Post on 22-Aug-2020
Rural Innovation in Advanced
Illness Care: Programs and
Policy Opportunities
Facilitator: Jane Pederson, MD, MS
Chief Medical Quality Officer
Stratis Health
National Summit on Advanced Illness Care
Minneapolis, MN
October 10, 2019
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Session overview • Identify unique rural challenges and
opportunities related to advanced illness care
– Karla Weng, Stratis Health
• Learn about Innovative Rural Models
– Julie Benson, Lakewood Health System
– “B” Brian Mistler, Resolution Care
– Lori Vrolson, Central MN Council on Aging
• Discuss policy considerations that impact rural
innovation in meeting advance illness care
needs locally
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Stratis Health• Independent, nonprofit organization founded in 1971
and based in Minnesota
– Mission: Lead collaboration and innovation in health care
quality and safety, and serve as a trusted expert in
facilitating improvement for people and communities
• Core expertise: design and implement improvement
initiatives across the continuum of care
– Funded by government contracts and private grants
– Work at the intersection of research, policy, and practice
• Rural health and serious illness care are long-
standing organizational priorities
– Have worked with more than 40 rural communities in
multiple states to develop palliative care programs
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What is rural?
• 97% of U.S. land mass is rural
• 19.3% of the population lives in rural
(approx. 60 million people)1
• Multiple formal definitions, but often
based on perception
– Am I Rural? 2
– Frontier: Fewer than 7 people per square
mile
1 US Census Bureau: What is Rural America2 Rural Health Information Hub (www.ruralhealthinfo.com)
Source: https://www.census.gov/content/dam/Census/library/publications/2016/acs/acsgeo-1.pdf
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Rural Populations
• Older, Sicker, Poorer:
– Rural median age is 51 compared to urban
median age of 45.1
– Rural age-adjusted, all-cause mortality per
100,000 persons is 830.5 compared to urban
mortality of 703.5.2
– Rural median household income is $46,000
compared to urban of $62,000.3
1U.S. Census Bureau, 2011-2015. Measuring America.
www.census.gov/content/dam/Census/library/visualizations/2016/comm/acs-rural-urban.pdf2 North Carolina RHRC (2017). Rural Health Snapshot (2017).
https://www.ruralhealthresearch.org/publications/11103 U.S. Census Bureau, 2009-2016. Small Area Income and Poverty Estimates.
www.census.gov/programs-surveys/saipe.html
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Rural Healthcare Delivery:
Rural is not small urbanRural healthcare organizations have special federal
designations and payment programs:
• Critical Access Hospitals (CAH) – 1350, in 45 states• 25 beds or less, 96 hour average length of stay
• 35-miles from hospitals (can vary)
• Rural Health Clinics (RHC) – about 4500, in 45 states• Non-urban
• Health Care Professional Shortage or Medically Underserved
Area
• Health Centers (FQHC, or other designation) • Approximately 1 in 5 rural residents are served by the Health
Center Program
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Rural Healthcare Delivery:
Rural is not small urban
• Access to health care services often
limited in rural, including services which
are important in caring for those with
serious illness:
• Home Care
• Hospice
• Mental Health, Substance Abuse
From: RHIhub Data Explorer
From: RHIhub Data Explorer
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Rural Challenges for Advanced
Illness Care• Chronic Workforce Shortages
• Financial Challenges
– CAHs, RHCs, and FQHCs are typically exempt from Medicare
Value-Based Reimbursement programs (e.g., Hospital
Readmissions Reduction Program)
– Predominate payers are Medicare and Medicaid
• Lower Medicare Advantage penetration: In 2018, 24% in rural
compared to 34% overall1
– 113 Rural Hospital closures since 2010 (and many more at risk)
• Transportation, social isolation, access to healthy foods
• Lack of research and models specifically for rural care
delivery
1RUPRI Center for Rural Health Policy Analysis Medicare Advantage Enrollment 2 North Carolina Rural Health Research Program Hospital Closures
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Rural Opportunities• Networks and relationships are often strong and well
connected
– Personal relationships
– Organizational connections
• Training is available to enhance rural practitioner
skills, and allows for care that builds on long-term
provider and patient relationships.
