Palliative Care Benchmarking: Timing is Everything

1. Palliative Care Benchmarking: Timing is Everything Mary Ann Gill, RNMA Executive Director, Palliative Care Services Project Manager, Palliative Care Leadership Center mgill@mchs.com

2. Presented at Recovering Our Traditions II— Journey to Excellence A Catholic Health Care Perspective On End-of-Life Care January 26-28, 2006 San Antonio, Texas

3. Sponsored by Supportive Care Coalition Pursuing Excellence in Palliative Care Catholic Health Association of the United States The George Washington Institute for Spirituality and Health

4. Outline • Palliative Care: Mount Carmel’s history and evolution • Infrastructure, Models • Strategies to achieve Quality • Establishing Benchmarks

5. Mount Carmel: Multi-Hospital System with Vertical Integration • Serving Columbus, Ohio, for >125 years • Three hospitals -- 53,000+ inpatient admissions • Care Continuum-- Hospice, Homehealth, + • College of Nursing, Medical Education • ASC’s and UCC’s • Owned Physician Practices • Medicare +Choice Product • Member, Trinity Health System

6. Mount Carmel Health System Table of Organizationand APCS

7. The Mount Carmel Hospice Operating since 1985 Established presence in health system Initiated collaboration re: system-wide pain management program in 1994 Historic presence in hospital ethics committees Focus of Hospice – care at home

8. Mount Carmel Palliative Care Services Palliative Care HospiceAcute Palliative Care Consult ServiceAPC Units

9. Mount Carmel Acute Palliative Care : Initial Vision Optimal pain and symptom management (physical, emotional, spiritual) for hospitalized patients with chronic advanced diseases Competent response to patient directives, choices Timely transfers from ICU, ED, SNF Concurrent disease focused treatment + palliative care Effective Continuum to Hospice

10. Strategy: Understand Chronic Disease • Chronic disease is continuous with episodic acuity • Chronic disease consumes 78% of healthcare expenditures • Characterized by shifting severity, pace, setting, and treatment • So multifaceted must involve IDT, care coordination • Must be able to weave the care of specialists into the overall plan

11. Background:Hospitals’ Current Challenges • More chronically ill patients often spending 10 or more days in ICU • Many DRGs cover 50% cost of ICU, yet market presses for more ICUs • Boutique hospitals attracting patients • Hospitalists replacing Primary Care physicians • Increasing numbers of uninsured or Medicaid

12. Background: Hospital Survival Strategies • Reduce variable costs • Reduce LOS (especially ICU) • Increase Physician Satisfaction • Increase Patient Satisfaction • Meet Healthcare report card benchmarks and become “best hospital”

13. Background: Hospice and Homehealth Realities and Survival Strategies • Earlier referral • Appropriate Hospital Discharge Plan • Access to patients in hospital to plan admission • Increase LOS to provide care and spread costs • Advance Care Planning process in place • Adherence to formulary

14. Background: Sources of Evidence • SUPPORT Study • Dartmouth Studies • National Concensus Project, • JCAHO

15. Background: SUPPORT Recommendations Create palliative care in hospitals • interdisciplinary team process • patient and family focus • pain and symptom management focus • ready access to Palliative Professionals

16. Background: Why Palliative Care Is Needed in Hospitals Chronically ill patient volume projections Hospitals struggling with how to manage this population re: LOS, resource utilization >50% patients die in hospitals = hospitals should be greatest source of Hospice referrals Hospitals need to import Hospice paradigm to create effective management of chronic disease and in-hospital mortality.

17. Strategy: Articulate a Vision Optimal pain and symptom management (physical, emotional, spiritual) for hospitalizedpatients with chronic advanced diseases Competent response to patient directives and choices Timely transfers from ICU, ED, SNF Concurrent oncology treatment and palliative care Seamless continuum to community

18. Strategy: Clearly Define Terms Hospice Care: Interdisciplinary care for dying patient with predictable prognosis; also for family– spiritual, emotional support--primarily in home setting including bereavement support MC Acute Palliative Care: Interdisciplinary care for seriously ill patient with unpredictable prognosis during acute hospitalization ; spiritual/emotional support for patient/family; concurrently preparing for improvement or decline/death

19. Strategy: Use Hospital data to determine Need • 5% Hospital Admissions annually • Top 20 DRGs resulting in death • Readmission rates within 6 months • Number of SNF patients entering ED • ICU deaths post 5 day LOS

20. Strategy: Define Program • In-Patient or Out-pt Consult Service? Units? Upstream or End of Life? • Administrative Responsibility • Location • Staffing • Routine, Standard Processes • Continuum Partners

21. Strategy:Describe Tools Needed Standard admission orders and criteria Rounds Worksheet Procedures: e.g. Palliative Extubation Educational materials • Staff/Students/physicians • Patient/family Data Base

