Centers of Care
Advanced Illness Management
AHA Annual Meeting AIM Panel April 30, 2013
Laura Mavity, MD, Clinical Director
Katie Hartley, BSN, CHPN, Administrative Director
St. Charles Health System
•Sole Community Four Hospital System
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–
–
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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
Central Oregon
Madras
Site
Redmond
Site
Bend Site
Prineville
Site
St. Charles Health System IDS
•WHAT: Our IDS is
designed to achieve the
Triple Aim
•HOW: Delivered through
the Centers of Care model
Centers of Care
Triple Aim and Palliative Care
•To Improve the Health of Our Population (Better Health)
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–
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
Centers of Care
SCHS Advanced Illness Management Center 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
Palliative 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 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
SCHS Advanced Illness Management Center of Care
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 Specialty
CARDIOLOGY
2%
CRITICAL CARE
ER
1%
*OTHER
1%
4%
RENAL
2%
NEUROSURG
3%
ONCOLOGY
10%
HOSPITALIST
55%
PULMONARY
22%
*OTHER: CT SURGERY, NEUROLOGY,
GEN SURG, ORTHO, GI, REHAB,
INTERNAL MED, VASCULAR SURGERY
Disposition after AIM Consultation
INPATIENT REHAB
2%
HOME
HOSPICE
27%
DEATH
24%
HOME HEALTH
10%
HOME
10%
SNF
11%
INPATIENT
HOSPICE
16%
C
UN
H
1
PS
YC
TH
O
LI
C
6
O
R
AB
O
6
M
ET
R
Y
7
UL
A
O
LO
G
M
A
9
VA
SC
/IM
M
AL
20
TR
AU
EN
C
G
I
DI
A
Y
60
R
AR
NA
R
80
C
IC
CE
R
LO
G
AN
RO
140
ID
EU
160
PU
LM
O
N
# of Pts
Diagnosis Classes for AIM Consultation
151
128
120
100
73
54
42
40
0
1
1
AIM Payer Classification
SELF PAY
4%
AUTO
1%
COMMERCIAL
0.4%
GOVERNMENT
PROGRAMS
2%
MANAGED CARE
8%
MEDICAID
9%
MEDICARE
76%
SCHS Advanced Illness Management Center of Care
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
SCHS Advanced Illness Management Center of Care
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
SCHS Advanced Illness Management Center of Care
•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
AIM Center of Care Initiatives: ACCESS
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: ACCESS
Needs Assessment
Why are you considering outpatient services?
• Staffing
• Patient Focus
• Stakeholders
AIM Center of Care Initiatives: ACCESS
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
AIM Center of Care Initiatives: ACCESS
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
AIM Center of Care Initiatives: ACCESS
Outpatient AIM Consultation Service
Cancer Center Advanced Stage Lung Cancer initiative
2011
Inpatient - 7 consultations
2012
Inpatient - 35 consultations
•Disposition:
- 9 died in the hospital
- 5 discharged with home health
- 1 discharged to inpatient rehab
Outpatient:
•Quarters 1, 2, and 3 - 1 consultation
•Quarter 4 - 11 consultations
- 15 left the hospital with hospice
- 1 discharged to SNF
- 1 discharged home without services
AIM Center of Care Initiatives: ACCESS
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
AIM Center of Care Initiatives: WORKFORCE
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: WORKFORCE
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: AWARENESS
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: AWARENESS
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 endof- life wishes expressed and respected
AIM Center of Care Initiatives: AWARENESS
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
AIM Center of Care Initiatives: AWARENESS
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
AIM Center of Care Initiatives: AWARENESS
St. Charles “Pioneer Sponsor” Projects
• Pilot at Heart Failure University
A 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 Initiatives: AWARENESS
• 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 Care
Mosaic Art Piece
SCHS Advanced Illness Management Center of Care
Mosaic Art Piece