Reducing Avoidable Readmissions: The
Business and Clinical Impact of Palliative Care
Susan Enguidanos, PhD, MPH
enguidan@usc.edu
Agenda
• Introduction to & Need for Palliative Care
• Evidence of Palliative Care Effectiveness
• Examples of Two Models of Palliative Care:
• Inpatient (Hospital-based)
• Home-based
• Palliative Care and 30-day Readmissions
• Getting Started
Introduction to
Palliative Care
Rise in Aggressive
Care?
Teno et al., 2013
65+ Medicare Beneficiaries
ICU Use
(Riley & Lubitz, 2010)
Background:
Patient & Family Need
Current dying experience is far from
one that is desired by most Americans
•
Majority of Americans prefer to die at home
(Hays et al., 2001; Gallup, 2000)
• 33.5% die at home (2009; Teno et al., 2013)
•
•
Patients continue to die in pain (Meier, 2006)
46% of Do Not Resuscitate orders written within 2 days
of death
Palliative Care &
Site of Death
• Studies show that
most people
prefer to die at
home*
• Palliative Care
patients more
likely to die at
home (Brumley,
Enguidanos,
Jamison et al.,
2007)
P=.013
*(Townsend, Frank, Fermont, et al., 1990; Karlsen & Addington-Hall, 1998; Hays et al., 2001)
7
What is Palliative
Care?
Goal:
“…to prevent and relieve suffering & to support the best
possible quality of life for patients & their families,
regardless of the stage of the disease or the need for
other therapies.”
What Palliative Care Does:
“Expands traditional disease-model medical treatments
to include the goals of enhancing quality of life for
patient & family, optimizing function, helping with
decision making, & providing opportunities for personal
growth.”
National Consensus Project for Quality Palliative Care, 2013
Curative / remissive therapy
Presentation
Death
Palliative care
Hospice
Adapted from Lynn and Adamson, 2003
9
Core Components
of Palliative Care
• Interdisciplinary team: MD, RN, SW,
Chaplain
• Physical, medical, psychological,
social & spiritual support
• Patient & family education & training
• Develop plan of care
• Coordinated, patient-centered care
10
Core Components
of Palliative Care
• Pain & symptom management
• comprehensive primary care to manage
underlying conditions
• Aggressive treatment of acute
exacerbation per patient and family
request
• Facilitates transfer to hospice if
appropriate
11
Palliative Care Models
Hospital-based,
Inpatient Palliative
Care Programs
Home-based
Palliative Care
12
Inpatient Palliative Care
(IPC)
• Consultative
IPC service
involves family
meeting with
patients/family
• Follow-up care
as needed
13
Home-based Palliative
Care
• Eligibility
• Diagnosis of congestive heart failure (CHF),
chronic obstructive pulmonary disease (COPD), or
cancer
• Life expectancy about 1 year
• Primary care physician “would not be surprised” if the patient
died in the next year
• Palliative Care (PC)
• Multiple home visits provided by interdisciplinary
palliative team
• Access to all usual medical care services
Palliative Care vs.
Hospice
Physicians not required to give a 6
month prognosis
Patients do not have to forego
curative care
Palliative care physician coordinates
care to prevent service
fragmentation
National Use of Hospice
Care (NHCPO, 2011, 2012)
Clinical and
Economic Impact of
Palliative Care
Inpatient Palliative Care
Lower Costs of Care
$25,000
Lowered
cost by
$4855
$21,252
$20,000
$15,000
$10,000
$14,486
Usual Care
IPC
$5,000
$0
More days in Hospice care (p= .04)
(Gade, Venohr, Connor et al., 2008)
Fewer ICU Admissions at
Readmission (IPC)
25
21
20
15
12
10
5
0
Usual Care
IPC
(Gade, Venohr, Connor et al., 2008)
Other IPC Evidence
(Morrison et al., 2008)
• Comparison Group Study
• IPC patients discharged had savings of
$1696 in direct costs per admission
(p=.004)
• $279 in direct costs per day (p<.001)
• IPC patients who died had savings of
$4908 in direct costs per admission
(p=.003)
• $374 in direct costs per day (p<.001)
The Economic and
Clinical Impact of IPC
• Mean daily costs for IPC patients
•  33% (p< .01) pre- to post-intervention
• 14.5% compared to usual care (p< .01)
• LOS  30%
• Pain  by 86%
• Dyspnea  by 64%
(Ciemins, Blum, Nunley, Lasher, Newman, 2007).
