The Evolving Role of Palliative Care in the Health Care
Continuum
Summit on the Care of the Seriously Ill
South Carolina Healthcare
Ethics Network Annual Meeting
October 12, 2011
John E. Barkley, MD, FCCP
Chief Medical Officer
Post-Acute Care Services
Carolinas HealthCare System
Outline
 Review the Current “Curative Model” of Care & Associated
Outcomes
 Learn Definitions of Palliative Care, Palliative Medicine &
Hospice
 Review clinical, economic, demographic data that serve as
the basis for need of Palliative Care across the continuum
 Learn current national standards for quality Palliative Care
 Review impact of Palliative Care in select patient populations
2
Current State
3
“Curative” Model
Palliative care
begins
Cure/Control/Restore/Rehabilitate
Diagnosis of Life
Threatening Illness
Hospice
Death
4
Cancer vs. Non-Cancer Illness
Trajectories to Death
Cancer
30 MONTHS
Decline
End-organ disease
Crises
Death
Time
Field & Cassel, 1997
Slide 5
6
Patients are Suffering
 The SUPPORT Principal Investigators. JAMA 1995; 274: 1591-1598.
 Desbiens NA et al. Crit Care Med 1996; 24:1953-1961.
 Singer et al. JAMA 1999;281(2):163-168.
 Somogyi-Zalud E et al. JAGS 2000; 48:S140-145.
 Nelson & Danis. Crit Care Med 2001; 29(2): N2-N9.
 Nelson JE et al. Crit Care Med 2004; 32:1527-1534.
 Nelson JE et al. Arch Intern Med 2006; 166:1993-1999.
6
Caregivers are Suffering
 Tolle et al. Oregon report card. 1999 www.ohsu.edu/ethics
 Emanuel et al. Ann Intern Med 2000;132:451.
 Steinhauser et al. JAMA 2000;284:2476-82.
 Lee et al. Am J Prev Med 2003;24:113.
 Teno et al. JAMA 2004;291:88-93.
 Wright et al. J Clin Oncol 2010;28:4457-64.
DEATH: RR 1.8 if care giving >9 hrs/wk for ill spouse
RR 1.6 among caregivers reporting emotional strain
7
Definitions
8
Definitions of Palliative Care
Interdisciplinary care that aims to relieve
suffering and improve quality of life for patients
with advanced illness, and their families.
It is provided simultaneously with all other
appropriate medical treatment.
www.capc.org
9
…Definitions
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 - Medicare Hospice Conditions of Participation –Final Rule
June 5, 2008
10
…Definitions
 Palliative Medicine Practitioners
• Recognized by American Board of Medical Specialties – 2006
• Major or sole clinical focus is the study and care of patients with:
– Complex medical illness
– Uncontrolled symptoms
– Limited prognosis
11
Definitions - Palliative Care vs. Hospice
 Non-hospice palliative care
•
Appropriate at any point in a serious illness
•
Provided at the same time as life-prolonging treatment
•
No prognostic requirement
 Hospice
•
Palliative care for the terminally ill
•
Two physicians certify prognosis ≤ 6 months
•
Medicare Part A “carve out”…give up traditional Medicare A & B coverage
•
Must forgo “curative” treatments
12
…Definitions
 Primary palliative care: refers to the basic skills
and competencies required of all physicians and
other health care professionals.
 Secondary palliative care: refers to specialist
clinicians that provide consultation and specialty
care.
13
Imperatives for Palliative Care
14
Large and Growing Problem:
People with Chronic Medical Conditions
•
Almost 50% of U.S. population has at least one chronic
medical condition, consuming 80% of healthcare
resources
–
–
–
•
180
Number of People With Chronic
Medical Conditions (in millions)
171
164
Between 2005 and 2030, the
number of Americans with
chronic conditions will increase
by almost 30%
–
157
160
149
Hypertension is the most common chronic condition, with 50M+
people in the U.S. needing treatment for high blood pressure
23M people have asthma, with economic costs projected at $20B
in 2010
24M people have diabetes; one-fourth are unaware they have it
20% to 30% of all Americans are
projected to have diabetes by 2050
141
140
133
7000 people age 65 per day
125
120
118
100
1995
2000
2005
2010
2015
2020
2025
2030
Sources: Partnership for Solutions, John Hopkins
University; Health Affairs, 26, no. 1 (2007): 142-15315
International Comparison of Spending on Health,
1980–2006
Total expenditures on health
as percent of GDP
Average spending on health
per capita ($US PPP)
16
7000
Australia
Canada
Denmark
France
Germany
Netherlands
New Zealand
Sweden
Switzerland
United Kingdom
United States
14
6000
12
5000
10
4000
8
Australia
Canada
Denmark
France
Germany
Netherlands
New Zealand
Sweden
Switzerland
United Kingdom
United States
6
4
2
0
3000
2000
1000
0
1980
1984
1988
1992
1996
2000
2004
1980
1984
Data: OECD Health Data June 2008
1988
1992
1996
2000
2004
Medicare Beneficiaries - Chronic Conditions & Spending
No chronic
conditions
1%
1-2 chronic
conditions
10%
5+ chronic
conditions
66%
3 chronic
conditions
10%
4 chronic
conditions
13%
Source: G. Anderson and J. Horvath, Chronic Conditions: Making the Case for Ongoing Care. Baltimore, MD:
Partnership for Solutions, December 2002.