• Many needs related to advanced illness care can be
met locally, which is typically the preference of
patients and families
– Telehealth or other consulting arrangements can support
access for specialty needs
• National standards/best practices are relevant
– Flexibility and creativity to support implementation
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Community Capacity Focused Formula
for Program Development
Community data
and goals
Access to national
standards & resources
Stakeholder
input
Facilitated planning
process
A program designed
for your community
Community action
plan
Rural Palliative Care Resource Center
www.stratishealth.org/palcare
Staples, Minnesota
Lakewood Health System
“
”
We must start to think of the patientand the family as the sun, and the healthcare delivery system as one of the many
planets that orbits around the sun.
Home-based palliative care is the future ofquality medical care for the sickest and
most complex patients and their families
Diane E. Meier, MD, FACPDirector, Center to Advance Palliative Care
Julie Benson, MD FAAFPFamily Physician – 22 yearsMedical DirectorHospice and Palliative Medicine
Population 2,974Serving 38,000Bordering 4 counties
Lakewood Health System
Staples
Critical Access HospitalRural Health Clinic
5 primary care clinicsSenior Services
Long Term Care 2 Assisted Living facilitiesBehavioral Health Unit
Hospice & Home CareAmbulance & TransportationPharmacyDurable Medical equipment
3 of 4 counties among the poorest in the
state
More than 15% of population living in
poverty
Demographics by age
https://mn.gov/admin/assets/greater-mn-refined-and-revisited-msdc-jan2017_tcm36-273216.pdf
More older people in poverty
https://mn.gov/admin/assets/greater-mn-refined-and-revisited-msdc-jan2017_tcm36-273216.pdf
90%
10%How we die• Of all deaths, only a few
people (< 10%) die suddenly and unexpectedly.
• Most people (> 90%) die after a period of illness, with gradual deterioration until an active dying phase at the end of life.
Institute for Clinical Systems Improvement
Palliative Care
Palliative care is specialized medical care for people with serious illnesses. It is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis.
CAPC - Center to Advance Palliative Care
Models of Palliative Care
Venues of Care
Institutional-based
Hospitals
Long term care centers
Assisted Living
Community-based
Clinic
Home care
Street/Shelter
Episodes of Care
Consultative
Clinic
Hospital
LTC - Long term care
Longitudinal
Homecare
Clinic
LTC - Long term care
Assisted Living
Key Concept
Palliative care can be:
Primary Palliative Care: Best practices during the routine care of all patients with serious or life-threatening illness
Specialist Palliative Care: Comprehensive, interdisciplinary care by professionals with special competencies
Primary Palliative Care
Natural extension of family medicine
From birth to death
Coordinate complicated multi-specialty care
Long term relationships with patients
The Interdisciplinary Team (IDT)
• RN Case Managers• MD – family physician/HPM• Social Workers• Chaplain• Pharmacist• Care Center RN/social worker• CNAs• Volunteers• Therapists – PT/OT/SLP/massage• Respiratory Therapist
Homecare & Hospice team
Any homecare client who has serious illness and not appropriate for hospice is screened for palliative care services
Recent readmissions, decreasing PPS, increased symptom burden, social service needs, surprise question
RN is case manager
Meet as IDT after hospice IDT to discuss
Chaplain, social services and pharmacy services are not billed at this time
Home-based Palliative Care
Care Center RNs
Any care center resident who has serious illness and not appropriate for hospice is screened for palliative care services
Recent readmissions, decreasing PPS, increased symptom burden, social service needs, surprise question, family conflict
RN is case manager
IDTs meets with CC RNs to review status and update care plan
Chaplain, social services and pharmacy services are not billed at this time
Long Term Care-based Palliative Care
Clinic-based RN case management
Any LHS patient who has a serious illness and not appropriate for homecare or hospice is eligible for palliative care services
Recent readmissions, decreasing PPS, increased symptom burden, social service needs, surprise question (no universal screening tool being used yet)
Working toward embedding in Oncology
RN is case manager
Telephonic contact and when in clinic/ED/hospital/infusion therapy
IDT meets every 2 weeks to review care plans and update team; schedule MD home/clinic visits
Chaplain, social services and pharmacy services are not billed at this time
Community-Based Palliative Care
Palliative Care
Meet with patients and their families whenever possible on admission
IDT meets every 2 weeks to review care plans and update staff on any changes
Discuss hospice information visit
Discuss referral to hospice when appropriate
Palliative Care
Frequent phone calls to staff and family
Meet with patients in ED or hospital if able
Serve as medical interpreters as needed
Palliative Care
Assist with documenting goals of care
Assist with documenting Advance Directives
Family meetings
Phone answered 24 hours a day
Palliative Care to Hospice Care
Educate about hospice
Assist transition to hospice when appropriate
Remain involved as needed for family support
Bereavement care
Grief support groups
Results
Increased referrals to hospice and longer stays
Decreased ED visits
Reduced readmissions
Increased patient and family satisfaction
Increased staff satisfaction (Quadruple Aim)
Challenges
Reduced hospice referrals in some populations
Transitions between service lines
Transitions to paying services lines
Patients and families becoming attached to staff and not wanting to transition
Reimbursement
Data collection
Rural Considerations
Leverage resources already in place
Customize RN case management
Cross-train staff in
Medical Home
Care center
Hospital
ED
Clinic
The Future of Technology toImprove Rural Healthcare
Resource Access & Greater Collaboration
C-TAC National Summit on Advanced Illness Care
Minneapolis, MN
October 10, 2019
“B” Mistler, Ph.D.b@resolutioncare.com
ResolutionCare
Michael Fratkin, M.D.