Home-based PC:
Patient Satisfaction
Satisfaction with Care
45
40
40.88
39.35
43.56
40.89
35
30
Enrollment
25
-Days Follow 90
up
20
15
10
Usual Care
Palliative Care
p=.02
Brumley, Enguidanos, Jamison et al., 2007
Home-based Palliative Care:
Total Service Costs
Palliative
n=292
Usual Care
$25,000
$20,000
$15,000
$20,221
$12,670
• Adjusted costs of
care for PC
patients 32.6%
less than UC
• Saves $7,551
$10,000
$5,000
$0
23
All Costs
p<.001
(Brumley, Enguidanos,
Jamison et al., 2007)
Home-based Palliative Care:
Patient Acute Care Service Use
Percent Using
(n=297)
60%
Palliative
50%
Usual Care
40%
32%
58%
36%
30%
20%
20%
10%
0%
*ED
* P<.01
*Hospital
Brumley, Enguidanos, Jamison et al., 2007
Home-based Palliative Care Patient
Unadjusted Medical Service Use
(n=297)
* P<.01
Brumley, Enguidanos, Jamison et al., 2007
30-Day Readmission among
Seriously Ill Older Adults:
Why Do They Come Back?
Readmission Rates among
IPC Patients
• Among IPC patients discharged, overall
readmission rate = 10%
• Overall hospital readmission = 15%
• Reduced readmission by 1/3
Enguidanos, Vesper, & Lorenz (2012). 30 day readmissions among
Seriously Ill Older Adults. Journal of Palliative Medicine, 1-6.
Type of Care at
Discharge (n=408)
(Enguidanos et al., 2012)
70.0%
60.0%
58.8%
50.0%
40.0%
30.0%
20.0%
14.7%
10.0%
14.2%
8.6%
3.7%
0.0%
Hospice
Home-based Home Health
PC
Nursing
Facility
Home-No Care
Readmission Rate by Post
Discharge Service Use
(Enguidanos et al., 2012)
Predictors of 30 Day
Readmit
Examined age, gender, ethnicity, marital status,
pain, diagnosis, # chronic conditions, anxiety,
ADs, and their association with 30 day readmit
No Advance Directive
2.7x’s more likely
Added discharge disposition to the model
Nursing Facility 5x’s &
Home (no care) 3.7x’s more likely
As compared to discharge to Hospice & HBPC
Enguidanos, Vesper, & Lorenz (2012). 30 day readmissions among Seriously Ill Older
Adults. Journal of Palliative Medicine, 1-6.
Interviews with Seriously Ill
30-Day Readmits (n=10)
CHF & Cancer
Patients
Three themes
identified:
1.
2.
3.
Lack of Support &
Purpose
Rehospitalization as
appropriate care
Lack of access to
care/information
Theme: Lack of
Support & Purpose
• Lack of support & purpose
• Living alone and lack of support
• “I wasn’t cooking for myself, I
•
•
wasn’t doing anything…I just
wasn’t eating”
“It’s just a matter of me
…motivating me”
“If there was something I could
look forward to…”
Theme:
Appropriate Care
• Hospital care most appropriate for medical
condition and treatment preferences
“ I get to retaining the fluids again and then
right back to where we were [hospital]”
• Preference for aggressive care
“ I ain’t going nowhere, and I’m fighting”
Theme: Lack of access to
care/information
• “I should be comfortable.
I shouldn’t have to
go, ‘Oh, I got pain I need pain meds.’ I
shouldn’t be going after pain medication…I
was told I should come back to the ER to get
my pain medicine.”
• “Sometimes I have questions”
• “I could have REALLY used a
hospital bed”
• Inability to physically transport spouse
to specialist appt
Discussion
• Limited access to holistic care
• Enrollment in hospice and palliative care have
clear benefits, but problems getting there
• Late referrals to hospice
• Limited number of home-based palliative
care
• Most IPC referrals are late in the disease
trajectory
• Too late to change the course of care or
improve quality
Discussion
• Lack of continuity problematic:
• Quality of life
• Most people prefer to die at home.
Late transfers increase odds of death
in hospital (Gonzalo, 2011).
• Care may not be consistent with
wishes.
Getting Started
Building a Palliative
Care Program
1.
2.
3.
4.
5.
Making the Case for Palliative Care
Designing a Palliative Care Program
Financing a Palliative Care Program
Implementing a Palliative Care Program
Measuring Quality & Impact of Palliative
Care Programs
Source: Center to Advance Palliative Care
www.capc.org
Making the Case:
Benefits to Hospitals
• Lower costs for hospitals and payers
• A systematic approach to caring for outlier
patients
• Flexible programs support the primary care
physician
• Meeting JCAHO Accreditation Standards
• Easing burdens on staff and increasing staff
retention
• Meeting the needs of an aging population
Source: Center to Advance Palliative Care
Components Needed
for Success
• Strong Support from Administration
Gather internal/external evidence
• Program Champion
ID within or locate (eg, AAHPM Membership)
• Palliative Care Training and Mentoring
CAPC, national leaders (eg, von Gunten)
• Clarity
Clearly identified goals/mission
• Visibility
Case finding, presentations, etc.
Source: Davis, Jamison, Brumley, & Enguidanos, 2006