Palliative Care in MiPCT: Extending the Continuum of Care

Phil Rodgers, MD FAAHPMAssociate Professor, Department of Family Medicine

Associate Director for Clinical Programs, Palliative Medicine ProgramUniversity of Michigan Health System

MiPCT 2013 Annual SummitOctober 2013

Phil Rodgers, MD FAAHPM

I have no potential conflicts of interest or financial relationships to declare related to today’s presentation.

No Potential Conflict of Interest to Declare

Objectives

Understand the fundamentals of palliative care, and its value to securing the continuum of high quality primary care

Identify specific opportunities to provide primary palliative care to your patients with advanced illness

Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.

73 FR 32204, June 5, 2008Medicare Hospice Conditions of Participation – Final Rule

What is Palliative Care?

4

Traditional Model of Care

Curative Care

Hosp

ice

Presentation/Diagnosis

Death

HOSPICE CARE

HEALTH

Diagnosis Death

Curative & Life Prolonging Care

Prevention

CURATIVE CARE

ILLNESS DEATH

Bereavement

Palliative CareSymptom

Management

Life

Closure

EOL/

Dying

New Model of Palliative Care

How is Palliative Care Different than Hospice?

o Palliative care is appropriate at any point in a serious illness. It is provided at the same time as life-prolonging treatment. No prognostic requirement, no need to choose between treatment approaches.

o Hospice is a medical benefit that supports care for those in the last weeks to few months of life. Patients must have a 2 MD-certified prognosis of <6 months, and often must give up insurance coverage for curative or life prolonging treatment in order to be eligible.

(Medicare Hospice Benefit: 84% Medicare, 5% Medicaid, 3% uninsured)

Palliative care in the US Today

75% of US hospitals >50 beds have Palliative Care programs 85% of US medical schools have hospital-based palliative care

programs Palliative Care now recognized by ACGME, ABMS, NQF, and CMS States in the US with higher hospital palliative care penetration

have: Fewer Medicare hospital deaths Fewer intensive care unit / cardiac care unit (ICU / CCU) days Fewer admissions during the last 6 months of life Fewer ICU / CCU admissions during terminal hospitalizations Lower overall Medicare spending / enrollee

Goldsmith BA, Dietrich J, et al. J Palliative Med 2008; 11(8):suppl 1-9 Teno JM, Clarridge BR, Casey V et al. JAMA 2004;291(1):88-93

Why Palliative Care Now?

We’re living longer, with more illness Burdens of symptom management and

care needs are increasing Treatment options and outcomes are

more complex Family caregivers and supports systems

are strained, eroded or absent Increasing emphasis on value in health

care delivery

Target Population for Complex Care Coordination and Palliative CareDistribution of Total Medicare Beneficiaries and Spending

10%

63%

37%

90%

Total Number of FFS Beneficiaries: 37.5 million

Total Medicare Spending: $265 billion

Average per capita Medicare spending (FFS only): $7,064

Average per capita Medicare spending among

top 10% (FFS only): $44,220

NOTE: FFS is fee-for-service. Includes noninstitutionalized and institutionalized Medicare fee-for-service beneficiaries, excluding Medicare managed care enrollees. SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost & Use file, 2005.

100

90

80

70

60

50

40

30

20

10

%Claimants

Cost perClaimant

ManagementApproachPatient Type

Care Management Targeted to Needs of Patients

• Worried well• Self-resolving illness• Low grade acute illness Demand

ManagementLow

CaseManagemen

t

• Chronic diseases• Moderate to severe acute illness

DiseaseManagementMedium

HighComplex CareManagement

Palliative Care

Complex Patients• Significant diagnosis• Multiple co-morbidities• Often terminal• Several providers of care• Psychological / social / financial

upheaval

4

Outcomes of Palliative Care

Improved patient and family satisfactionReduction in symptom burdenReduced costsProlonged Survival

Improved Family SatisfactionMortality follow back survey palliative care vs. usual care

Casarett et al. J Am Geriatr Soc 2008;56:593-99.