Founder & CEO@MichaelDFratkin
michael@resolutioncare.com
“B” Brian Mistler, Ph.D.
Chief Operating Officer
b@resolutioncare.com
Today, in California alone, more than 500,000 people
are clinically eligible for palliative care.
Less than 1% of them have access to it.
OurMission
To bring capable,
compassionate care
to everyone,
everywhere in the
face of serious illness.
SensePlace
300 miles/ 5 hrs from
San Francisco
Same distance as
Washington DC
to Greensboro N.C.
of
50 million Americans live in rural areas.
27% of all Americans prefer a rural area.
Major city population including NYC, LA, & Chicago declining.
Sources: Ingraham, Christopher. “Americans Say There’s Not Much Appeal to Big-City Living. Why Do so Many of Us Live There?” Washington Post, December 18,
2018, sec. Business. | Smarsh, Sarah. “Opinion Something Special Is Happening in Rural America.” The New York Times, September 17, 2019, sec. Opinion.
Considerations forRural
Higher age-adjusted death rates made worse by poverty
Higher rates of of chronic illness
Multiple Chronic illnesses are present more often
Sources: National Center for Health Statistics. Health, United States, 2016: With Chartbook on Long-term Trends in Health. Hyattsville, MD. 2017. | Moy E, Garcia MC,
Bastian B, et al. Leading Causes of Death in Nonmetropolitan and Metropolitan Areas — United States, 1999–2014. MMWR Surveill Summ 2017;66(No. SS-1):1–8.
Considerations forRural & Low Income
Technological innovation to support collaboration & care
Lack of access to nearby medical services
Poverty impacting the social correlates of health
Technology means
National networks for collaboration and support.
Measurement that is clear and available in realtime,
Value-based models using interdisciplinary teams,
Maximize resources e.g. internet & peer mentoring,
Telehealth that is transparent & people-centered,
Benefits of
Telemedicine
▪ 35% of people we care for utilizing
telemedicine from their home or a non-
clinical outpatient setting.
▪ Patients benefit from the ability to access a
team of experts from their home, as travel
can be a challenge.
▪ Clinical team saves time & increases their
impact to help more people.
▪ Organization attracts top talent to work
anywhere… critical for growth & to transcend
provider shortages.
Sources: Lupu D, on behalf of the AAHPM Workforce Task Force. Estimate of Current Hospice and Palliative Medicine Workforce Shortage. J Pain Symptom Manage.
2010 Dec 6; 40(6):899-911.
Interdisciplinary
Team Effort
Move from fee-per-service to capitated payments enables full spectrum team care and efficient resource leverage
Interdisciplinary care
delivered to the home,
directly involving patient,
family and caregivers.
Telehealth technology enables a networked demand-supply model, with geographic reach and layered services
Technolog
y
Value Based Community
Care
Coordinator
Social
Worker
Spiritual
SupportNurse
Physician
Community
Health Worker
Patient &
Family
Evidence of Impact on Quality and Cost:Telemedicine Patient Survey Data
▪ 88% like using telemedicine.
“Video conferencing takes the delay out of my care.”
“I don’t have to leave my home for check-ins and minor issues.”
“I was surprised how there was no delay. It was quicker because there was no driving to the
doctor’s office, no extra wait time
to get my mom’s meds.”
