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Reducing Avoidable Readmissions: The Business and Clinical Impact of Palliative Care

Reducing Avoidable Readmissions: The Business and Clinical Impact of Palliative Care. Susan Enguidanos, PhD, MPH enguidan@usc.edu. Agenda. Introduction to & Need for Palliative Care Evidence of Palliative Care Effectiveness Examples of Two Models of Palliative Care:

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Reducing Avoidable Readmissions: The Business and Clinical Impact of Palliative Care

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  1. Reducing Avoidable Readmissions: The Business and Clinical Impact of Palliative Care Susan Enguidanos, PhD, MPH enguidan@usc.edu

  2. Agenda • Introduction to & Need for Palliative Care • Evidence of Palliative Care Effectiveness • Examples of Two Models of Palliative Care: • Inpatient (Hospital-based) • Home-based • Palliative Care and 30-day Readmissions • Getting Started

  3. Introduction to Palliative Care

  4. Rise in Aggressive Care? Teno et al., 2013

  5. 65+ Medicare Beneficiaries ICU Use (Riley & Lubitz, 2010)

  6. Background: Patient & Family Need Current dying experience is far from one that is desired by most Americans • Majority of Americans prefer to die at home (Hays et al., 2001; Gallup, 2000) • 33.5% die at home (2009; Teno et al., 2013) • Patients continue to die in pain (Meier, 2006) • 46% of Do Not Resuscitate orders written within 2 days of death

  7. Palliative Care & Site of Death • Studies show that most people prefer to die at home* • Palliative Care patients more likely to die at home (Brumley, Enguidanos, Jamison et al., 2007) P=.013 *(Townsend, Frank, Fermont, et al., 1990; Karlsen & Addington-Hall, 1998; Hays et al., 2001)

  8. What is Palliative Care? Goal: “…to prevent and relieve suffering & to support the best possible quality of life for patients & their families, regardless of the stage of the disease or the need for other therapies.” What Palliative Care Does: “Expands traditional disease-model medical treatments to include the goals of enhancing quality of life for patient & family, optimizing function, helping with decision making, & providing opportunities for personal growth.” National Consensus Project for Quality Palliative Care, 2013

  9. Curative / remissive therapy Presentation Death Palliativecare Hospice Adapted from Lynn and Adamson, 2003

  10. Core Components of Palliative Care • Interdisciplinary team: MD, RN, SW, Chaplain • Physical, medical, psychological, social & spiritual support • Patient & family education & training • Develop plan of care • Coordinated, patient-centered care

  11. Core Components of Palliative Care • Pain & symptom management • comprehensive primary care to manage underlying conditions • Aggressive treatment of acute exacerbation per patient and family request • Facilitates transfer to hospice if appropriate

  12. Palliative Care Models Hospital-based, Inpatient Palliative Care Programs Home-based Palliative Care

  13. Inpatient Palliative Care (IPC) • Consultative IPC service involves family meeting with patients/family • Follow-up care as needed

  14. Home-based Palliative Care • Eligibility • Diagnosis of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or cancer • Life expectancy about 1 year • Primary care physician “would not be surprised” if the patient died in the next year • Palliative Care (PC) • Multiple home visits provided by interdisciplinary palliative team • Access to all usual medical care services

  15. Palliative Care vs. Hospice • Physicians not required to give a 6 month prognosis • Patients do not have to forego curative care • Palliative care physician coordinates care to prevent service fragmentation

  16. National Use of Hospice Care (NHCPO, 2011, 2012)

  17. Clinical and Economic Impact of Palliative Care

  18. Inpatient Palliative CareLower Costs of Care Lowered cost by $4855 More days in Hospice care (p= .04) (Gade, Venohr, Connor et al., 2008)

  19. Fewer ICU Admissions at Readmission (IPC) (Gade, Venohr, Connor et al., 2008)

  20. Other IPC Evidence(Morrison et al., 2008) • Comparison Group Study • IPC patients discharged had savings of $1696 in direct costs per admission (p=.004) • $279 in direct costs per day (p<.001) • IPC patients who died had savings of $4908 in direct costs per admission (p=.003) • $374 in direct costs per day (p<.001)

  21. The Economic and Clinical Impact of IPC • Mean daily costs for IPC patients • 33% (p< .01) pre- to post-intervention • 14.5% compared to usual care (p< .01) • LOS  30% • Pain  by 86% • Dyspnea  by 64% (Ciemins, Blum, Nunley, Lasher, Newman, 2007).

