Managing Advanced Illness to Advance Care
Executive Briefing - AHA Annual Meeting
Tuesday, April 30, 2013
10:45am – 12:15pm
© 2012 American Hospital Association
Advanced Illness Management Strategies: Part I
The first CPI report framed AIM as
a four-phase process to be
addressed through three
strategies—access, workforce and
awareness
The report also examined in depth
how hospitals can increase access
to AIM programs and change the
way medical services are utilized to
improve outcomes and honor the
wishes of patients and families.
2
Advanced Illness Management Strategies: Part II
This second and follow-up report:
• Expands and explains more
precisely the three key
strategies of AIM—access,
workforce and awareness
• Provides health care systems
strategies and case examples
that focus on patient and
community awareness and
engagement and a ready, willing
and able workforce.
3
Why Integrate AIM Programs?
AIM programs allow hospitals to navigate the first-curve to
second-curve transition and fill the gap.
In the hospital setting, AIM programs are proven to:
• Provide patients with improved quality of life, reduced
major depression and increased length of survival
• Lower utilization of clinical treatments and hospital
admissions among enrolled patients
• Improve satisfaction scores for patients, family,
caregivers and the multidisciplinary AIM-trained staff
• Reduce aggregate spending
4
Phases of AIM
5
Managing the Gap:
Strategies to Developing a Successful AIM Program
6
Three Key AIM Strategies
Access
Patient access to AIM services
can be greatly increased when
all hospitals and care systems
are able to support and delivery
high-quality AIM.
Workforce
Excellence in AIM depends upon
the education and training of
health care professionals that
can deliver quality hospice,
palliative and end-of-life care.
Awareness
Patient and family AIM
awareness and understanding of
the benefits of advanced illness
planning and management can
be significantly raised through
communitywide strategies.
7
(1) Strategies to Increase Access to AIM Services
• Develop a multidisciplinary care team with leadership
buy-in
• Identify qualifying patients through evidence-based
protocols
• Think beyond the traditional four walls of the hospital to
promote AIM collaboration throughout the surrounding
community
• Use a performance improvement framework to
measure, monitor, evaluate and adapt the program
between disease states and throughout time
8
(2) Strategies to Expand Patient and Community
Awareness and Engagement
• Increase patient accessibility to information about end-of-life care
by developing awareness and “conversation-readiness” among
health care professionals; work with stakeholders on the
importance of conversations, advance directives and early
decision making; provide effective language assistance services;
and address low health literacy
• Launch community development strategies that spread awareness
of cultural diversity and support partnerships with local leaders
and organizations that cater to the patient population’s
demographics, education levels, culture and language
• Develop a workforce that embraces diversity to address the
needs of patients and families from a variety of backgrounds and
is equipped with the skills and knowledge necessary to support
and guide those facing end of life
9
(3) Strategies to Build a Ready,
Willing and Able Workforce
• Develop educational programs that offer ongoing training
for health care professionals to learn the necessary skills
and competencies for engaging in sensitive conversations
and that train health care providers on the role and impact
of spirituality in end-of-life care
• Use a multicultural guide/spiritual toolkit to support
understanding and meeting diverse patient needs
• Create a solid program infrastructure to sustain a successful
palliative and end-of-life care program
10
Thank you!
http://www.aha.org/about/org/
cpi.shtml
11
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
–
–
–
–
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)
–
–
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
Sharp HospiceCare’s
Transitions Program
A New Model for Late Stage
Disease Management
Daniel R. Hoefer, MD
CMO, Outpatient Palliative Care and Hospice
Suzi K. Johnson, MPH, RN
Vice President
Sharp HealthCare Hospice and Palliative Care
• First generation outpatient palliative care
• Second generation outpatient palliative care
1. UCSF
2. Kaiser
3. Sutter (AIM)
4. VA
5. Care More
6. Health Care Partners
7. Partners Medical Group (Boston)
8. University of Pittsburgh
9. Long Island Jewish
10. Hospice of the Valley
11. Sharp HealthCare
Goals
CMS Goals:
1.Better individual patient care
2.Better population care
3.Lower growth in health care expenditures
4.Prevent readmissions
Sharp Transitions Goals:
1.Better individual patient care
2.Better population care
3.Reverse the growth in heath care expenditures
4.Better professional caregiver support
5.Better professional family support and conflict resolution
6.Prevent any admissions including primary admissions
Principles of Transitions
• Proactive In home Disease Management
• Proactive Psychosocial Management
• Accurate description of what the health care industry
can and cannot provide
Cultural Mind Shift
“The continued application of traditional treatment
strategies which are valuable to the patient at an
earlier time in their health experience has the opposite
effect on patients at end of life resulting in inferior
outcomes.”
Daniel Hoefer, MD
CMO, Outpatient Palliative Care and Hospice
Sharp HospiceCare
Issues Important in the Management of a
Pre-terminal Aging Population:







Mobility Deficit
Transportation Deficit
Financial Restraint
Social Support/Family Deficit
Cognitive Deficit
Compliance Deficit
Change in Goals of Care
It is better to bring healthcare to patients at this
time, than to bring patients to healthcare.