▪ Four out of five people had no concerns with the majority of their care being provided via telemedicine.
*Results from internal survey March 2017
ResolutionCare
▪ Cost of care for the three months before and after starting palliative care
services was 33-50% less for pilot participants.
▪ Patients were admitted 40% less to the hospital in the last 30 days of life than
non-study patients.
▪ Demonstrated ≈$3 in hospital cost savings for every $1 spent on the
palliative care program.
Telehealth works for clients, clinicians, consequences, and costs.
Evidence of Impact on Quality and Cost:Partnership Healthplan of California Partners in Palliative Care
▪ 95% of participants in pilot study reported they received the best possible care from their Palliative
Care team and would recommend the team to others.
ResolutionCare
Benefits of telehealth
Higher needs of populations
Technologies growth is key
Interdisciplinary team driven
Model works and saves $$
Future of rural populations
The future is exciting...
Key Takeaways
Sources: Images from Chemistry World, Synthego, and from “Rob Knott on The Future of NHS Procurement.” Spend Matters, August 24, 2017.
http://spendmatters.com/uk/rob-knott-future-nhs-procurement/. | Bondade, Navin. “The New AI Toilets Will Scan Your Poop To Diagnose Your Ailments.” Techgrabyte
(blog), September 27, 2019. https://techgrabyte.com/ai-toilets-scan-poop-diagnose-ailments/.
.
Sources: Oculus Connect.
Sources: Tesla
Sources: “Sequoia Sempervirens.” In Wikipedia, September 24, 2019. https://en.wikipedia.org/w/index.php?title=Sequoia_sempervirens&old id=917680331.
THANK YOUFor more information, please contact:
ResolutionCare
Dr. “B” Brian Mistler
b@resolutioncare.com
Dr. Michael Fratkin
michael@resolutioncare.com
Silos to circles
Reducing Silos in
Aging Services: A New
Collaborative Model to
Foster Healthy Aging
Silos to Circles
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Identified needs of older adults in
our community along with current
assets and gaps
2016 Planning Process
1
2
3
Articulated and agreed upon
shared community goals
Outlined a plan that could help us implement the shared goals
Pooled rural community plans
together and approached a funder for implementation
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Rural Pilots
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Common Hub Elements
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The Conversation Continues
➢2016 Conversations
➢Reconvene October 2017
➢Establish Coalition- February 2018
➢Implement Work Plan Goals
Keeping It LocalOver 30 local community members and providers
Community Members County Public Health (SHIP)
County Health and Human
Services-Aging & Disabilities
Community Education
Health Systems Home Care and Hospice
Services
Food Services and Assistance Local Businesses
Regional Area Agency on
Aging- Senior LinkAge Line
Regional Libraries
Senior Living Communities Senior Service Agencies
Mission: to increase awareness of, access to, and satisfaction with, existing services and health resources in the community. To strengthen the relationships between senior community members, service providers, and health systems to benefit older adults and their caregivers.
Communities Served: Southern Chisago County Including: North Branch, Chisago Lakes (Lindstrom, Chisago City, Taylors Falls, Center City, Schafer), North Branch and Wyoming
Resource Hub and Education
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Chisago Age Well Volunteer Community Connectors
Spreading the Message
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LeilaniRebecca
Keri
What does the community think?
What have you learned from the Chisago Age Well?
That there are so many programs out there, so much information
and resources available. Everyone works together as a team,
one united front, to assist in any way possible, which I find so refreshing!
I have picked up something new at every single meeting.
Knowledge is power!
How would you describe the benefits of the project for the local
communities?
Absolutely wonderful! One realizes they are not alone with an aging parent,
an aging spouse, becoming a senior citizen yourself. One is not judged.
Thanks for all you do for Seniors, we are all better for your kindness.
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Website
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QuestionsContact
Terri Foley, LeadingAgeMN Foundation
terri@leadingagemn.org
Lori Vrolson, Central MN Council on Aging
lori@cmcoa.org
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Discussion
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Questions?
Jane Pederson, MD, MS
952-853-857
jpederson@stratishealth.org
Rural Palliative Care Resource Center www.stratishealth.org/palcare
Stratis Health is a nonprofit organization that
leads collaboration and innovation in health
care quality and safety, and serves as a trusted
expert in facilitating improvement for people and
communities.