Moving Palliative Care
Upstream
David E. Weissman, MD
Professor Emeritus
Medical College of Wisconsin
Consultant, Center to Advance Palliative Care
Objectives
• List three benefits of integrating palliative care principles
early into the course of chronic disease management.
• Describe three new models of palliative care service
delivery that seek to engage patients early in the disease
course.
• Characterize national efforts to impact health care policy
concordant with palliative care principles.
Historical Perspective
• Phase I Hospice
1970s-80s
• Phase 2 Palliative Care
1990s-2000s
• Phase 3 Spread
2010s-
The Palliative Care Intervention
• Interdisciplinary teams
– Patient-centered goals of care discussion
• Realistic prognostication
– Pain and symptom relief
– Disposition planning reflecting patient goals
– Patient/Family support
– Bereavement support
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Key Palliative Care Outcomes
– Reduced ICU length of stay
– Rapid symptom relief
– Earlier referral to hospice services-longer
– Greater patient/family satisfaction
– Lower hospital cost
– Prolonged survival (outpatient intervention)
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Standards and Certification
• Joint Commission Certification (2011)
• NQF Palliative Care Care Standards (2012)
• Commission on Cancer requirement, Cancer
Center Accreditation (2011)
• Board Certification, Hospice and Palliative
Medicine
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Physicians
Nurses: AP, RN, LPN
Social workers
Chaplains (pending)
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What is left to accomplish?
• In hospitals, at best, only 25-50% of palliative
care needs are being met.
– Variable penetration to areas of highest need:
• ICUs, ED, Oncology, Neurology, Renal
• Between hospitals and hospice there is a large
gap of palliative care needs across the
Continuum of health care.
– Outpatient services
– Long-term and Home care
– Home care
Hospitals
• Not all hospitals have consult services
• Those that do are typically overworked
– High rate of stress/burnout
– Many “martyrs”
– Adding more staff is problematic
• More staff leads to more consults
The Referral Conundrum
• Consults predominantly occur based on
clinician values, rather than patient needs
– Clinician values/attitudes inhibit provision of
excellent palliative care services
• My patient isn’t ready; my patient is not dying
• I’m not ready for palliative care
• I will not give up on my patient
• Education alone will not fix this problem.
Reality Check
• There will never be enough palliative care
specialists (all disciplines) to meet the
demand.
• Overall health care dollars will be
shrinking.
Solutions
1. Increase team efficiency: Accountability
and Value
2. New team models
3. Integrate palliative care principles into
high-risk locations
4. Identify unmet needs
5. Expand Generalist Palliative Care
6. Improve care across the continuum
1. Increase Team Efficiency
• Close examination of the process of care
delivery
– Staff time studies
– Determine cost/case
– Use metrics to determine efficiency and value
2. New Team Models
• “Counselor” Model
– Med Center Central Georgia/UMDNJ
• Staff
– Specially trained communication “counselors”
(Nursing, Mental health background)
• Intervention
– Manage most goal of care discussions
– Work in both parallel and series with PC team
3. Integration Projects
• Efforts to broaden the spread of palliative
care principles into locations of high unmet
needs, through …
– setting collaborative goals
– early patient identification (triggers)
– systems change to guide right care at right
time—routine family meetings
– quality improvement-data driven change
www.capc.org/ipal
4. Find the Unmet Needs
A patient-centered approach would be to
design a system where palliative care
interventions are based on patient and/or
disease factors, rather than clinician
attitudes/values.
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Patients are fully informed about treatment options.
Patients have equal access to all hospital resources.
Patients receive only the life-sustaining treatments
they desire/are appropriate to their medical
condition/prognosis.
Common trigger systems
• ICU
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Length of stay
Multi-organ failure
Metastatic cancer
Prolonged unconsciousness
Nursing home admission
• Emergency department
• Oncology clinic
• Special populations
– LVAD/CHF
– Nursing home admits
– PEG or trach consideration
5. Generalist Pall. Care
Need to imbed Palliative Care principles into
the system of health care delivery
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Commitment: time/$
Assessment: case finding—all patient screen
Responsibility: QI
Education: all clinical staff
Standards: who/what/when
Primary/Specialty Care
• Primary Pall Care: all clinicians
– Routine communication/symptom control
• Specialty Pall Care
– Family meetings—esp. “difficult cases”
– Complex symptom management
– Time management
– Support for difficult decisions
6. Move into the Continuum
• Outpatient Palliative Care
 Free-standing
 Co-management clinics: oncology, other
 Home visits
 IPAL-OP www.capc.org/ipal
• Long Term Care
 Dedicated Pall Care staff
 Geriatric NP model
 Consultative external team
What else is new?
The Joint Commission
The Joint Commission:
Palliative Care Advanced Certification Program
http://www.jointcommission.org/certification/palliative
_care.aspx
HEALTH REFORM
Palliative Care is Central to the
Success of Health Reform
• >95% of all health care spending is for the
chronically ill
• 64% of all Medicare spending goes to the 10%
of beneficiaries with 5 or more chronic
conditions
• Despite high spending, evidence of poor quality
of care
Palliative Care, Health Reform
and Chronic Disease Care
• Health reform initiatives
– Reduce readmissions
– Reduce cost
– Improve quality/Reduce variation
– Shift chronic disease care out of the hospital
– Care coordination/Bundling/ACOs
Palliative Care services/outcomes are perfectly
aligned with all these priorities!
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Payers are getting into Palliative Care
What can you do?
1. Seek information:
– What health reform initiatives are your
administrators concerned about?
– What committees are working on health
reform topics?
2. Offer to participate; share information on
palliative care role/impact
– Mortality and readmission reduction
– Cost control
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What can you do?
3. Push for collaborative initiatives
– ICU/ED/Cardiology/Cancer/Hospitalists
– Focus on improving generalist palliative care
rather than striving for more consults
4. Remind everyone about the 50%!
– Seek opportunities identify patients with
unmet needs
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CONTACT ME
• dweissma@mcw.edu
• www.capc.org