Palliative Care:
Advancing Quality and Improving Costs
MAY 6, 2015
DEBORAH K. ZASTOCKI, DNP, RN, NEA-BC, FACHE
What is Palliative Care?
2

Specialized medical care for people with serious illness

Provides patients with relief from the symptoms, pain and
stress of a serious illness – whatever the diagnosis

Goal is to improve quality of life for both the patient and the
family

Appropriate at any age and at any stage of a serious illness

Can be provided at the same time as disease treatment to help
people live as well as possible while facing illness

It includes end of life care and hospice
3
Consider the Facts:
4
5
Our current state:
% of Advance Directives( AD)
or POLST Completed ~ 25%
Availability of the
AD or POLST at
time of critical
decision < 50%
ED providers
who honor
POLST
~30%
6
Patient wishes honored and implemented
25% * 50% * 30% = 4%
Jeanne J. Venella DNP, MS, CEN, CPEN
Chief Nursing Officer
Nuvon, Inc.
Caught in a Whirlwind
 JWJ: 80 y/o male, Married 57 years, 3 Children and is a
Veteran
 Co-Morbidities include:
 Congestive Heart Failure 6/2006 , PM with Defib
 Pulmonary Fibrosis 2/2009


After patient requested a consult at the Transplant Center
Enrolled in a Phase I trial in the summer of 2010
 Diabetes
 Prostrate Cancer
 Stage I Lung Cancer 11/14
The Vicious Cycle
 92 readmissions- for heart failure
 4 readmissions within 24 hours (2 to ICU)
 Heart Failure remote monitoring (4 week only)
 Multiple severe falls at home
 I learned more from my DNP student than I ever heard before from his
care team
 O2 cord color (green), choking, swallowing pills, falling, & driving with
high flow O2
 At tertiary care center: He qualified for lung radiation in 1/2015, while
on 8 L/ O2 /per min. He was told his odds were 50% to live 5 years, not
taking into account his other diseases
 No communication between hospital, physician specialists, home care,
VA and Primary Care MD
Remarkable “Will” to Live
 During these 11 years, JWJ managed:
 All his appointments
 Follow-ups, MD-MD communications
 Lab work and results
 Medications (at times over 42 pills/day)
 Drove CT Scans to Center City Philadelphia from NJ
 And in his family life,
 Saw all 6 grandchildren graduate high school
 5 from college (2 from his alma mater)
 Celebrated his 80th birthday
Palliative Care
 Palliative care was recommended 3 weeks prior to his
death
 Hospice was finally arranged 2 weeks prior
 Remained at home until 27 hours prior to his death
Can’t We Do Better?
 Even with a clinical expert on his team, we often:
 Experienced very poor communication
 Lack of hand-offs to primary and specialty MDs
 Lack of honesty
 Overall poor planning and coordination
 Sadly, I know we are not the only ones!
Palliative Care Quality and Cost
Tammy I. Kang, MD MSCE
Director, The Pediatric Advanced Care Team
Program Management Director, Medical Directors
The Children’s Hospital of Philadelphia
Palliative Care is in the Public Eye…
How Does Palliative Care
Differ From Hospice?
• Non-hospice palliative care is appropriate at any point in a
serious illness. It is provided at the same time as life-prolonging
treatment. No prognostic requirement, no need to choose
between treatment approaches.
• Hospice is a form of palliative care that provides care for those
in the last weeks/few months of life. Patients must have a 2 MDcertified prognosis of <6 months + give up insurance coverage
for curative/life prolonging treatment in order to be eligible.
(Medicare Hospice Benefit: 84% Medicare, 5% Medicaid, 3% uninsured)
Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.
The Demographic Imperative:
Chronically Ill, Aging Population Is Growing
• The number of people over age 85 will double to 10 million
by the year 2030.
• The 23% of Medicare patients with >4 chronic conditions
account for 68% of all Medicare spending.
US Census Bureau, CDC, 2003. Anderson GF. NEJM 2005;353:305
CBO High Cost Medicare Beneficiaries May 2005
Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.
Does Higher Spending Improve Outcomes?
More is Less and Less is More
Higher spending does not lead to better outcomes.
Medicare claims data for 4.7 million beneficiaries and 4,300 hospitals:
• Dramatic geographic variation in utilization
• Regions of highest utilization (most specialist visits, hospital days,
ICU use), have highest mortality and v.v. after (partial) risk
adjustment.
JAMA 2006; 296:159-160.
www.dartmouthatlas.com/atlases/2006_chronic_care_atlas.pdf
ES Fisher et al Health Affairs 2004; suppl web exclusive: VAR 19-32.
ES Fisher et al. Annals Intern Med 2003; 138:288-98.
Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.
Caregiving Increases Mortality
Nurses Health Study: prospective study of 54,412 nurses
• Increased risk of MI or cardiac death: RR 1.8 if
caregiving >9 hrs/wk for ill spouse
Lee et al. Am J Prev Med 2003;24:113
Population based cohort study 400 in-home caregivers +
400 controls