Distribution of Total Medicare Beneficiaries and Spending, 2005
37%
Average per capita
Medicare spending
(FFS only): $7,064
90%
63%
Average per capita
Medicare spending
among top 10%
(FFS only): $44,220
10%
Total Number of FFS Beneficiaries: Total Medicare Spending:
37.5 million
$265 billion
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.
Health Care Reform
Health Care Reform = Clinical Integration
Clinical Integration = Care Coordination Across the Continuum
1
New “Rules of the Game”
 Less $$$ not more
 Value vs. Volume
 “Zero Sum Game”
•
Top quartile rewarded
•
Bottom quartile pays the bill
 Bundled/Grouped/Episode-specific payments
Patient-Centered Care Continuum
Population
Health
Management
Chronic Disease
Management
Pharmacy
Specialists
Data
Management
LTACH &
Acute Rehab
Medical
Home
EH R
EH R
Home Care
Ancillary
Providers
Palliative Care
Patients
EHR
Long Term
Care
Hospitals
Public Health
Agencies
Hospice
2
National Recommendations
for
Quality Palliative Care
22
National Consensus Project & National Quality Forum
 Foundational elements
• National definition & description of high quality
comprehensive palliative care
• Resource for practitioners addressing palliative care needs
of patients & families
• Educational framework & blueprint for structure and
provision of palliative care
Eight Domains with 38 Preferred Practices
1.
Structure and Process of Care
2.
Physical Aspects of Care
3.
Psychological and Psychiatric Aspects of Care
4.
Social Aspects of Care
5.
Spiritual, Religious and Existential Aspects of Care
6.
Cultural Aspects of Care
7.
Care of the Imminently Dying Patient
8.
Ethical and Legal Aspects of Care
CAPC Consensus Panel Papers
 Operational Features for Hospital Palliative Care Programs (2008)
 Operational Metrics for Hospital Palliative Care Programs (2008)
 Palliative Care Inpatient Unit Operational Metrics (2009)
 Clinical Care & Customer Service Metrics (2010)
 Identifying Patients in Need of a Palliative Care Assessment in the
Hospital Setting (2011)
Practical Road Maps to Follow
26
NCCN Guidelines Version 2.2011
 Definition
• “Palliative care is both a philosophy of care and an
organized, highly structured system for delivering care to
persons with life-threatening or debilitating illness. Palliative
care is patient and family-centered care that focuses upon
effective management of pain and other distressing
symptoms, while incorporating psychosocial and spiritual
care according to patient/family needs, values, beliefs, and
culture(s). The goal of palliative care is to prevent and
relieve suffering and to support the best possible quality of
life for patients and their families, regardless of the stage of
disease or the need for other therapies. Palliative care can
be delivered concurrently with life prolonging care or as the
main focus of care.”
27
NCCN Guidelines Version 2.2011
 Standards of Palliative Care
•
Institutions should develop a process that ensures all patients have access to palliative
care services from the initial visit
•
All cancer patients should be screened for palliative care needs at their initial
visit, at appropriate intervals, and as clinically indicated
•
Patients and families should be informed that palliative care is an integral part of
their comprehensive cancer care
•
Educational programs should be provided to all healthcare professionals and trainees
so that they can develop effective palliative care knowledge, skills, and attitudes
•
Skilled, palliative care specialists and interdisciplinary, palliative care teams should be
readily available to provide consultative or direct care to patients/families who request
or require their expertise
•
Clinical health outcomes measurement should include palliative care domains
•
Quality of palliative care should be monitored by institutional quality improvement
programs
28
Critical Care
Early integration of palliative care with intensive care for
all ICU patients, regardless of prognosis, and their
families, is a clinical practice guideline.
–
Selecky PA et al. Chest 2005;128:3599-610. (American College of
Chest Physicians)
–
Lanken PN et al. Am J Respir Crit Care Med 2008;177:912-27.
(American Thoracic Society)
–
Truog RD et al. Crit Care Med 2008;36:953-63. (American College
of Critical Care Medicine).
