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Transcript of 1 Replication of a Home-Based Palliative Care Program: A Multi-site Study Susan Enguidanos, PhD...
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Replication of a Home-Based Replication of a Home-Based Palliative Care Program: Palliative Care Program:
A Multi-site StudyA Multi-site Study
Susan Enguidanos, PhDSusan Enguidanos, PhDDirector, Research CenterDirector, Research Center
Partners in Care FoundationPartners in Care Foundation
Assistant ProfessorAssistant Professor
Davis School of GerontologyDavis School of Gerontology
University of Southern CaliforniaUniversity of Southern [email protected]@aol.com
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Goals of DiscussionGoals of Discussion
Brief overview of End-of-Life CareBrief overview of End-of-Life Care Introduction to Home-based Palliative Introduction to Home-based Palliative
CareCare Evidence of EffectivenessEvidence of Effectiveness Policy ImplicationsPolicy Implications Next StepsNext Steps
33
Definition of TermsDefinition of Terms
Hospice: Medicare benefit for last 6 Hospice: Medicare benefit for last 6 months of life for those with terminal months of life for those with terminal illness.illness.
Palliative Care: pain and symptom Palliative Care: pain and symptom relief provided for those with serious relief provided for those with serious illness. illness.
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Challenges in ProvidingChallenges in ProvidingEnd-of-Life CareEnd-of-Life Care
Fragmentation of careFragmentation of care Aging populationAging population Costs of medical careCosts of medical care
• 25% of Medicare revenue is spent on 5% who 25% of Medicare revenue is spent on 5% who die each year die each year
• Average cost of care in last year of life is Average cost of care in last year of life is $26,000 (1996 costs)$26,000 (1996 costs)
• Average cost of care in last 2 years $ 58,000Average cost of care in last 2 years $ 58,000
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Relieve suffering (hospice)Relieve suffering (hospice)
Curative / life-prolonging therapyCurative / life-prolonging therapy
Presentation Death
A dichotomous intentA dichotomous intent
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Barriers to HospiceBarriers to Hospice
Systemic Physician Patient
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Impact of BarriersImpact of Barriers
Patients are referred late to Hospice• Median length of stay=22 days
Patients often die in pain Patient EOL preferences are not
considered Patients die in the hospital (60%)
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Home Based Palliative Care ModelHome Based Palliative Care Model Bridge traditional medical care and Bridge traditional medical care and
Hospice careHospice care In home end-of-life care for patients In home end-of-life care for patients
with one year life expectancywith one year life expectancy Blended model of careBlended model of care Shift focus of care from hospital to Shift focus of care from hospital to
homehome
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HospiceHospicePalliative carePalliative care
Curative / remissive therapyCurative / remissive therapy
Presentation Death
1010
Core Components Core Components of Palliative Careof Palliative Care
Interdisciplinary team Interdisciplinary team Physical, medical, psychological, Physical, medical, psychological,
social & spiritual supportsocial & spiritual support Care provided in homeCare provided in home Patient & family education & Patient & family education &
trainingtraining Coordinated, patient-centered plan Coordinated, patient-centered plan
of careof care
1111
Pain & symptom managementPain & symptom management• comprehensive primary care to manage comprehensive primary care to manage
underlying conditionsunderlying conditions• aggressive treatment of acute exacerbation aggressive treatment of acute exacerbation
per patient and family requestper patient and family request 24 hour phone support, visits if 24 hour phone support, visits if