• Increased risk of death: RR 1.6 among caregivers
reporting emotional strain
Schulz et al. JAMA 1999;282:2215.
Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.
Palliative Care in Hospitals is Growing
19
Beneficial
Patient/
Family
Centered
Equitable
Quality
Timely
Efficient
Safe
20
Is it Beneficial?
Outcomes of Palliative Care:
• Reduction in symptom burden
• Improved patient and family satisfaction
• Reduced costs
Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.
Palliative Care Is Beneficial
Mortality follow back survey palliative care vs. usual care
Casarett et al. J Am Geriatr Soc 2008;56:593-99.
•
N=524 family survivors
•
Overall satisfaction markedly superior in palliative care group, p<.001
•
Palliative care superior for:
 emotional/spiritual support
 information/communication
 care at time of death
 access to services in community
 well-being/dignity
 care + setting concordant with patient preference
 pain
 PTSD symptoms
Other studies demonstrating benefit of palliative care: Jordhay et al Lancet 2000; Higginson et al, JPSM, 2003; Finlay et al, Ann Oncol 2002; Higginson et al, JPSM
2002. See capc.org/research-and-references-for-palliative-care/citations
Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.
RCT of Nurse-Led Telephone
Palliative Care Intervention
•
•
•
•
•
N= 322 advanced cancer patients in rural NH+VT
Improved quality of life and less depression (p=.02)
Trend towards reduced symptom intensity (p=.06)
No difference in utilization, v. low in both groups
Median survival: intervention group 14 months, control
group 8.5 months, p=.14
Bakitas M et al. JAMA 2009;302(7):741-9
Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.
Relationship Between Quality of Life and End-of-Life Care
Wright, A. A. et al. JAMA 2008;300:1665-1673.
Copyright restrictions may apply.
How Palliative Care Reduces
Length of Stay and Cost
Palliative care:
• Clarifies goals of care with patients and families
• Helps families to select medical treatments and care
settings that meet their goals
• Assists with decisions to leave the hospital, or to
withhold or withdraw death-prolonging treatments
that don’t help to meet their goals
capc.org/research-and-references-for-palliative-care/citations Lilly et al, Am J Med, 2000; Dowdy et al, Crit Care Med, 1998; Carlson et
al, JAMA, 1988; Campbell et al, Heart Lung, 1991; Campbell et al, Crit Care Med, 1997; Bruera et al, J Pall Med, 2000; Finn et al, ASCO,
2002; Goldstein et al, Sup Care Cancer, 1996; Advisory Board 2002; Davis et al J Support Oncol 2005; Smeenk et al Pat Educ Couns
2000; Von Gunten JAMA 2002; Schneiderman et al JAMA 2003; Campbell and Guzman, Chest 2003; Smith et al. JPM 2003; Smith,
Hillner JCO 2002; www.capc.org; Gilmer et al. Health Affairs 2005. Campbell et al. Ann Int Med.2004; Health Care Advisory Board. The
New Medical Enterprise 2004. Elsayem et al, JPM 2006; Fromme et al, JPM 2006; Penrod et al, JPM 2006; Gozalo and Miller, HSR
2006; White et al, JHCM 2006; Morrison RS et al Arch Int Med 2008
Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.
Association Between Cost and Quality of Death
in the Final Week of Life (adjusted P = .006)
Zhang, B. et al. Arch Intern Med 2009;169:480-488.
Copyright restrictions may apply.
Medical Care Received in the Last Week of Life
by End-of-Life Discussion
Wright, A. A. et al. JAMA 2008;300:1665-1673.
Copyright restrictions may apply.
Palliative Care Shifts Care
Out of Hospital to Home
Service Use Among Patients Who Died from CHF, COPD, or Cancer Palliative Home
Care versus Usual Care, 1999–2000
Usual Medicare home care
Palliative care intervention
40
35.0
30
20
13.2
11.1
9.4
10
5.3
2.3
2.4
0.9
4.6
0.9
0
Home health
visits
Physician
office visits
ER visits
Hospital days
Brumley, R.D. et al. 2007. J Am Geriatr Soc.
Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.
SNF days
Hospital Palliative Care Reduces Costs
Cost and ICU Outcomes Associated with Palliative Care Consultation in 8 U.S. Hospitals
Live Discharges
Costs
Usual
Care
Hospital Deaths
Δ
Palliative
Care
Usual
Care
Palliative
Care
Δ
Per Day
$867
$684
$183*
$1,515
$1,069
$446*
Per Admission
$11,498
$9,992
$1,506*
$23,521
$16,831
$6,690*
Laboratory
$1,160
$833
$327*
$2,805
$1,772
$1,033*
ICU
$6,974
$1,726
$5,248*
$15,531
$7,755
$7,776***
Pharmacy
$2,223
$2,037
$186
$6,063
$3,622
$2,441**
Imaging
$851
$1,060
-$208***
$1,656
$1,475
$181
Died in ICU
X
X
X
18%
4%
14%*
*p<.001
**p<.01
***p<.05
Morrison, RS et al. Archives Intern Med 2008;
Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.
Mean direct costs/day for patients who died and who
received palliative care consultation versus matched
usual care patients
Usual care
PC consult day 7
PC consult day 10
PC consult day 15
2000
1500
1250
1000
750
500
25
23
21
19
17
15
13
11
9
7
5
3
250
1
Direct Cost ($)
1750
Hospital Day (Day 1= First full day after day of admission)
Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.
Published data on cost savings