Slide 29
Outcomes of Palliative Care
Slide 30
How Does Palliative Care Work?
 Interdisciplinary team (MD, NP, RN, MSW, Pastoral Care,
others) with patient-centered, family focused care approach
•
Addresses physical symptoms and emotional suffering
•
Clarifies goals of care with patients and families
•
Helps patients & families select medical treatments and care settings that
match their goals
•
Improves patient-physician-family communication and decision-making
•
Provides practical and emotional support for exhausted family caregivers
•
Enhances transitions and continuity of care across settings
“Right Care, Right Time, Right Place”
31
Temel JS et al. NEJM 2010; 363(8): 733-742.
32
Early PC + Oncology vs. Oncology
 FACT-L
98.0 vs. 91.5 (p=.03)
 Depression
16% vs. 38% (p= .01)
 Resuscitation preferences documented
53% vs. 28% (p = .05)
 “Aggressive Care”
33% vs. 54% (p = .05)
Temel JS et al. NEJM 2010; 363(8): 733-742.
33
Median Survival
11.6 vs. 8.9
P = .02; HR 1.7
34
“Coping with Cancer”
“Do you recall having a discussion with your treating MD
about care preferences at EOL”
 NCI funded study
 7 outpatient sites from 2002-2008
 638 patients with Advanced/Metastatic Cancer
 37% reported having EOL discussions before baseline
Wright, A.A. et al. JAMA, 2008; 300(14): 1665-1673.
Zhang, B. et al. Arch Intern Med 2009; 169(5): 480-488.
Mack, J.W. et al. J Clin Oncol 2010; 28(7): 1203-1208.
Wright, A.A. et al. J Clin Oncol 2010; 28(29): 4457-4463.
“Coping with Cancer”
Patient Impact
 EOL discussions ≠ higher rates of major depressive disorder or more worry
 68% received EOL care that was consistent with baseline preferences
 Less likely to receive “aggressive care”
•
Mechanical ventilation
•
Attempted resuscitation
•
ICU admission
 QOL lowest and physical distress highest with more “aggressive care”
 More enrolled in hospice & had longer LOS
 No survival differences
 “Aggressive care” resulted in 36% higher costs
“Coping With Cancer”
Caregiver Impact
 ICU or hospital deaths = psychiatric illness in
bereaved caregivers
 Worse QOL
 More regret
 Higher risk of a major depressive disorder
37
Arch Intern Med 2008; 168(16):1783-1790
Live Discharges
Costs
Usual
Care
Hospital Deaths
Δ
Palliative
Care
Usual
Care
Palliative
Care
Δ
Per Day
$830
$666
$174*
$1,484
$1,110
$374*
Per Admission
$11,140
$9,445
$1,696**
$22,674
$17,765
$4,908**
Laboratory
$1,227
$803
$424*
$2,765
$1,838
$926*
ICU
$7,096
$1,917
$5,178*
$14,542
$7,929
$7,776*
Pharmacy
$2,190
$2,001
$190
$5,625
$4,081
$1,544***
Imaging
$890
$949
($58)***
$1,673
$1,540
$133
Died in ICU
X
X
X
18%
4%
14%*
*P<.001
**P<.01
***P<.05
Health Affairs 2011; 30(3): 454-563
39
Health Affairs 2011; 30(3): 454-563
40
Health Affairs 2011; 30(3): 454-563
41
Hospital “X”
 Consult Volume – 765
 Length of Stay
•
Mean Day of Consult – 7.4
•
Mean Days to Discharge- 6.3
•
Mean LOS – 13.7
 Direct Variable Cost Savings - $1,865,146.00
 Clinical Revenue - $110,847.00
 Palliative Medicine Providers Cost - $271,089.00
 Net Cost Savings for Hospital “X” – $1,704,904 .00
 Net Savings/Case - $2229.00 ($354/day)
Conceptual Shift from “Curative Model”
Life Prolonging Care
Medicare
Hospice
Benefit
Life Prolonging
Hospice Care
Old
New
Care
Palliative Care
Diagnosis
Death
43
How to Proceed?
 System-based approach
• “Top down & bottom up”
• Development & full integration of Primary & Secondary PC
into all care including chronic disease management
programs
Primary palliative care: refers to the basic skills and competencies
required of all physicians and other health care professionals.
Secondary palliative care: refers to specialist clinicians that provide
consultation and specialty care.
44
45
Summary
 Patient & Caregivers are suffering under current model
 Many imperatives for Palliative Care making it an essential
strategy going forward
 National recommendations exist
 Positive impact of Palliative Care well documented
 Complete integration across the continuum requires:
• Top down + bottom up approach
• Development of Primary & Secondary Palliative Care
• Evidence-based practices
•
QA/PI
46