Current Culture of Health Care
• Reactive versus Proactive
• Paternalistic
• Dependent
The Traditional Medical Model
“This Disease Can Be Cured”
27% of patients with incurable terminal disease
believed they could have been cured
Unresectionable non-small-cell lung cancer
54%
AIDS
32%
CHF
22%
ALS
16%
COPD
12%
Daniel P Sulamsy, OFM, MD, PhD, et al, The Accuracy of Substituted Judgment in Patients with
Terminal Diagnoses, April 1998, Annals of Internal Medicine, Vol 128(8), PP 621-29
Hospitalizations last year of life - CHF
Acceptable or Not?
• Historical average hospitalizations for CHF during the
last year of life 3.5
Where Patients with CHF Die
Acceptable or Not?
• Historically 63% of CHF patients died in the
hospital (2005)
Expanding the Care Continuum
•
•
•
•
•
Home Setting
Focus on high risk late stage chronic illnesses
Skilled Clinicians
Flexible Models
Cost efficient
Four Pillars of Transitions
Extending the evidence based benefits of Hospice Care to
patients at an earlier point in their healthcare.
Comprehensive in-home patient and family education
about their disease process; proactive medical
management
Evidence-based Prognostication
Professional Proactive Management of the Caregiver
Advance Health Care Planning
Pillar One
In Home Proactive Disease Management
Registered Nurse
Medical Social Worker
Spiritual Care
Primary Care MD
Palliative Care MD
Decrease Primary Admissions
& Re-admissions
Improved
Symptom
Management
Improved
Compliance
Improved Disease
Management
The best medication reconciliation occurs in the home
Pillar Two
Evidenced-Based Medical Prognostication
1.
2.
3.
4.
343 doctors
Estimates on 468 terminally ill patients
Mean patient survival – 24 days
Considered accurate if estimate within 33% for any
give patient
5. 20% of the time accurate
a. 80% of the time inaccurate
b. 63% over-optimistic
British Medical Journal; Extent and Determinants of Error in Doctors Prognoses in Terminally Ill
patients; Prospective Cohort Study; Vol 320(7233), 19 Feb 2000 pp.469-473
The Clinical Consequences of
Institutionalized Over-optimism
(Pillar Two Continued)
6. The average over-optimistic estimate was off by 530%
a. Increases the risk that treatment decisions by
patients, families and healthcare providers are
NOT consistent with reality
b. Leaves patients and families emotionally unready
for inevitable outcomes
c. Increase risk that providers will lose credibility
British Medical Journal; Extent and Determinants of Error in Doctors Prognoses in Terminally Ill
patients; Prospective Cohort Study; Vol 320(7233), 19 Feb 2000 pp.469-473
Diagnosis and Treatment
vs.
Diagnosis, Treatment and Prognosis
Biometric models + functional decline patterns +
specific biological data + general biological data +
adjusting for your personal tendencies = accurate,
effective, professional and compassionate
information.
Event Prognostication – Prognostication
which guides the patient in an expected
series of events.
Anticipatory Guidance
CHF
82 Year old male
Co-managed with specialist
Functional Decline
Progressive decline SOB
Slow rise in ADL decline
Pillar Three
Professional Evidence-Based Care
for the Caregiver
Evidence based medicine - Hospice care is
associated with an absolute reduction in death rates in
the caregiver at 18 months post death of the patient of
0.5% (1 in 200)
Nicholas Christakis, et al, The Health Impact of Health care on families: a Matched Cohort Study of
Hospice Use by Decedents and Mortality Outcomes in Surviving, Widowed Spouses, Social Science
and Medicine 2003, vol57 pp.465-475
Pillar Four
Advance Health Care Planning
Evidence based medicine shows that AHCDs (which
would include POLST) do not consistently match the
health care desired by the patient with the care
received by the patient
Problems with Advance Health Care
Directives
 They are not disease specific
 They are too vague or contradictory to be interpreted
in the context of the care which is being provided
Resolve Morale Conflict Proactively
Create Disease Specific Directives
Transitions
Case Management Design
• Active Phase
• Maintenance Phase
• Role of Hospice
– 24 hour call availability
– Full integration and hand offs between programs
Transitions
Active Phase
RN Case Manager
 4-6 visits in 6 week time frame
MSW
 1-2 visits for goals of Care discussion; completion
of POLST
Transitions
Maintenance Phase
RN Case Manager
 Telephonic case management – every 2-4 weeks
until transferred to hospice
 Home visits as needed for assessment
 Coordinate care with MD ongoing
 Transfer to hospice when appropriate
Hospitalization ER Utilization: All cause
During Transitions
94% reduction in primary CHF admissions
Synergy
Transitions to Hospice
….The impact of change…
Cost of Care
Thank You