McCarthy IM, Robinson C, Huq S et al. (2014), Cost savings from palliative
care teams and guidance for a financially viable palliative care program. Health
Services Research. - See more at: https://healthmanagement.org/s/significantcost-savings-with-early-palliative-care#sthash.ZyHYg6uh.dpuf
Cost Savings and Enhanced Hospice Enrollment with a Home-Based Palliative
Care Program Implemented as a Hospice–Private Payer Partnership," published
in the new edition of the Journal of Palliative Medicine (Volume 17, Number
12, 2014).
Camilla Zimmermann, Nadia Swami, Monika Krzyzanowska, Breffni Hannon,
Natasha Leighl, Amit Oza, Malcolm Moore, Anne Rydall, Gary Rodin, Ian
Tannock, Allan Donner, Christopher Lo. Early palliative care for patients with
advanced cancer: a cluster-randomised controlled trial. The Lancet, 2014
Nathaniel JD, Garrido MM, Chai EJ, Goldberg G, Goldstein NE. Cost Savings
Associated with an Inpatient Palliative Care Unit: Results from the First Two
Years. . J Pain Symptom Manage. 2015 Apr 3. pii: S0885-3924(15)00160-8. doi:
10.1016/j.jpainsymman.2015.02.023. [Epub ahead of print]
Key recommendations


In 2012, American Society of Clinical Oncology recommended offering
palliative care alongside standard oncologic care to all patients with
metastatic cancer and uncontrolled symptoms. The recommendation
was based on findings from seven randomized clinical studies, which
showed that integrating palliative care into oncology services led to
improvements in symptoms, quality of life, and patient satisfaction, and
reduced caregiver burden. Involving palliative care also led to more
appropriate use of hospice and intensive care.
In Dying in America, a consensus report from the Institute of Medicine
(IOM), a committee of experts finds that improving the quality and
availability of medical and social services for patients and their families
could not only enhance quality of life through the end of life, but may
also contribute to a more sustainable care system.
Studies demonstrating Quality

Improved quality of life at end of life related to home-based palliative
care in children with cancer. Friedrichsdorf SJ et al. J Palliat Med.
(2015)

Early palliative care improved quality of life in patients with newly
diagnosed metastatic NSCLC. Arnold B et al. Ann Intern Med. (2010)

Reduction of opioid side effects by prophylactic measures of palliative
care team may result in improved quality of life. Myotoku M et al. J
Palliat Med. (2010)

Effects of a palliative care intervention on clinical outcomes in patients
with advanced cancer: the Project ENABLE II randomized controlled
trial. JAMA. 2009 Aug 19;302(7):741-9. doi: 10.1001/jama.2009.1198.