necessarynecessary Volunteer & bereavement servicesVolunteer & bereavement services Transfer to hospice if appropriateTransfer to hospice if appropriate
Core Components Core Components of Palliative Careof Palliative Care
1212
Palliative Care vs. HospicePalliative Care vs. Hospice
Physicians not required to give a 6 Physicians not required to give a 6 month prognosismonth prognosis
Patients do not have to forego Patients do not have to forego curative carecurative care
Palliative care physician coordinates Palliative care physician coordinates care to prevent service fragmentationcare to prevent service fragmentation
1313
Progression ofProgression ofIn Home Palliative Care Model In Home Palliative Care Model
Pilot study conducted in Kaiser Pilot study conducted in Kaiser Permanente (KP) Southern California Permanente (KP) Southern California in 1998 in 1998
Comparison group study KP Southern Comparison group study KP Southern California in 1999California in 1999
Won National KP Voh’s Award for Won National KP Voh’s Award for Quality in 2002Quality in 2002
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Project Overview Project Overview Funded by Garfield Memorial FundFunded by Garfield Memorial Fund
Randomized controlled trial in Kaiser Randomized controlled trial in Kaiser Permanente Colorado & Hawaii Permanente Colorado & Hawaii (2002-2004)(2002-2004)
Study period: 2 years (approximately Study period: 2 years (approximately 18 months of data collection)18 months of data collection)
310 patients recruited from 2 sites310 patients recruited from 2 sites• Colorado n=150, Hawaii n=160Colorado n=150, Hawaii n=160
1515
Data CollectionData Collection Phone interviews at baseline and Phone interviews at baseline and
every 30 days up to 120 daysevery 30 days up to 120 days• Functional statusFunctional status• SatisfactionSatisfaction
At death or discharge from studyAt death or discharge from study• Service utilization Service utilization • Medical care cost dataMedical care cost data• Site of deathSite of death
1616
Garfield Multisite Garfield Multisite Study DesignStudy Design
Measurement Intervals Enrollment 30 Days 60 Days 90 Days 120 Days Death or End of Study
Study Groups
-Demographics -Service
-PPS -PPS -PPS -PPS -PPS Use -Satisfaction w/ -Satisfaction w/ -Satisfaction w/ -Satisfaction w/ -Satisfaction w/ Services Services Services Services Services
Intervention Group
Comparison Group
R
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Enrollment CriteriaEnrollment Criteria KP Health Plan Member Not receiving Hospice Diagnosis of congestive heart failure (CHF), chronic
obstructive pulmonary disease (COPD), or cancer 1 or more emergency department/hospital visits in
12 months Palliative Performance Scale 7 or less Life expectancy about 1 year
• Primary care physician “would not be surprised” if the patient died in the next year
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Study GroupsStudy Groups Usual Care (UC)Usual Care (UC)
• One visit by home health nurse to One visit by home health nurse to assess for further needassess for further need
• Access to all usual medical care servicesAccess to all usual medical care services Palliative Care (PC)Palliative Care (PC)
• Multiple home visits provided by Multiple home visits provided by interdisciplinary palliative team interdisciplinary palliative team (physician, nurse, social worker, HHA, (physician, nurse, social worker, HHA, volunteers, pastor on request)volunteers, pastor on request)
• Access to all usual medical care servicesAccess to all usual medical care services
1919
Patient Patient FlowchartFlowchart
718 Potential Participants referred to
the study
Excluded (n=408):199 Ineligible67 Admitted to Hospice59 Refused35 Died26 In other study19 Other
310 Randomized
155 Assigned to Intervention:
2 Withdrew8 died before receiving care
155 Assigned to Usual Care3 withdrew
152 Included in Final Analysis145 Included in Final Analysis
2020
Demographics of Demographics of Study ParticipantsStudy Participants
Mean Age 74 (sd=12)Mean Age 74 (sd=12)• 77% of study participants 77% of study participants
