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Meeting Them Where They Are: How Home Based Palliative Care Can Improve Care for the Seriously Ill JAMIE BRANT, MD INTERNAL MEDICINE/PALLIATIVE CARE AMG SENIOR MEDICAL GROUP MEDICAL DIRECTOR UNIVERSITY OF UTAH-ADJUNCT ASSISTANT PROFESSOR INTERNAL MEDICINE

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Page 1: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Meeting Them Where They Are:How Home Based Palliative Care Can

Improve Care for the Seriously Ill

JAMIE BRANT, MD

INTERNAL MEDICINE/PALLIATIVE CARE

AMG SENIOR MEDICAL GROUP MEDICAL DIRECTOR

UNIVERSITY OF UTAH-ADJUNCT ASSISTANT PROFESSOR INTERNAL MEDICINE

Page 2: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Disclosures

No financial disclosures

Page 3: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Goals of presentation

Understand the current state of the U.S. healthcare system

Identify problems of current healthcare delivery

Understand the changing demographic in the U.S.

Understand the full palliative assessment

Know the literature behind the benefits of home based healthcare

delivery

Be inspired to look at creative ways to care for frail, older adults and

those living with severe chronic illness

Develop awareness of potential areas of research.

Page 4: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Upstream/Downstream:

A Fable for our TimesDonald Ardell, PhD.

As medicine was developing, there has been progressively more

focus on reacting rather than being pro-active. Now as baby

boomers age, we see the need for more upstream discussions

about goals of care, prevention of complications due to waiting

and meeting patients literally and figuratively where they are.

Page 5: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

State of U.S. Medical System

Progressively more compartmentalized

Who “owns” the patient-getting orders

Evidence based

Litigious

Overly optimist in prognostication

Time limited

Reactive

Christakis NA, Lamont EB. Extent and Determinants of Error in Doctor’s Prognoses in Terminally Ill Patients: Prospective Cohort Study. BMJ. 2000; 320:469-472

Page 6: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Demographics are changing

Longer life spans and higher birth rate (baby boomers)

Growth in number of older adults unprecedented

Double the geriatric population over the next 25 years (72 million)

By 2030-olders adults will account for 20% of population

More than a quarter of all Americans and two out of every three older

Americans have multiple chronic conditions

Treatment for this population accounts for 66% of the country’s health

care budget

CDC-State of Aging and Health-2013

Page 7: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

In-Home Palliative Geriatric

Approach

Care goals-central guiding light-most important part

Improve QOL thru symptom management

Help plan for future with anticipatory guidance

Follow geriatric tenants of care

Page 8: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Story of Mr. H

Page 9: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Was this a successful final chapter?

What were the barriers?

Page 10: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

The Problem…Difficult Access

Page 11: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

The Problem: Fragmented Care

Page 12: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

The Problem….Difficult Communication

Multiple “cooks in the pot.”

Inconsistent messages

Difficult to communicate

Page 13: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

The Problem….Evidence Based?

Frail elderly and chronically ill not included in the studies.

Some Geriatric/palliative specific data but not robust

May be evidence based specific for geriatrics but not within goals

More gray area

Page 14: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

The Problem….Not Patient

Centered

Page 15: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Goals of Care

Most frail and chronically ill often want to put limitation on care

POSLT as example

Many are DNR

Many elect limited interventions

Some decline hospitalization

Some elect no antibiotics except for comfort

Many decline artificial hydration and nutrition

Page 16: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

The Problem….Prognosis

Not Considered

Page 17: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Prognosis Combined with Goals

Page 18: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Ahalt et al, JGIM

2011

Page 19: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

How do we Prognosticate?

Page 20: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Shortcomings of Clinical Predictions

Tend to overestimate patient survival by a factor of between 3 and 5.

Tend to be more accurate for very short-term prognosis than long-term prognosis.

37% would not prognosticate even if asked

Influenced by relationships

The length of provider- patient relationships increases the odds of making an erroneous prediction.

Christakas, Annals on Int Med, 2001

Page 21: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Prognostic Pearls

Trajectory is very important

Lower PPS is more accurate

Patients less concerned with accuracy than delivery

Unified message

Let patient decide how much information to give

Discuss in terms of weeks/month/years

What does this have to do with primary care in the home?

Casarett, DJ, Quill, TE. I’m not ready for hospice: Strategies for timely and effective hospice

discussions. Ann Int Med; 2001 146: 443-449

Page 22: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Barriers to discussion

Lack of time

Fear of taking away hope

Discomfort with the discussion

Denial in patients

Cognitive decline

Lenherr, Gabriel, et al. To speak or not to speak-do clinicians speak about dying and death with geriatric patients at

the end of life? Eur J Medical Sciences. 2012. 142: 1-7

Page 23: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

The Problem…No Time!

