Palliative Medicine

With This Presentation, We Will:

• Convince you that Palliative Care is an Ethical and Quality Imperative –

which will also be reflected in our quality measures

• Create a sense (of urgency) that we need to do better

• Improve your understanding of Palliative Care:

– Debunk myths

– Understand what happens in a PC consult

– Provide some statistics

• Encourage you to be more open to advancing a culture related to Palliative

Care

• Discuss the activities that are being planned in to improve the care of

patients with serious advanced illness.

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Palliative Care – What and Why?

• Palliative Care is a specialized focus on care for the

whole person, including pain and symptom relief,

navigating the health care system, and getting

documents in place.

• At the right time, it’s providing the optimal end of life

care, including hospice, and bereavement support for

the family

• Most patients would like this help

• Most patients, when asked, would like to die at home

• But, we often don’t discuss these issues with them….

Or

A Deeper Understanding of Palliative Care

A Deeper Understanding of Palliative Care

How Does Palliative Care Work?

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How to Introduce Palliative Care consult

• Mr X as you know, you have a serious illness. I would like to get help from my

colleagues in palliative medicine, so we can work together to make sure you

are as good as you can be. The palliative care team focuses on improving

your symptoms, navigating our health care system and understanding what is

most important for you. We will always be available to help them as well as

you and your family.

• PLEASE BE POSITIVE and NEVER SAY: There is nothing more we can do!

There is always something we can do (it just may not be curative)!

• This introduction makes the palliative care team’s job much easier!

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ACP Documents

• Ongoing process of developing future medical care plans

• Not a “one size fits all” discussion

• Must be individualized to patient readiness and stage of health

LaPOSTPower of Attorney

for Health Care Living Will

Triggers for Palliative Care Discussions

• Serious advanced disease with a prognosis of one year or less (the “surprise”

question)

• Pain and symptom management issues

• Expected transition from curative to comfort focused treatments

• Frequent ED and hospital admissions in the last year

• Discussion of goals of care and advance care planning with completion of

documents

• Advanced lung, cardiac, renal, hepatic or neurologic disease (advanced dementia)

• Advanced Stage III or IV cancer, or recurrence

• Sudden acute event such as stroke, or heart attack with poor prognosis

• Disease triggers: aspiration, pneumonia, COPD, CHF or septicemia

• Lack of disease trajectory understanding

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Palliative Care Conversations• Types of issues palliative care addresses in patient with:

– Decreasing functional status who is no longer receiving curative therapy. Wife needs help. DISCUSSED HOSPICE and what it offers. LaPOST

completed.

– Financial and self care troubles still receiving curative therapies. ASKED for social work assistance and talked about palliative care home visits

– Symptom management (diarrhea) including improved pain control. Needs help getting DME and pain RX

– Symptom management (pain and shortness of breath) with little social support. Encouraged patient to let family know how ill he is. Offered to be on

call. Discussed home based palliative care and hospice.

– Known liver metastasis with increasing jaundice and pain. Made arrangements for GI/radiology evaluation. Pain meds adjusted.

– Heart failure does not want to return to hospital. Adjusted diuretics. Hospice referral made. Can get parenteral meds if included in care plan.

LaPOST completed.

– Dementia with poor oral intake and recent uti (treated with no improvement). Hospice referral made. LaPOST will be completed at home by

hospice.

– Pancreatic cancer with poorly controlled pain and family resistant to increasing pain meds. Long discussion about meds, relative potency and

expected results.

– Perioperative planning for H&N Cancer and symptom control. Discussed trach and PEG placement. Pain management.

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If We Don’t Augment Palliative Care

• Goals of care conversations and their relation to treatment options are rare

• Goal consistent care is rarely elicited therefore is frequently not achieved

• Patients and families struggle to cope with their circumstances

• Moral distress for everyone involved

• Unnecessary ED admissions, hospitalizations, acute care

• UNNECESSARY PAIN AND SUFFERING

• Providing good Palliative Care services is a moral and ethical

imperative!

– …..it is reflected in our quality measures, and makes care more affordable

May P, Normand C, et al. Economics of Palliative Care for Hospitalized Adults: A Meta-analysis, JAMA Intern Med, 2018 Apr 30.

Advanced Care Planning reduces Health

Care Costs by $2 for every $1 spent

Early Results

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JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC

2018 Palliative Care Inpatient Consult Volume Across the System

Jefferson Hwy Westbank Kenner

Palliative Care Inpatient Penetration (% of Discharges)

National benchmark:

5-10% penetration depending

upon patient acuity

Kenner experienced tremendous

PC growth YOY

78%

6% 5% 3% 1% 1% 1% 1% 1% 1%

0%

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OMCWB : Top 10 Ordering Specialties : 2016-2018

2016 2017 2018 % of Total Ordered

26%

20%

13%

6%

4% 3% 3% 3% 3% 2%

0%

5%

10%

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25%

30%

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OMCNO : Top 10 Ordering Specialties : 2016-2018

2016 2017 2018 % of Total Ordered

44%

22%

16%

3% 3% 3% 2% 2% 1% 1% 1%

0%

5%

10%

15%

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25%

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45%

50%

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OMCK : Top 10 Ordering Specialties : 2016-2018

2016 2017 2018 % of Total Ordered

Palliative Care Consults Top 10 Ordering Specialties

MEDVANTAGE CLINICPRIMARY CARE & WELLNESS

Kathy Jo Carstarphen, MD, MPH, MA

What Could Our Care of Very Sick

Patients Look Like?

MEDVANTAGE CLINIC – A MODEL FOR COMPREHENSIVE CHRONIC DISEASE MANAGEMENT

Prior to LHC Partnership

(from 10/2016 – 3/2018)

Since initiation of LHC Amb Palliative Care Program

(from 3/2018 – 2/2019)

53.8% of deceased patients

were enrolled in hospice at

the time of death.

