation
• Bereavement

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Primary Care Advanced Disease Coordination

Advance Advance Care Planning Next Steps

Continuum of Care

Specialty Clinics Disease Management

(CHF, Nephrology, Pulmonary, Hem‐ Onc) Additional Services Organ/Tissue Donation Additional Services Social Services Spirituality Bereavement Organ/Tissue Donation Palliative Care Nursing Coordination of Care Hospice

La Crosse Compared to National Averages

10 20 30 40 50 60 70 80 90 100 % of severely or terminally ill patient with an advance care plan % of physicians who are aware of the advance care plan Consistency between known care plan and treatment provided La Crosse Nationally

22 J Am Geriatr Soc 2010;58:1249–1255.

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GHS

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Ask your CFO

Do you really want to be balancing your books by over treating unsuspecting and unwilling seniors?

How we do it

Higher Quality, Lower Cost for Medicare Patients System Characteristics

• Living the Mission of not‐for‐profit culture
• Broad Integrated System
• Physician Leadership/Engagement
• Process Change; PDSA/Lean, etc.
• Hire people (esp. MD’s) who believe the mission

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How we do it

Higher Quality, Lower Cost for Medicare Patients Patient Level Characteristics

• Care Management/Coordination of Care
• Availability of EHR
• Short LOS
• Use of Generics
• Advance Planning

Primary Care Advanced Disease Coordination

Advance Advance Care Planning Next Steps

Continuum of Care

Specialty Clinics Disease Management

(CHF, Nephrology, Pulmonary, Hem‐ Onc) Additional Services Organ/Tissue Donation Additional Services Social Services Spirituality Bereavement Organ/Tissue Donation Palliative Care Nursing Coordination of Care Hospice

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What Is Palliative Care

The goal of palliative care is to ease the physical, emotional, and spiritual suffering of people with progressive disease or medical

• conditions. Palliative care focuses on quality
• f life and comfort.

Palliative Care

Palliative care can be provided in the clinic or hospital, at home, or in a nursing home. The palliative care team works closely with the patient’s primary physician to provide treatment options for the following:

• Pain
• Fatigue
• Shortness of breath
• Nausea
• Loss of appetite
• The palliative care team also addresses concerns such as depression, loss of

control, anxiety, loneliness, and fear of being a burden or dying.

• Bereavement

“Symptom management and support through transitions in life.”

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Specialist Palliative Care Elements:

• Patient‐centered, family orientated
• Expert symptom management
• Excellence in communication and care

planning

Primary impact is on the patient

A. Prevention and relief of pain and other symptoms B. Clarification of prognosis and goals of care C. Changes to kind and setting of care provided

Outcome Measures: Secondary impact is on those around patient

D. Family – less confused, more satisfied, better coping E. Nurses, doctors – appreciate specialist help, less distress

Tertiary impact is on institutions, systems, payors

F. Providers and payors – Fiscal and operational changes

• Frequency, intensity, duration, costs, revenues
• Different settings, entities

G. Assist hospital or other provider/setting with overall quality and performance metrics

Institutions & Systems Social Patient

Cassel 2013

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Conceptual Shift for Palliative Care

Medicare Hospice Benefit

Life Prolonging Care

Old Palliative Care

Hospice Care

Life Prolonging Care

New

Dx Death

• pyright

enter to dvance alliative are eproduction by permission only

C 2008 C A P C . R .

Four Takeaways from La Crosse

• 1. Conversations and relationships matter.
• 2. Innovation in end‐of‐life care requires highly

personalized local solutions.

• 3. While the end‐of‐life advance directive

document is standardized, the process for each patient and family will be unique and intimate.

• 4. Accessibility of records.

How to Die In America: Welcome to La Crosse, WI Forbes, 9/23/14

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The Reach of

48 United States Canada Spain Singapore Germany The Netherlands Australia

Advance Care Planning Implementation

Futurescan 2015

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Jeff Thompson, MD

Chief Executive Officer

jethomps@gundersenhealth.org www.gundersenhealth.org

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Appendix Today’s Problem

• Most healthcare dollars are spent on a small

percentage of beneficiaries who have complex chronic conditions and/or advanced illness.

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What Is Needed Is More Complicated Than a Form or Chart

• We need to create and implement a whole new

set of clinical practices…and advance care planning microsystem.