N=524 family survivors Overall satisfaction markedly superior in palliative care

group, p<.001 Palliative care superior for:

Emotional and spiritual support Information and communication Care at time of death Access to services in community Well-being and dignity Care type and setting concordant with patient preference Pain and symptom control

Improved Symptom ControlBakitas M et al. JAMA 2009;302(7):741-9

N= 322 advanced cancer patients in rural NH+VT Improved quality of life and less depression (p=.02) Trend towards reduced symptom intensity (p=.06) No difference in utilization, very low in both groups Median survival: intervention group 14 months,

control group 8.5 months, p=.14

How Palliative Care Reduces Length of Stay and Cost

Palliative care:Clarifies goals of care with patients and familiesHelps families to select medical treatments and

care settings that meet their goalsAssists with decisions to leave the hospital, or to

withhold or withdraw death-prolonging treatments that don’t help to meet their goals

capc.org/research-and-references-for-palliative-care/citations Lilly et al, Am J Med, 2000; Dowdy et al, Crit Care Med, 1998; Carlson et al, JAMA, 1988; Campbell et al, Heart Lung, 1991; Campbell et al, Crit Care Med, 1997; Bruera et al, J Pall Med, 2000; Finn et al, ASCO, 2002; Goldstein et al,

Sup Care Cancer, 1996; Advisory Board 2002; Davis et al J Support Oncol 2005; Smeenk et al Pat Educ Couns 2000; Von Gunten JAMA 2002; Schneiderman et al JAMA 2003; Campbell and Guzman, Chest 2003; Smith et al. JPM 2003; Smith, Hillner JCO 2002; www.capc.org; Gilmer et al. Health Affairs 2005. Campbell et al. Ann Int Med.2004; Health Care Advisory Board. The New Medical Enterprise 2004. Elsayem et al, JPM 2006;

Fromme et al, JPM 2006; Penrod et al, JPM 2006; Gozalo and Miller, HSR 2006; White et al, JHCM 2006; Morrison RS et al Arch Int Med 2008

Palliative Care Shifts Care Out of Hospital to Home

Service Use Among Patients Who Died from CHF, COPD, or Cancer Palliative Home Care versus Usual Care, 1999–2000

13.211.1

2.3

9.4

4.6

35.0

5.3

0.9 2.4 0.90

10

20

30

40

Home healthvisits

Physicianoffice visits

ER visits Hospital days SNF days

Usual Medicare home care Palliative care intervention

Brumley, R.D. et al. 2007. J Am Geriatr Soc.

Hospital Palliative Care Reduces CostsCost and ICU Outcomes Associated with Palliative Care Consultation in 8 U.S. Hospitals

Live Discharges

Hospital Deaths

Costs Usual Care

Palliative Care Δ Usual

Care Palliative

Care Δ Per Day $867 $684 $183* $1,515 $1,069 $446*Per Admission

$11,498

$9,992 $1,506*

$23,521

$16,831 $6,690*

Laboratory $1,160 $833 $327* $2,805 $1,772 $1,033*ICU $6,974 $1,726 $5,248* $15,53

1$7,755 $7,776***

Pharmacy $2,223 $2,037 $186 $6,063 $3,622 $2,441**Imaging $851 $1,060 -

$208***$1,656 $1,475 $181

Died in ICU X X X 18% 4% 14%**p<.001**p<.01***p<.05

Morrison, RS et al. Archives Intern Med 2008;

Palliative Care Can Improve Survival

Randomized controlled-trial, 151 patients with metastatic NSCLC

Palliative care plus cancer treatment vs. usual cancer care

Intervention group showed: Better QOL and symptom scores Less ‘aggressive care’ at end-of-life Prolonged survival (~2 months)

Temel J, et al. New Engl J Med 2010; 363(8): 733-42

What does Palliative Care Do?