were over 65. The age were over 65. The age range spanned from 38-range spanned from 38-101101
51% Male51% Male Primary DiagnosisPrimary Diagnosis
• 46.5% Cancer46.5% Cancer
• 32.7% CHF32.7% CHF
• 20.8% COPD20.8% COPD Mean of 2.5 major medical Mean of 2.5 major medical
conditions (sd=1.4)conditions (sd=1.4)
Marital StatusMarital Status• 52.2% Married52.2% Married• 29.3% Widowed29.3% Widowed• 8.1% Single8.1% Single• 6.7% Divorced6.7% Divorced• 3.7% Unknown3.7% Unknown
EthnicityEthnicity• 63% Caucasian63% Caucasian• 16% Asian/Pacific 16% Asian/Pacific
IslandersIslanders• 13% Hawaiian13% Hawaiian• 5% Latino5% Latino• 2% African American2% African American• 1% Other1% Other
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Baseline Group ComparisonsBaseline Group Comparisons No differences between study groups at No differences between study groups at
enrollment in terms of:enrollment in terms of:• Demographics: ethnicity, age, gender, Demographics: ethnicity, age, gender,
marital status, income levelmarital status, income level• Palliative Performance ScalePalliative Performance Scale
Palliative Care more satisfied with Palliative Care more satisfied with services at baselineservices at baseline
Usual Care had significantly more days Usual Care had significantly more days on service before deathon service before death
2222
Baseline VariablesBaseline VariablesUsual Care Usual Care
(n=153)(n=153)InterventionIntervention
(n=145)(n=145)PP
Female, No. (%)Female, No. (%) 81 (53)81 (53) 65 (45)65 (45) NSNS
Age, mean (SD)Age, mean (SD) 74 (13)74 (13) 75 (11)75 (11) NSNS
Racial minority, No. (%)Racial minority, No. (%) 53 (35)53 (35) 56 (39)56 (39) NSNS
Married, No. (%)Married, No. (%) 73 (48)73 (48) 82 (57)82 (57) NSNS
Primary Diagnosis of Cancer, No.(%)Primary Diagnosis of Cancer, No.(%) 74 (49)74 (49) 64 (44)64 (44) NSNS
Primary Diagnosis of CHF, No. (%)Primary Diagnosis of CHF, No. (%) 52 (34)52 (34) 45 (31)45 (31) NSNS
Primary Diagnosis of COPD, No. (%)Primary Diagnosis of COPD, No. (%) 26 (17)26 (17) 36 (25)36 (25) NSNS
Education Level, mean (SD)Education Level, mean (SD) 12 (2)12 (2) 12 (2)12 (2) NSNS
Lives with family member, No. (%)Lives with family member, No. (%) 105 (69)105 (69) 114 (79)114 (79) NSNS
Lives in own house/apt., No. (%)Lives in own house/apt., No. (%) 113 (74)113 (74) 114 (79)114 (79) NSNS
Annual income < 20,000, No. (%)Annual income < 20,000, No. (%) 53 (35)53 (35) 46 (32)46 (32) NSNS
Days on Service (Survival), #Days on Service (Survival), #. (%). (%) 200 (242)200 (242) 164 (196)164 (196) .029.029
Functioning (PPS), mean (SD)Functioning (PPS), mean (SD) 59 (12)59 (12) 58 (13)58 (13) NSNS
Satisfaction, mean (SD)Satisfaction, mean (SD) 39 (6)39 (6) 41 (5)41 (5) .025.025
2323
Patient SatisfactionPatient Satisfaction
80.474.1
93.1
80
92.387
93.4
80.8
0102030405060708090
100
Palliative Care Usual Care
Per
cent
Sat
isfie
d
Baseline
30 Day
60 Day
90 Day
Percent Very Satisfied at Enrollment (n=277), 30 Days Percent Very Satisfied at Enrollment (n=277), 30 Days (n= 216), 60 Days (n=168) and 90 Days Post-enrollment (n= 216), 60 Days (n=168) and 90 Days Post-enrollment
(n= 149) by Study Group(n= 149) by Study Group
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Adjusted Mean Satisfaction Adjusted Mean Satisfaction Scores at Enrollment and 90 Scores at Enrollment and 90
Days Post-enrollment by Study GroupDays Post-enrollment by Study Group
40.89
39.35
43.56
40.88
3536373839404142434445
Palliative Care Usual Care
Mea
n sa
tisfa
ctio
n sc
ore
At enrollment
90 days after enrollment
P=.004 P=.4
2525
Acute Care Acute Care Service Use (n=297)Service Use (n=297)
20%
32%36%
58%
0%
10%
20%
30%
40%
50%
60%
Per
cent
Usi
ng
*ED *Hospital
Palliative
Usual Care
* P<.01
2626
Unadjusted Medical Unadjusted Medical Service Use (n=297)Service Use (n=297)
0.290.672.2
7.34
1.773.18 4.42
9.11
30
12.39
0
5
10
15
20
25
30
Mea
n N
um
ber
of
Day
s/V
isit
s
*ED *Hospital SNF *MDOffice
*HomeVisits
PalliativeUsual Care
* P<.01
2727
Total Service CostsTotal Service Costs
$12,670
$20,221
$0
$5,000
$10,000
