Centers of Care Advanced Illness Management

AHA Annual Meeting AIM Panel April 30, 2013Laura Mavity, MD, Clinical Director Katie Hartley, BSN, CHPN, Administrative Director

Centers of CareAdvanced Illness Management

•Sole Community Four Hospital System – Pioneer Memorial Hospital (CAH, 25 beds)– St. Charles Bend (261 beds)– St. Charles Madras (CAH, 25 beds)– St. Charles Redmond (48 beds)

•Primary Care and Subspecialty Practices•Home Health and Hospice Services•Behavioral Health Services

St. Charles Health SystemSt. Charles Health System

Central OregonCentral Oregon

•WHAT: Our IDS is designed to achieve the Triple Aim

•HOW: Delivered through the Centers of Care model

St. Charles Health System IDSSt. Charles Health System IDS

Centers of CareCenters of Care

•To Improve the Health of Our Population (Better Health)– Complex planning and management of advanced illness patients eases stress

for their loved ones– Intensive support for caregivers and families

•To Improve the Patient Experience (Better Care)– Improve pain and symptom control– Address emotional, psychosocial, and spiritual suffering in life-limiting illness– Clear and realistic patient-centered care goals– Seamless discharge planning to community resources– Improved patient and family satisfaction– Improved hospital staff and physician support and satisfaction

•To Reduce the Cost of Care (Better Value)– Streamline healthcare – avoid undesired or non-beneficial care– Reduce inappropriate resource utilization– Avoid hospital readmissions

Triple Aim and Palliative CareTriple Aim and Palliative Care

Centers of CareCenters of Care

•Realistic patient and family-centered care goals– Re-evaluated throughout the duration of illness– Empowering patients and families about healthcare choices

– Facilitate referrals to appropriate community programs

– Advanced care planning

•Expert symptom and comfort management

– Whether pursuing aggressive life prolonging care or comfort measures only

– Independent of prognosis

•Focus on patients with progressive life limiting illness with prognosis of two years or less

SCHS Advanced Illness Management Center of CareSCHS Advanced Illness Management Center of Care

Palliative Care DeliveryPalliative Care Delivery

• The Clinical Approach:

- Basis is family conference

- Time intensive assessment of patient and family values, symptoms and their understanding of disease and prognosis to develop patient-centered care goals

- Ongoing intensive communication and support for patients and families with accessibility for questions or concerns

• The Conceptual Model:

Dedicated team Focus + Time

Decision Making + Clarity + Follow through

Foundations of Palliative CareFoundations of Palliative Care

• Dying is normal• Advance care planning is important• Coordination of care and services is imperative• Medical care provided should be based on the patient

and his or her family’s goals and values

St. Charles AIM Palliative Care Consultations• St. Charles Bend 2009

- 2009 - 222 consults

- 2010 - 382 consults

- 2011 - 436 consults

- 2012 - 500+ consults• St. Charles Cancer Center 2010• AIM Center of Care 2011• Outpatient Consultations Spring 2012• St. Charles Redmond Fall 2012


AIM Consultation Requests by SpecialtyAIM Consultation Requests by Specialty

*OTHER: CT SURGERY, NEUROLOGY, GEN SURG, ORTHO, GI, REHAB, INTERNAL MED, VASCULAR SURGERY

Disposition after AIM ConsultationDisposition after AIM Consultation

Diagnosis Classes for AIM ConsultationDiagnosis Classes for AIM Consultation

AIM Payer ClassificationAIM Payer Classification


2012 Data Highlights:

• $4,000 average direct variable cost avoidance per inpatient

• AIM consultation

• AIM patient 30 day readmission rate 4.86% (expected 10.4%), overall readmission rate 8.74%

• Average time from admission until AIM consultation: 4.1

days

• Average LOS after AIM consult: 2.7 days

• Most common reason for consultation: Goals of Care Discussion/Advance Care Planning


2012 Data Highlight

Average symptom burden (ESAS) before and after consultation

BEFORE AFTER

PAIN 0.83 0.47

ANXIETY 0.36 0.11

DYSPNEA 0.59 0.28

N/V 0.14 0.04

•Develop seamless care flows for patients with advanced illnesses throughout our regional health care system

•Collaboration/Partnerships

– St. Charles AIM Program:

• Inpatient consultations all four hospitals• Outpatient consultations all four sites including St. Charles

Cancer Center Bend and Redmond

– Regional hospice and Transitions programs

– Regional physicians, practices, and community programs


Outpatient Consultation Service Development •Justification = most patients spend most of their time outside of hospitals•Opportunity

– Improves quality patient care– Potentially decreases in-hospital mortality– Increases efficiency in health care systems

and accountable care organizations

AIM Center of Care Initiatives: ACCESSACCESS

Needs Assessment

Why are you considering outpatient services?