  22. Home-based PC: Patient Satisfaction p=.02

  23. Home-based Palliative Care:Total Service Costs • Adjusted costs of care for PC patients 32.6% less than UC • Saves $7,551 (Brumley, Enguidanos, Jamison et al., 2007) n=292 p<.001

  24. Home-based Palliative Care: Patient Acute Care Service Use (n=297) * P<.01

  25. Home-based Palliative Care Patient Unadjusted Medical Service Use (n=297) * P<.01

  26. 30-Day Readmission among Seriously Ill Older Adults: Why Do They Come Back?

  27. Readmission Rates among IPC Patients • Among IPC patients discharged, overall readmission rate = 10% • Overall hospital readmission = 15% • Reduced readmission by 1/3 Enguidanos, Vesper, & Lorenz (2012). 30 day readmissions among Seriously Ill Older Adults. Journal of Palliative Medicine, 1-6.

  28. Type of Care at Discharge (n=408) (Enguidanos et al., 2012)

  29. Readmission Rate by Post Discharge Service Use (Enguidanos et al., 2012)

  30. Predictors of 30 Day Readmit Examined age, gender, ethnicity, marital status, pain, diagnosis, # chronic conditions, anxiety, ADs, and their association with 30 day readmit No Advance Directive 2.7x’s more likely Added discharge disposition to the model Nursing Facility 5x’s & Home (no care) 3.7x’s more likely As compared to discharge to Hospice & HBPC Enguidanos, Vesper, & Lorenz (2012). 30 day readmissions among Seriously Ill Older Adults. Journal of Palliative Medicine, 1-6.

  31. Interviews with Seriously Ill 30-Day Readmits (n=10) CHF & Cancer Patients Three themes identified: • Lack of Support & Purpose • Rehospitalization as appropriate care • Lack of access to care/information

  32. Theme: Lack of Support & Purpose • Lack of support & purpose • Living alone and lack of support • “I wasn’t cooking for myself, I wasn’t doing anything…I just wasn’t eating” • “It’s just a matter of me …motivating me” • “If there was something I could look forward to…”

  33. Theme: Appropriate Care • Hospital care most appropriate for medical condition and treatment preferences “ I get to retaining the fluids again and then right back to where we were [hospital]” • Preference for aggressive care “ I ain’t going nowhere, and I’m fighting”

  34. Theme: Lack of access to care/information • “I should be comfortable. I shouldn’t have to go, ‘Oh, I got pain I need pain meds.’ I shouldn’t be going after pain medication…I was told I should come back to the ER to get my pain medicine.” • “Sometimes I have questions” • “I could have REALLY used a hospital bed” • Inability to physically transport spouse to specialist appt

  35. Discussion • Limited access to holistic care • Enrollment in hospice and palliative care have clear benefits, but problems getting there • Late referrals to hospice • Limited number of home-based palliative care • Most IPC referrals are late in the disease trajectory • Too late to change the course of care or improve quality

  36. Discussion • Lack of continuity problematic: • Quality of life • Most people prefer to die at home. Late transfers increase odds of death in hospital (Gonzalo, 2011). • Care may not be consistent with wishes.

  37. Getting Started

  38. Building a Palliative Care Program • Making the Case for Palliative Care • Designing a Palliative Care Program • Financing a Palliative Care Program • Implementing a Palliative Care Program • Measuring Quality & Impact of Palliative Care Programs Source: Center to Advance Palliative Care www.capc.org

  39. Making the Case:Benefits to Hospitals • Lower costs for hospitals and payers • A systematic approach to caring for outlier patients • Flexible programs support the primary care physician • Meeting JCAHO Accreditation Standards • Easing burdens on staff and increasing staff retention • Meeting the needs of an aging population Source: Center to Advance Palliative Care

  40. Components Needed for Success • Strong Support from Administration • Gather internal/external evidence • Program Champion • ID within or locate (eg, AAHPM Membership) • Palliative Care Training and Mentoring • CAPC, national leaders (eg, von Gunten) • Clarity • Clearly identified goals/mission • Visibility • Case finding, presentations, etc. Source: Davis, Jamison, Brumley, & Enguidanos, 2006

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