$15,000
$20,000
$25,000
All Costs
Palliative
Usual Care Adjusted costs of Adjusted costs of care for those in care for those in PC were 32.6% PC were 32.6% less than those less than those receiving UCreceiving UC
Saves Saves $7,551$7,551
p<.001 F=16.66
n=292
2828
Average Cost Per DayAverage Cost Per Day
$95
$213
$0
$50
$100
$150
$200
$250
Per Day Cost
Palliative Usual Care
Adjusted average Adjusted average per day cost of per day cost of care by study care by study group based on group based on the average days the average days on serviceon service• PC = $95PC = $95• UC = $213UC = $213
p<.001
n=292
2929
Site of Death (n=217)Site of Death (n=217)
0%
10%
20%
30%
40%
50%
60%
70%
80%
Home Hospital SNF InPt.Hospice
Palliative Care
Usual Care
Studies show Studies show that most people that most people prefer to die at prefer to die at home* home*
Patients enrolled Patients enrolled in the Palliative in the Palliative Care program Care program were were significantly significantly more likely to die more likely to die at home (71% at home (71% vs. 51%: p=.001)vs. 51%: p=.001)
*(Townsend, Frank, Fermont, et al., 1990; Karlsen & Addington-Hall, 1998; Hays et al., 2001)
P=.013
3030
Family CommentsFamily Comments"We are so grateful our mother could participate "We are so grateful our mother could participate
in your Palliative Care Program. What a gift! It in your Palliative Care Program. What a gift! It made possible an independent life until her made possible an independent life until her death. Thank you for patience, devotion and death. Thank you for patience, devotion and capable care."capable care."
““But there were moments of stark beauty too. A But there were moments of stark beauty too. A hospice priest counseled us about the freedom hospice priest counseled us about the freedom that comes from letting go of control. My father that comes from letting go of control. My father thought quietly, then told me as I helped him thought quietly, then told me as I helped him back to bed that this realization had been a back to bed that this realization had been a powerful assist, an emotional turning point. powerful assist, an emotional turning point. Each day, he told my sister later, had become a Each day, he told my sister later, had become a gift, not a burden."gift, not a burden."
3131
ImplicationsImplications
First rigorous study to examine the First rigorous study to examine the effectiveness of an in-home, community-effectiveness of an in-home, community-based, palliative care program based, palliative care program
Provides strong clinical and financial Provides strong clinical and financial evidence supporting the provision of evidence supporting the provision of palliative care in the homepalliative care in the home
Tremendous implications for improving Tremendous implications for improving end of life care for terminally ill end of life care for terminally ill • KP adapted as standard care throughout KP adapted as standard care throughout
Southern CA & moving to nationalSouthern CA & moving to national
3232
Policy ImplicationsPolicy Implications
Evidence provided here and in a Evidence provided here and in a previous study support the need for previous study support the need for fundamental changes in the design fundamental changes in the design of our health care system to bridge of our health care system to bridge care between standard medical care care between standard medical care and hospice care.and hospice care.
Modification of Hospice benefit or Modification of Hospice benefit or development of a new “pre-hospice” development of a new “pre-hospice” benefitbenefit
3333
Future StudiesFuture Studies
Replicate within alternate funding Replicate within alternate funding structure, e.g., medical groupstructure, e.g., medical group
Demonstration project to test Demonstration project to test benefited model of care, e.g., benefited model of care, e.g., hospicehospice
Test similar chronic care model Test similar chronic care model provided upstream, earlier in disease provided upstream, earlier in disease trajectorytrajectory