• An ACP microsystem is an organized group of

people who have the role and responsibility to elicit, to understand, to document and to honor a patient’s preferences about future medical care.

• “It takes a whole health system to honor one

patient’s preference.”

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Strategies to Engage Others in End

• f Life Discussions
• Try to understand the history, culture, and dynamics
• View the work as an “improvement project” and use

systematic methods

• Identify key champions
• Pay attention to what people are saying
• Listen to stories
• Keep people informed and involved
• Identify informal and formal networks and resources

Potential With Medicare?

• Some facts

– ≈ $500‐600 Billion annual spend (FFS, Part A and B) – 5‐6% of Medicare beneficiaries die each year – 27‐28% of Medicare spending on last year of life

• So that is about $125B ‐ 162B in last year
• Could that be reduced by 25% ($31 ‐ 40 Billion) and also

improve the quality of life for patients, families and providers? Our data says “Yes”

SOURCES: The Board of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Annual report 2014 [Internet]. 2014 July 28 [cited 2014 Sept 25]. Available from: http://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Statistics‐Trends‐and‐ Reports/ReportsTrustFunds/Trustees‐Reports‐Items/2012‐ 2014.html?DLPage=1&DLSort=0&DLSortDir=descending Centers for Medicare and Medicaid Services. 2013 CMS statistics. [Internet] 2013 Aug [cited 2014 Sept 25]. Available from: http://dnav.cms.gov/

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How About State‐funded Medicaid Cost?

• About $200B annual spend
• Using the Medicare analysis ratios, 27% in last year
• f life = $54B
• Could that be reduced by 25% 13B?

How About VA Costs?

• VA costs are estimated to be 40% more than

Medicare in last year of life How About Other Commercial Insurance Companies? Those patients with PCS involvement were found to have statistically significantly less average total hospital charge, average total radiology charge, and average total Physician charges.

$22,967 $16,165 $2,579 $2,060 $211 $156 $3,052 $2,435 $0 $5,000 $10,000 $15,000 $20,000 $25,000 Total Hospital Total Pharmacy Total Radiology Total Lab Non-PCS PCS

Palliative Care Service (PCS)

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The Standard Approach to Advance Directives

• Providing information to adults/patients about their legal

rights to refuse treatment and to complete a statutory document like a living will or power of attorney for health care

• Asking patients if they have an advance directive at admission

to hospitals, nursing homes, and hospice programs

• Encouraging the completion of statutory documents that

either have no instructions or instructions that have little clinical value

• Asking simplistic questions like: If your heart stops, should we

do CPR?

Cost of Care in the Last Two Years of Life

Hospital Inpatient Days per Descendent, Last Two Years, 2010 Total Medicare Reimbursement of Care/Patient During Last 2 Years of Life, 2010

Gundersen Lutheran 9.7 $48,771 Marshfield/St. Josephs 18.9 $67,734 University of Wisconsin 17.1 $79,372 Cleveland Clinic 25.5 $86,279 Mayo Clinic 17.5 $72,444 UCLA 28.5 $137,248 New York University Medical Center 32.3 $131,624 National Average 20.3 $79,337 10th Percentile 14.4 $58,866

*Source: Based on 2007 Dartmouth Atlas Study Methodology. The Dartmouth Atlas methodology examines hospital inpatient care for the last two years of a Medicare patient’s life. http://www.dartmouthatlas.org/data/table.aspx?ind=23&tf=23&ch=1&loc=5125,7343,7776,4434,7413,62 57,7760,7692&loct=5&fmt=45 2007 average total cost of care was $60,694. 2010 average total cost increased to $79,337

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La Crosse Community AD Collaborative

• In 1991 the presidents of Gundersen Clinic,

Lutheran Hospital, Skemp Clinic and Franciscan Hospital agreed to develop a community advance directive program

• ADs in the La Crosse area was exactly the same as

ALL other reports in the USA: 15%

• They established the La Crosse Area Advance

Directive Task Force and provided support for this group to develop a community wide advance care planning system that would have wide community support

Palliative Care

• Palliative care is whole person care for patients

with advanced disease and their families.

• It brings hospice principles out into the

population of patients not yet ready for hospice

• This is a large population…

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Institute of Medicine 2014 Report

“One of the best‐known advance directive initiatives is Respecting Choices, a community wide effort begun in 1991 in La Crosse, Wisconsin”