An Extra Layer of Outpatient Support: Lessons Learned from a “Without Walls” Palliative Care Program Leanne Yanni, MD Medical Director, Palliative Medicine Bon Secours Virginia Health System January 22, 2015
Join us for upcoming CAPC webinars and virtual office hours ➔ Webinar: – Healthcare Reform: Implications for Palliative Care Featured Presenter : Diane E. Meier, MD, FACP Thursday, January 29, 2015 | 1:30 - 2:30 pm ET ➔ Virtual Office Hours: – “Open Topics” session with Diane E. Meier, MD, FACP Friday, January 23,2015 | 10:00am - 11:00 am ET – Billing and RVU’s with Julie Pipke, CPC Friday, January 23,2015 | 4:00 - 5:00 pm ET – Clinical Protocols with Andrew E. Esch, MD, MBA Monday, January 26,2015 | 12:00 - 1:00 pm ET 2
An Extra Layer of Outpatient Support: Lessons Learned from a “Without Walls” Palliative Care Program Leanne Yanni, MD Medical Director, Palliative Medicine Bon Secours Virginia Health System January 22, 2015
Objectives ➔ Examine the structure of a “without walls” outpatient palliative care program ➔ List quality end of life measures that may be achieved as a result of outpatient palliative care ➔ Identify specific challenges faced in the first 2 years of program development ➔ Apply lessons learned while developing your own outpatient program 4
Bon Secours Virginia Health System ➔ Catholic Health System ➔ Medical Group – Operates Physician Practices, Home Health, and Hospice across Virginia – >600 providers; >165 locations – Accountable Care Organization ➔ Palliative Medicine is a specialty practice within the Medical Group ➔ 3 of 4 Richmond Hospitals TJC Certified (Advanced Certification for Palliative Care) 5
1 Why? Conduct Needs Assessment Vision ➔ A dynamic multi-faceted Palliative Medicine practice that provides care without walls to meet the needs of patients with serious illness Align Vision with Health System Priorities ➔ Mission to care for the “poor and dying” ➔ Accountable Care Organization ➔ Enhance quality / reduce cost “Provider Conscience” ➔ If we had just seen this patient before they were admitted. ➔ What is going to happen to this patient after discharge? 6
2 Outpatient: The 1 st Year Select the Venue ➔ Key = Medical Group Hospitals ➔ Set up as an Office Practice ➔ Shared space for 1 st year ➔ Patients by MD referral Office Other Facilities ➔ MD – RN Model Practice Offices Hospice Home 7
Outpatient Parameters Standardization Scheduling ➔ All appointments are 60 ➔ Referral process minutes ➔ Electronic Health Record Templates ➔ 6-8 patients/day ➔ ESAS ➔ NN in room with MD for ➔ Advance Care Planning all New and most Follow Up visits ➔ Discharge Folders – Brochure ➔ Weekly interdisciplinary – Opioid Safety team rounds (2+ hours) – After Visit Summary ➔ Visits outside of office day 8
Outpatient Referral Form 9
Outpatient Referral Form 10
ESAS and Advance Care Planning 11
Outpatient Parameters Full day at 2 sites • • Following ~ 80 patients • ~ 20 referrals/month • 3 New Appointments/Office Day Staffing Estimates Visits “without walls” at • FY12 FY13 FY14 FY15 other locations: Days 1 2 2-3 3-4 – Oncology Office MD 0.2 0.4 0.6 1.0 – Infusion Center NP 0 0 0 1 – Skilled Nursing RN 1 2 3 3 Facility/Nursing Home LPN 0.4 1 1 2 – Home +/- Hospice 12
Visits “Without Walls”: How? ➔ “Without Walls” based on: ➔ MD/NP “Flex” Scheduling – Urgency of clinical need – 8-12 non-inpatient weeks/year per provider – Patient functional status – Non-inpatient weeks cover (Can they get to other “without walls” need appointments?) – Patient convenience ➔ Administrative Time (Oncology/Infusion Center) – 0.5 of Medical Director • Concurrent Scheduling ➔ Full-Time Nurse ➔ Most Difficult Practitioner and Nurse – Chronic non-urgent visits Navigators 13
Staff Schedule 14
The Nurse Navigator ➔ Ambulatory Clinical Resource for Advanced Medical Home ➔ >65 Nurse Navigators (Embedded and Virtual) ➔ Intense training process including specific electronic health record documentation ➔ 3 full time Palliative Nurse Navigators – Medical Home budget 15
The Palliative Nurse Navigator ➔ Specifically selected and interviewed ➔ Specific competencies developed ➔ Communication skills emphasized ➔ Integrated into office visit model ➔ Trained in Advance Care Planning ➔ Assess and address needs in “without w alls” visits 16
Our Space 17
The Challenges