Pain and physical symptom management Clear communication Difficult or complex treatment decisions Managing care transitions Detailed and practical help at all stages of care Emotional and spiritual support

“Right Care, Right Place, Right Time”

Palliative Care Delivery

Tertiary Palliative CareDelivered by subspecialty Palliative Care Teams

Secondary Palliative CareDelivered by clinicians frequently caring for seriously ill patients

Primary Palliative CareDelivered by all interdisciplinary clinicians to patients with serious illness, and their families

Primary Palliative Care

Many patients die in the care of their PCP Effective palliative care is high-quality primary

care through the end of life Primary care providers are uniquely situated to

provide comprehensive care to patients and families facing life-limiting illness

Our growing challenge is to provide this care in a coordinated, sustainable way

Primary Palliative Care ‘Tasks’

Prognosis – help communicate prognosis to inform patient/family decision-making

Planning – establish goals of care consistent with patient/family desires and values

Palliation – carefully assess and address physical, emotional, interpersonal and spiritual symptoms

Prescribe Hospice – discuss when/if hospice care is an appropriate option

Smucker D. Clin Fam Prac; Elsevier, June 2004

Prognosis: Consider and

communicate

Palliation:Integrate Palliative

and Disease-Oriented Measures

Planning:Clarify Patient’s

Values and Goals of Care

Prescribing Hospice:Understand eligibility criteria and explain

options for care

Tasks of Primary Palliative Care

Smucker D. Clin Fam Prac, June 2004

Why is Prognosis Assessment Important?

Important to medical teams Assist clinicians in their decision making Avoid costly interventions that may cause

suffering Guides recommendations for interventions likely

to be beneficial Optimization of resource allocation and

utilization of support services

Why is Prognosis Assessment Important?

Important to patients and their families: Information helps patients and families in

choosing therapeutic options

Planning for emotional and financial management through advancing illness and end-of-life

Not receiving a prognosis is the most common reason families say they are dissatisfied with end-of-life care

Karnofsky Performance Scale

100% Normal, no complaints, no evidence of disease 90 Able to carry on normal activity: minor symptoms of disease 80 Normal activity with effort: some symptoms of disease 70 Cares for self: unable to carry on normal activity or active work 60 Requires occasional assistance but is able to care for needs 50 Requires considerable assistance and frequent medical care 40 Disabled: requires special care and assistance 30 Severely disabled: hospitalization indicated, death not imminent 20 Very sick, hospitalization necessary: active treatment necessary 10 Moribund, fatal processes progressing rapidly 0 Death

DA Karnofsky, JS Burchenal, 1949

Predictions of survival

Time predictions: “How long do you expect this person to live”?

Outcome predictions: “ What is the probability you think this person will be alive in 6-12 months”?

or

“Would I be surprised if this patient died within the next 12 months”?

Outcome predictions more accurate than time predictions

Br J Cancer 1990;62:685-689

Planning: Outcomes

Advanced DirectivesLiving WillsDurable Power of Attorney for Health

Care (DPOA-HC) “Do-not-resuscitate orders”

Prolonged mechanical ventilationArtificial nutrition (tube feeding)

Starting the Conversation

“What are you hoping for?” “What are you afraid of?” “What is most important to you in your life?” “Have you thought about what it might be

like if we can’t help you live the way you want to live?”

“Have you thought about dying? Have you talked to anyone about it?”

When to Start: Clinician Cues

At time of serious diagnosis Advanced CHF, cancer, dementia, etc.

At time of functional change

At time of crisis or disease progressionHospitalizations, ICU staysInitiation of advanced therapies

• Artificial nutrition/hydration• Dialysis, LVAD, tracheostomy, etc.

. . .Patient and Family Cues

“I don’t know if I can do this much longer” “I don’t want to come back to the hospital

again” “We can’t stand to see Mom like this” “What happens if this (procedure/

medicine/treatment) doesn’t work?” “I’m so tired, I just want to die”

Shared Decision-Making

Patient/Family Goals Values Hopes Resources

Medical Providers Clear information Prognosis Recommend plans

to meet goals, be consistent w/values

Commitment to always provide care

Words that Work

“We want to help you live as well as you can, for as long as you can”.

“You’re sick and it’s serious, but we’ll be with you no matter what happens”.

“What can I do for you now?” “We will do all we can to get you the best

care possible”.

Resources

Hospice Finder (www.mihospice.org) Palliative Care Programs and Resources (

www.capc.org) Educational Tools (www.eperc.mcw.edu) Patient and Family Resources

www.theconversationproject.orgwww.fivewishes.org