Greater time crunch to make sure we are meeting all quality

measures

Volume in clinic is immense

Creates a culture of reactivity for end of life.

Page 24: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

The Problem……COST

27% of Medicare dollars are spent in the last 1 year of life

50% of dollars are spent on most costly 5%

18% of the total expenditure is patient out of pocket

2.8 % of Medicare dollars are spent on hospice

Centers for Medicare & Medicaid Services, Office of the Actuary

Page 25: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Summary of Problem

Lots of patients getting lots of intensive medical care that they

don’t want at an astronomical cost!!

Rapidly growing number of Medicare recipients

Those who are the most ill/frail have the greatest difficulty

getting the care they need.

Limitations of our current medical system create roadblocks

for patients to remain in the driver seat

Support trial. Journal of the American Medical Association. 1995

Page 26: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Home based primary/palliative care

Page 27: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Patient Centric

(Guiding Light are Goals and Values)

ALF

Hospital

ER

MD

Page 28: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Components of home based PC visit

Goals of care

Focus on geriatric tenents-5-10% of admits due to medications

Strong consideration of prognosis-qualify for admit on best day-how

are you going to keep them out of the hospital.

Excellent communication w/ facilities, family, HH and

subspecialty/acute care MD’s

More time spent but lower overhead

Page 29: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Home Based Primary Care

Intervention

Page 30: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Components of Intervention

Physician/NP services delivered in home

Availability of in-home labs and other diagnostics

Focus on eliciting goals and values with Advance Care Planning

Strong Consideration of Prognosis

Avoidance of polypharmacy

Excellent communication among patients and families

Excellent communication in acute setting and with subspecialists

Care continued into the inpatient setting

Page 31: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Outcomes of the Intervention

Highest quartile of frailty had greatest cost savings

17% lower costs over 2 years compared with control group

Less hospital, skilled nursing, subspecialist visits

More home health, hospice and primary care expenditures

No difference in mortality or average time to death

Improved satisfaction

Page 32: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Palliative Home Nursing

Staffed by hospice nurses

Biweekly interdisciplinary team meetings

Team consists of nurse, physician, chaplain, and social worker.

Telephone triage line that provides 24-hour access to RN

No requirement that goal is comfort care

No requirement to forego life prolonging treatment

Ranganathan et al. Can Palliative Home Care Reduce 30-day Readmissions? Results of a Propensity Score Matched Cohort Study. J Palliatmed 2013 Vol 16, Number 10

Page 33: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Palliative Home Nursing

Can Palliative Home Care Reduce 30-Day Readmissions?

Palliative care patients had 9.1% 30-day readmission compared to 17.2 %

Controlled for known predictors of readmission (ex: presence of IV)

Mean visit frequency was 0.74 visits/day versus 0.23 visits per day on standard home care

Ranganathan et al. Can Palliative Home Care Reduce 30-day Readmissions? Results of a Propensity Score Matched Cohort Study. J Palliat med 2013 Vol 16, Number 10

Page 34: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Kaiser Permanente

Page 35: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Kaiser Permanente-Home Based

Palliative Care

CHF, COPD and cancer

Improved satisfaction (30 days and 90 days)

Fewer ER visits

Fewer hospitalizations

Fewer skilled days

45% reduction in cost

No change in mortality

Page 36: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Independence at Home

CMS demonstration project

14 participating sites across US

Three year study (on year 2)

Outcomes are patient experience through quality measure and

cost savings

Requirements-already established home-based primary care

Payment is fee for service (FFS) plus bonus for meeting quality

measures

Page 37: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Independence at home

Patient inclusion criteria

2+ chronic conditions

Have traditional medicare fee for service coverage

Need assistance with 2+ ADL’s

Have had a non-elective hospital admission in the last 12 months

Have received acute or subacute rehabilitation services in the last year

Page 38: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Independence at home

Practice inclusion criteria

Led by MD or NP’s

Are organized for the purpose of providing physician services

Have experience providing home-based primary care

Serve at least 200 eligible beneficiaries

Teams often include PA’s, pharmacists, social workers and other staff

Page 39: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Independence at home

Quality Measures

Hospitalizations and Emergency Room Visits

30 day hospital readmission rates

Medication reconciliation in the home within 48 hours of discharge

(50%)

In-home follow-up or phone follow-up within 48 hours of discharge from

hospital or ER (50%)

Patient preferences for treatment documented (80%)

Page 40: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Independence at Home

Outcomes Year 1

Fewer hospital admissions within 30 days

Follow-up contact from their provider within 48 hours of hospital

admission, discharge or ED visit

Medications reconciled by their provider within 48 hours of discharge

Preferences documented by their provider

Used less inpatient hospital and ER for certain conditions (avoidable)

such at DM, HTN, asthma, pneumonia or UTI.