Identity Crisis ➔ Palliative Medicine flyer in Sent: Monday, October 06, 2014 10:24 AM To: BSR-Palliative Outpatient new patient folder to Subject: phone call describe services Caller: Mrs. H Patient: Mr. H DOB: XX-XX-XXXX Reason for call: wants to know if we will come to house to give him flu shot and pneumonia shot or does she need to take him to drugstore. Call directed to: Hope Call back number: XXX-XX-XXXX Best call back time: when you can pls Level of urgency: Patient told to bring to drug store and response: “Done….she sounded a little disappointed. She said “ I thought this was the sort of thing palliative would take care of” 19
Things We Tried that Didn’t Work Agreeing to see patients for the ➔ MD Referral Model wrong reasons… ➔ Shared/Rotated outpatient responsibilities with all Electronic Health Record Referral MDs/NPs Statements ➔ “Referral received. Patient will ➔ MD seeing patients receive phone call from Palliative wherever they are / at any Medicine within 24 hours to time schedule first available appointment." ➔ Following patients in Hospice that we don’t ➔ "Referral received. Patient not know well scheduled. Practice notified of other resources to support patient needs." 20
Case Example ➔ 58 year old with end stage COPD, multiple admissions over the past year ➔ Consulted inpatient while in ICU, began to work with patient and family on understanding illness and prognosis ➔ Over several weeks post-discharge, symptoms and needs escalated (calls, office & home visits with different staff members) ➔ Escalated to emergency, MD visit to home and patient died that night without Hospice 21
Recognizing the Need 22
Lesson Learned What is “failure”? Graph of Patient Need ➔ Any ED visit, Admission, or Death BEFORE 1st Touch after referral Prioritize urgent needs Patient Need ➔ All referrals reviewed by LPN ➔ Urgent referrals receive immediate call by RN ➔ Recognizing escalating need (see graph) 0 0 Lesson Time ➔ Too much chronicity depletes the ability to respond to urgent need 23
Outpatient Data Set Measure Result Data Set: Mean age 62.5 years ➔ Start to June 30, 2014 Female 172/284 (61%) ➔ 284 unique patients Mean Initial Palliative 63 Performance Scale Measuring: Cancer* 179/273 (66%) ➔ Demographics Advance Directives* 193/269 (72%) ➔ Descriptors Do Not Resuscitate 146/264 (55%) ➔ Quality measures Deaths 145/259 (56%) ➔ ESAS Hospice Referral* all: 112/284 (39%) died: 104/145 (72%) ➔ Outcomes Hospice Length of median 21.5 days ➔ ACP Stay ➔ Hospice LOS 24
Outpatient Visits by Year 1059 OP Visits February 2012 to June 30, 2014 Unique # Encounters Patients FY12 – 2nd 59 166 FY13 – 1st 76 206 FY13 – 2nd 72 200 FY14 – 1st 77 192 FY14 – 2nd 110 295 Note: Data derived from billing, all outpatient, non-hospice codes 25
Length of Follow up ➔ Most patients we follow for <30 days (160) ➔ Fewer patients we follow longer (~90) N ➔ 30 days to 6 months (60) ➔ 6 months to 1 year (~30) ➔ Even fewer we follow for >12 months (~20) Days between initial and most recent visit 26
Low and High Frequency Patients Low Frequency High Frequency Patients Patients ➔ 5 or more visits ➔ 1 or 2 visits ➔ Fewer patients (64) ➔ More patients (169) ➔ Lower % deaths (43%) ➔ Higher % deaths (61%) ➔ Slightly younger (60yrs) ➔ Slightly older (64yrs) ➔ Lower % cancer (53%) ➔ Higher % cancer (69%) 27
# Visits/Patient and Hospice LOS 50 45 44 41 41 40 Hospice Median LOS (days) 39 35 33 33 30 29 25 23 21 20 15 10 5 0 0 1 2 3 4 5 6 7 8 9 10 Minimum number of clinic visits (at least N visits) 28
Basic Financials 1/1/12- 9/1/12- 9/1/13- 8/31/12 8/31/13 6/30/14 Billed 69,217 154,725 156,765 Reimbursed 23,888 53,699 46,668 (33%) (35%) (30%) Number of 173 406 398 Visits 29
Outcomes ➔ Most patients have or complete an Advance Directive with us ➔ Most patients are dying with support of Hospice – High percentage are referred to our health system’s Hospice program ➔ Among all patients who die, their median LOS in Hospice is longer than the national average ➔ The more visits we with have with a patient, the longer their Hospice LOS 30
Next Steps ➔ Full-Time LCSW for outpatient services ➔ Integrated “Palliative Home Model” – Similar to “AIM” or “Bridge” programs – Previously in Home Health • Home Health limitations to provide service to patients not homebound or without skilled need – Hospice model (RN / LCSW) with provider support (MD / NP) – Developing triggers for referral based on “compassionate care” population ➔ Honoring Choices Virginia ACP Pilot – Richmond Community / Respecting Choices Model 31
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