• Staffing

• Patient Focus

• Stakeholders


Model: Embedded Clinic •Collaborative relationship between a host clinic and palliative care staff•All costs of the clinic operations are born by the host clinic•Patients referred predominately from the host clinic•Defined clinical pathways or protocols may exist defining patient flow between the host and palliative care staff


Finances: Support and alignment •Most outpatient palliative care practices operate at loss

• Primary cost is labor

– Billing = <50% of expenses•NEJM Temel Study showed mean cost savings per outpatient consult $2,282

–Decreased inpatient visits-mean $3,110 per patient–Less chemotherapy-mean $640 per patient–Longer lengths of hospice stays

Temel et al. Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer. NEJM 2010; 363:733-742


Outpatient AIM Consultation ServiceCancer Center Advanced Stage Lung Cancer initiative

2011Inpatient - 7 consultations

2012Inpatient - 35 consultations•Disposition:

- 9 died in the hospital - 15 left the hospital with hospice - 5 discharged with home health - 1 discharged to SNF- 1 discharged to inpatient rehab - 1 discharged home without services

Outpatient:•Quarters 1, 2, and 3 - 1 consultation•Quarter 4 - 11 consultations


System standardization of processes and procedures• AIM consultation availability at all four hospitals

- St. Charles Bend, Cancer Center, Outpatient

- St. Charles Redmond, Cancer Center, Outpatient

- Pioneer Memorial Hospital and St. Charles Hospice Prineville

- Expand hospice staff role to include palliative care consultations- St. Charles Madras and Hospice

- Expand hospice staff role to include palliative care consultations• Coordination with multiple regional hospices, other service

organizations• Quality/Performance Improvement Program


St. Charles AIM Team/Center of Care expansion

• 2009: 1 part-time palliative care MD

• 2013: 3 palliative care MDs (2.35 FTE) and 2 hospice medical directors, dedicated AIM team SW, AIM RN case manager, AIM chaplain pending (shared position with Cancer Center)

Cambia Health Foundation Sojourns Pathway Grants $237,000

• CAPC Palliative Care Leadership Center training and mentorship

• UCSF palliative care program financial data analysis pilot project

AIM Center of Care Initiatives: WORKFORCEWORKFORCE

AIM Team members and Center of Care provide caregiver education

• 3 grand rounds delivered by AIM Team

• Dr. Diane Meier 9/12

• Dr. Ira Byock pending 11/13

• Palliative Care education for caregivers by AIM Team (palliative care, symptom management, hospice benefit, end of life process, care goal discussions, advance care planning)

• Over 30 presentations delivered annually

AIM Center of Care Initiatives: WORKFORCEWORKFORCE

AIM Team members provide regular community education

• Heart Failure University

• Pulmonary Rehabilitation “Better Breathers” group

• Kiwanis, Rotary Club presentations

• Wholeness Seminars at a local hospice agency

• System board presentations

AIM Center of Care Initiatives: AWARENESSAWARENESS

The Conversation Project

•Co-founded by Pulitzer Prize-winner Ellen Goodman and developed in collaboration with IHI

•A public engagement campaign with the transformative goal to have every person’s end-of- life wishes expressed and respected


The Conversation Project Pioneer Sponsor Program

•An IHI-sponsored Initiative

•Purpose is to better prepare health care delivery systems to receive and respect patients’ wishes about end-of-life care

•12 Pioneer Sponsors committed to ensuring health systems are “Conversation Ready” by developing and piloting processes to create these systems within health care


The Conversation Project “Pioneer Sponsor” Program

•St. Charles Health System is the only West coast “Pioneer Sponsor” with hospitals holding a rural designation within the system

•Reframe the provider-patient relationship around the question, “What matters most to you?”

•Ultimate objective is to package proven methods and provide programs with new tools and strategies to achieve these goals


St. Charles “Pioneer Sponsor” Projects

•Pilot at Heart Failure UniversityA program attended by newly diagnosed patients with heart failure as well as those with disease exacerbations

•Pilot of St. Charles Health System Caregiver Engagement

Personally engage our own caregivers in the conversation project’s process. Model program:


• AIM Center of Care Newsletter

– Distributed to community partners three times per year, relays educational opportunities, resources

• Bloom Project

• Comfort Care Program and Cart

• Integrative Therapies - partnership with Cancer Center

• Creation of Mosaic art piece with AIM Center of Care Partners


SCHS Advanced Illness Management Center of CareMosaic Art Piece

Centers of Care Advanced Illness Management

Documents

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