78.9% of deceased patients

enrolled in hospice at the

time of death.

94.6% of deceased hospice

patients died in their homes

So, the Benefits of Palliative Care are Clear

• 59% reduction in hospitalizations (Sutter Health)

• 81% decrease in acute care days (Aetna Medicare

Advantage Compassionate Care Program)

• 37% decrease in hospital admission rate (ProHealth)

Better Quality

Outcomes

• Improved Provider

and Patient Experience

Cost Avoidance• $8,289 reduction total cost of care/patient (Sutter Health)

• $4,200 per month for cancer patients, nearly $3,500 per month for

heart failure patients (Sharp Healthcare Transitions Program)

• >95% physician/patient satisfaction (Sutter Health)

• 95% satisfaction and would recommend to others (ResolutionCare)

• High member satisfaction and no member complaints in 10 years

(Aetna Medicare Advantage Compassionate Care Program)

Palliative Care Across the Care Continuum

Not Just an In-patient Initiative

Inpatient Hospice

• Established at Jeff Hwy, Kenner, and the Northshore. In development at Westbank, Baptist, St. Charles and St. Bernard

Inpatient PC Service

• Available at Jeff Hwy, Westbank and Kenner

Outpatient PC Clinics

• Offered at Jeff Hwy, Kenner and Westbank

Home Base PC

• LHC joint venture. 387 referrals and 274 admits through December 18. 38.7% of admits transitioned to hospice

The Quadruple Aim

The Quadruple Aim

Being Comfortable with Shared Decision

Making can lower the stress of practice

We Have to Change our

Culture

Culture

• Desired - We don’t care for illness, we care for patients – and so, we

ensure that patient’s have their wishes respected in all phases of life

• Resistance:

– Continued perception that providing palliative care is “giving up” on patients and that a

patient should only receive palliative care when they are on death’s door

• Failure to consistently consult palliative care, even when patients have

expressed a desire for more palliative care support

• Physician’s lack of comfort and/or competency having palliative care

conversations

• Clinicians not understanding Palliative Care and presenting palliative care in

a negative light to patients and families that could benefit from the service

Partnership with Respecting Choices

• Respecting Choices is an internationally recognized, evidence-based model

of advance care planning (ACP) that creates a healthcare culture of person-

centered care—care that honors an individual’s goals and values for current

and future healthcare.

• Respecting Choices partners with healthcare organizations to develop a

comprehensive system that facilitates and promotes advance care planning

and person-centered care

First Steps

• Focuses on healthy adults or those early in chronic illness. Will enable Ochsner to reach patients and their families earlier and will normalize palliative care from the outset.

Advanced StepsFocuses on

individuals with serious, life-limiting

illness. Results in decreased use of

resources in the last months to years of life by avoiding care the patient does not want

(e.g. use of aggressive

technology, ICU, ED visits)

SDMSI*•Whereas the other modules address the entire care team, SDMSI focuses on the central role of the physician/provider in helping patients make any treatment decision that aligns with their goals and values.

Combining First Steps, Advanced Steps and SDMSI covers the full continuum

of care and incorporates all team members.

*Shared Decision Making in Serious Illness

Respecting Choices Programs

Respecting Choices- Stakeholder Impact

• Produces care consistent with patient values and goalsPatients

• Increases understanding of their loved one’s preferences and reduces stress, anxiety and depression in surviving family membersFamilies and caregivers

• Improves clinician competency and comfort level with advance care planning conversations. Reduces moral distressClinical teams

• Expands palliative care capacity and delivery. Improves patient, family, and clinical team experience and job retention.Ochsner health system

• Reduces unnecessary care and medical spend. Improves access to and quality of advance care planning

Communities and public health

Respecting Choices: Track Record

Journey to Date

• Core Team Formation – Guidance from across the System

• Informal and Formal Education being done

• Measures of Success Developed

– # of Palliative Care Consults

– Use of ACP module (meaningful patient discussions about Advanced Care Planning)

• Faculty and other team members recruited (ensuring a steady ramp as we do so)

• System-wide Education – Respecting Choices

• Maturing Program

– Community Outreach

– Analytics to track progress and identify opportunity

Roadmap to the Future

• Develop Organizational Structure

• EDUCATION and STAFFING

• Improve capabilities of PC teams at all Ochsner facilities

• Especially important to include GME – training the future generation

– We can benefit LSU Shreveport by helping them with this

• Working with LHCQF and Secretary of State office on integrating the LaPOST

registry with EPIC for seamless information transfer.

What Needs to be done?

1. Understand that Palliative Care and Shared Decision Making about End of

Life issues is an ethical imperative for health care providers to address with

their patients

– Even patients who travel here to get a unique treatment for a severe illness will

eventually die at some point, and their risk of dying is usually higher than that of the

average patient their age (even if everything we do is successful)

– We take care of people (their physical and emotional needs, as well as those of

their families) – we don’t just treat illnesses

2. Over time, learn how to have these important conversations with patients

3. We have Palliative Care resources now (and will be growing these) to help –

take advantage of these services

– We are piloting a program to electronically help identify patients with high palliative needs

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Thank You!

• Susan E. Nelson MD FACP FAAHPM

– Internal Medicine/Geriatrics/Hospice and Palliative Medicine

– Palliative Medicine physician, Ochsner Health System

– Medical Director, Post Acute Care, Ochsner Health Network

– Chair, LaPOST Coalition, Louisiana Health Care Quality Forum

• 1514 Jefferson Highway, New Orleans LA 70121

• P: (504) 842-0961 F: (504) 842-0090 C: (225) 907-5927

• Susan.nelson@ochsner.org

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