Exposure to home-based pediatric palliative and hospice care and its
impact on hospital and emergency care charges at a single institution. J
Palliat Med. 2014 Feb;17(2):183-8. doi: 10.1089/jpm.2013.0287. Epub
2013 Dec 31.
Study Overview
• Patients with metastatic lung cancer randomly
assigned to receive standard oncologic care or
early palliative care, focused on symptom
control and psychosocial support for patients
and families, together with standard
oncologic care.
Depressed at 12 weeks 38% vs 16%
Anxious at 12 weeks 30% vs 25%
Median survival times 8.9
months vs. 11.6 months
Conclusions
• Patients receiving early palliative care had
lower rates of depression, a better quality of
life, and better mood scores.
• They also received less aggressive care at the
end of life, but surprisingly, had significantly
longer survival than did patients receiving
standard care alone.
Final Messages

Palliative care is about aligning treatments with the
patients / family’s goals, hopes and values

PC does not equal Hospice care

PC is relatively independent of prognosis

PC is more than just good care, it is an essential
component of healthcare quality

Integration of PC into care of patients with advanced
illness is an essential tool that overall can reduce
healthcare costs
Palliative Care
Program Development
David Free, DNP(c), MS, FNP-BC, ACHPN
National Palliative Care Coordinator
Seasons Hospice & Palliative Care
What does this all mean?
Sure, there’s the who, what and
Why of palliative care, Everyone is
talking about that, but…
What about the how?
US Department of Health and Human Services. Adapted from “Palliative and End-of-Life Care”
http://hab.hrsa.gov/tools/primarycareguide/PCGchap15.htm
Program Development
•
•
•
•
•
•
the Decision
The Model
The team
The metrics
The results
The Future
The Decision
The Evidence for Palliative Care
The Decision at Your Site
•
In the post-acute setting
• Community
 Bed-hold days
 Hospital readmissions
 Moderate to severe pain scores  Lost work days for family and
caregivers
 Advance directives and DNR
data
 Unmet symptom or pain needs
 Anticipated/actual deaths not
 Additional layer of support
on hospice
needed
 Patient/family satisfaction
 Patient/family satisfaction
scores
with care
 Additional layer of support for  Additional layer of support
busy staff
for busy staff or caregivers
•
Tertiary care
 30-day readmit numbers
 24-hour pain scores and other symptom
metrics
 Cost per day
 Length of stay
 Patient family satisfaction with care
 Additional layer of support for busy staff
The Key?
A champion
The Program Model
Internal Versus External
There are pros and cons to either,
but it really comes down to
organization needs and preference
The Team
• Certification & experience matter
“Anything worth doing is worth
doing right” (Hunter S. Thompson)
The Metrics
The Center To Advance Palliative Care
(CAPC)recommends:
1. Operational data (e.g. volume and type of
referrals, date of admission/consultation)
2.
Clinical data (e.g. pain and symptom control)
3. Customer data (e.g. patient, family, and health
care provider satisfaction surveys)
4. Financial data (e.g. billing revenues, cost per
day, length of stay)
Choosing, Monitoring, & Reporting
Performance indicators
CAPC encourages palliative care teams to:
1. Identify the data elements that are
needed/requested by key stakeholders
2. select metrics from CAPC National Registry
dataset or, if you are a hospital, the Joint
Commission Palliative Certification req’mts
3. Identify the variables currently collected or
stored in existing site databases
4. Choose or develop standardized tools to
gather information that cannot be obtained
from site databases
5. Work with an appropriate professional to build a
database or spreadsheet to store this info, and
a Data Dashboard to monitor and report
6. Enter and track annual program data through
CAPC’s National Palliative Care Registry
CQI & Partnership development
If we are are going to be ready for the
Impending silver tsunami, we must
respond to best evidence pointing to the
effectiveness,
quality,
and
cost
containment associated with palliative
care, and then work together, reduce
redundancy,
increase
cooperation
between and within organizations, break
down silos, and increase capacity in the
areas of elder, hospice, and palliative
care to meet the present & imminent need.
Great Resources
• Center to Advance Palliative Care
(CAPC): member organization, EBP
clearing house, National Registry, Holds
annual national seminar with workshops
on palliative care for Leaders in all
health sectors and systems)
• National Hospice and Palliative Care
Organization (NHPCO)
• Hospice Palliative Nurses Association
(HPNA)
• American Academy of Hospice Palliative
Medicine (AAHPM)
Questions
Are there any questions for any of
us?