Iowa Health System Leadership Symposium

1. Iowa Health System Leadership Symposium Palliative Care and Hospice The “Final” Frontier

2. “I am not Dr. James Bell”

4. Palliative Medicine(IHS Affinity Group ) Palliative Medicine is a medical specialty that provides comprehensive, interdisciplinary care for patients with serious illnesses (and their families) with emphasis upon the quality of life and relief of suffering.  Palliative Care is provided throughout the trajectory of a disease process without regard to prognosis and can be provided in concert with curative care, as well as near end of life.  The Palliative Care team works with patients in conjunction with their primary care physician to address any physical, psychosocial, emotional or spiritual issues the patient may experience.

5. Palliative Care Key domains • Goals of care • Symptom management • Resuscitation status • Advance Directives/DPOA • Psychosocial/Spiritual issues Key components • Focus on quality of life • Team approach for holistic care • Physician, nurse, social services, spiritual • Primary “procedure”: FAMILY MEETING

6. How Dinosaurs became extinct (The very first “Senior Moment")

7. Palliative Care is Not: Giving up Pulling the plug Losing hope Stopping aggressive therapies Shortening life A very good name for what we do

8. Palliative Care seeks to answer • When does “living longer” become “dying slower”? • How can we remedy the deconstruction of humanity? • How can we accomplish this in a way that is ethically sound, clinically excellent, and fiscally responsible?

9. Palliative Care vs. Hospice • Palliative Care is upstream. Primary determinant is potentially life-limiting disease (this differentiates from well elderly, frail, chronically ill but stable) • Often continue to seek aggressive treatments • Discussing choices with filter of quality of life • “Surprise question” • Hospice is that specialized form of Palliative Care with 2 requirements • Life expectancy of < 6 months • Focus on comfort

10. The Four Stages of Life

11. National Landscape FISCAL Total health care costs in 2008 of $2.4 trillion (16% of GNP, rising to 20% in 2015) Medicare hospital expenditures 2001: $93 billion (39% of total) 2004: $136 billion (44% of total) 2009: $220 billion (44% of total) 27-30% of total Medicare budget consumed in last year of life Medicare Hospice expenditures 2008-- $11.4 billion (3% of total Medicare budget) DEMOGRAPHIC Population over 85 will double to 10 million by 2030 20% of U.S. population will be over 65 by 2035 CLINICAL U.S.– 53% die in hospital (not where they want) With predicted 6 month survival of 50/50, 38% spend >10 days in ICU and 10% spend 4 weeks in ICU 50% of patients report moderate or severe pain at least half of the time in the last three days of life Source: SUPPORT investigators, JAMA 1995 USA has poor ratings on quality measures of health care among industrialized countries (40th overall, 27th in life expectancy)

12. NYT.030109.Business section page 1

13. Target Population for Palliative Care

14. Hospice/Palliative Care Landscape • Hospice enrollment 1.5 million/year (2008) • 40% of all deaths • <50% cancer • 4000 Board certified HPM physicians (2010) • 1 physician/31,000 eligible patients • Specialty status under ABMS (began 2007) • Palliative care programs • 33% of all hospitals • 55% with >50 beds • 80% with >250 beds

15. The case for a strong presence of Palliative Care and Hospice in the US is clear based on • Dramatically longer life expectancy • Dramatically larger cohort of older Americans • Dramatically increased health care costs for the sickest segment of the population • Well documented benefit • Palliative Care and Hospice has grown and developed significantly over the last decade, and there is a developing framework for best practices

16. Healthcare Quality • Quality is • Patient-centered • Beneficial • Timely • Safe • Equitable • Efficient • Measuring quality • Structure • Process • Outcome • Measurement of quality requires data! National Quality Forum www.qualityforum.org Institute for Healthcare Improvement

17. “I’m a doctor, not a starship captain!”

18. IHS Hospice Programs

19. IHS Palliative Care Programs

20. Iowa Health SystemPalliative Care/Hospice • IHS Hospice Affinity Group, Palliative Care Affinity Group • Des Moines, Cedar Rapids, Quad Cities, Waterloo, Cass County, Fort Dodge • Development of statewide data base • Development of metrics • Inpatient • Outpatient • Support program development for affiliates with early or no programs • Physician Affinity Group • Support physician training and certification in HPM • Support statewide efforts to develop shared database and metrics • Support best practices in the system by demonstrating value, reducing variability (2011 focus on symptom management)

21. IHS Palliative Care Metrics • Inpatient • Consultation volume • Consultation rate • Length of stay • Length of stay outliers • Cost savings on impact days • Billable revenue • Pain • Dyspnea • Outpatient • Consultation volume • Discharge distribution • Readmission to acute inpatient care

24. Cost Avoidance

25. Average hospital charge/day

26. Iowa Health SystemPalliative Care/Hospice • How we manage to collect data and demonstrate quality and value will likely dictate success or failure in the approaching health care arena • Will be reflected in our ability to negotiate value-based contracting • The Iowa Health System is poised for success by virtue of • Leadership with vision • Willingness to allocate resources • Critical mass • Clinical expertise