Page 41: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Independence at Home

Outcomes year 1

All 17 practices improved quality in at least 3 quality measures

4 practices met all six

Cost savings-25 million or around $3000 per beneficiary

One practice saved $1000/month on service.

Page 42: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Cost Savings: Summary

VA-24% lower VA cost and 11% lower Medicare cost

Kaiser Permanente-45% decrease in total costs

FFS model for HBPC-17% lower Medicare Costs

Current study is Independence at Home (Medicare pilot) in the fee for service arena-so far 25 million in savings

All showed improvement in satisfaction

None showed shorter length of life.

Beales, JL. Veteran’s Affairs Home Based Primary Care. Clin Geriatra Med, 2009

Independence at Home Demonstaration Project section 3024 of the Affordable Care Ace

Rabow, Michael et al. Moving Upstream: A Review of the Evidence of the Impact of Outpatient Palliative Care

Brumley RD et al. Effectiveness of a Home Based Palliative Care Program for End of Life. J Palliat Med 2003

DeJonge et al. Effects of Home Based Primary Care on Medicare Costs in High Risk Elders. JAGS 2014

Page 43: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Who benefits the most?

Frail elderly

Those with severe, chronic illness with frequent exacerbations

Those with limited access to care

Bimodal peak?

Healthcare utilization inversely proportional to prognosis ?

Page 44: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Unintended consequences

Lower cost

Better communication

Better anticipatory guidance

More appropriate care that is consistent with goals

Improved patient satisfaction

Page 45: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Current and Predicted

reimbursement ratios-FFS vs

alternative

2014-20% alternative/innovative reimbursement

2016-30% alternative/innovative reimbursement

2018-50% alternative/innovative reimbursement

Most FFS will be linked with performance and quality

CMS.gov. Affordable Care Act payment model saves more than 25 million in first performance year. June 18, 2015

Page 46: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

How do we pay for this?

Fee for service in private residence-challenging due to driving time

but several practices are doing this

Fee for service but in assisted living only

Innovative approaches:

Medicare pilot projects

Grant funding-often short lived

Partnership with insurance plan

Insurance plan owned programs

ACO-% of cost savings.

Page 47: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Back to Mr. H

How could this have gone differently?

Page 48: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Mr. H-Important part

He was married 58 yrs and lost his wife 1 year ago

He was the CEO of large company prior to retiring at age 68

He has had a lifelong love of learning

He moved to ALF after his wife died

He has children but all were out of state

Page 49: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Mr. H-Care goals/values

He values functional and cognitive independence which he feels

he has lost

Reports current QOL to be poor

He misses his wife terribly

He doesn’t want to prolong his life in any way.

He is ready to die and be with his wife.

NO ONE HAS ASKED AND NO ONE KNOWS HIS WISHES!!

Page 50: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Prolonging life?

Prolonging death?

Page 51: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Mr. H-choose your own adventure:

Goals of care discussed prior to illness

Hospice either initiated prior or discussed hospice to start

if there is acute decline

Mr. H died at his assisted living on his own terms

Less complicated grief for family

Page 52: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

Mr. H…Choose your own

adventure 2

Mr. H desperately wanted to attend his granddaughters

wedding

He was able to do so because of his hospitalization

He had the first dance from his wheelchair

Any amount of suffering was worth that moment

Page 53: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

In home geriatrics/palliative care

benefits

Coordination w/ subspecialists is extensive

In home evaluation provides important information

Ease of obtaining care

Provider serves as a QB

Experts in geriatric and palliative care, polypharmacy, falls etc.

Advance Care Planning is central theme

Improved satisfaction

Page 54: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

UPSTREAM EXAMPLES

Fall mitigation

Less polypharmacy

GOALS OF CARE –AVOID FUTILE CARE AND HONOR GOALS

Improved access

Cohesive care upstream with better communication/coordination

Page 55: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

But the glass is half full!!

Debbie downer no longer!!

Slow but steady change-finances influence as focus is on cost

savings but ultimately this may encourage more discussions

New reimbursement models support this type of healthcare delivery

HBPC tends to do this already

Page 56: Meeting Them Where They Are - School of MedicineShortcomings of Clinical Predictions Tend to overestimate patient survival by a factor of between 3 and 5. Tend to be more accurate

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