22. Strategy: Define Routine Processes • Interdisciplinary Team Functionality (team rounds, IDT conferences) • Palliative Consultation- physician, nurse clinician roles in coordination, mentoring • Intensive pain/symptom management /protocols • IDT education, competency development • Data collection, analysis, feedback • Continuum interface

23. Strategy: Employ processes for Palliative Chronic Disease Management Care Coordination across settings Education of patient to interpret symptoms to team and to provide self management Adaptation by all to changing role of physician (cardiologist to palliative physician and team) Emphasis on behavioral techniques to understand impact of chronic disease Problem: None of this is norm in chronic disease management Holman,H. JAMA September 1, 2004, vol 292, no. 9

24. Strategy: Differentiate PatientTypes Patients with exacerbation of chronic illness who choose palliative life-extending treatment Patients receiving disease-directed treatment who may benefit from palliation of sx arising from disease or treatment Patients with serious, life-limiting illnesses for whom hospitalization often segue into Hospice Patients with acute event such as CVA

25. Strategy: Determine Referral Source, Criteria, Process, and Management • ICU Physicians and Staff • ED Physicians and Staff • Oncology Physicians and Staff • Nephrology Physicians and Staff • Case Management Staff • Hospitalists Physicians

26. Strategy: Create a Palliative Care Continuum Presence / collaboration-- hospital Ethics committees and consultations Develop tools which support continuum-- Develop processes to identify continuum patients who enter hospital through Emergency Department Explain/ Understand Reimbursement ramifications fo all partners

27. Strategy: Build Rapid Cycle, “Organic Quality Processes & Importance of Timing • Patient, family, physician, PC Team determine care plan concurrently • Plan checked daily for validity by the palliative care team • Benefits/burdens of treatment weighed daily • Plan Changed rapidly if indicated • Family support ongoing and into bereavement • Discharge planning initiated on entry

28. Strategy: Define Relevant Data • Patient demographics • Clinical Characteristics Functional status Diagnosis Advance directive status at time of consult Presence and timing of DNR orders • Pain and other symptoms • Evidence-based Interventions • In-hospital and ICU death rate and length of stay • Discharge destinations, -- hospice, homehealth, SNF, home referrals • Readmission Rates

29. Outcomes • New patients, all patients served • Total Admissions to APCUs • Most Frequent Symptoms • % Cancer/Non Cancer • ALOS on APCU or Consultation • % from ICU, IMCU • ALOS in prior unit • P/F Satisfaction (HCAHPS) “Would you recommend?”

30. Data Cont’d • PPS • CMI • Variable Cost Savings • Contribution to Overhead • % transferred to hospices • Hospice ALOS

31. Delineate Clinical Benchmarks Accessible, expert Advance Care Planning begins at initial consult Assessment of patients’ needs for effective pain/symptom management at each encounter Provision of Interdisciplinary palliation for patients and families within explicit time frames - Timely transfer of patients from ICU and ED into APCS; from APCUs to Hospice & to other providers

32. Sample: Diagnosis Types Primary Diagnosis % Cancer 38.6% Non Cancer 61.4% Cardiac 17.0% Pulmonary 15.3% CVA 9.6%

33. Sample: Discharge Destinations Continuum (48% Discharged) Hospice Home Hospice 25.2% ECF Hospice 8.8% ECF-Skilled 7.1% Homehealth 3.7% Other 3.9%

34. Hospital Reimbursement Basics Medicare Prospective Payment System Major Disease Categories Diagnosis Related Groups Case Mix Index Comorbidities and complications Expected Costs and Expected Payments Based on Bell Shaped Curve Utilization

35. Hospital Reimbursement Variables Principal Diagnoses mapping to DRG Co-morbidities & Complications effect payment Impact of Palliative Consultant and Attending Physician Documentation on DRG • MedPac Report to the Congress: Medicare Payment Policy March, 2002

36. Hospital Costs & Rev vs LOS ICU @ $750 /day+ Cost LOSSES! Cost per day LOS (Days in acute care bed)

37. Strategy: Palliative Financial Management • LOS Reduction=ICU Palliative Consultation at day X • Variable Cost Reduction = Earlier Transfer from ICU • Direct Admissions = Avoiding ICU, Control LOS • Consultation Team Productivity Standards

38. Financial Benchmark Processes • Permeable relationship between Clinical and Financial components • Commitment to Financial Data Collection • Using Data to demonstrate cost savings • Effective Care Coordination impact on variable costs • Early Identification Criteria impact on LOS management • Effective Payer strategies

39. Strategy: Manage Payers • Education of Commercial Payers • Coordination with Provider Relations • Challenge denials • MedPac Report to the Congress: Medicare Payment Policy March, 2002

40. Challenges • Just getting to the data • Understanding it • Interpreting it so as to project volumes and revenues

41. How APCS Controls Costs • Coordination of Services • Reduce LOS (Early Discharge) • Change of setting (Transition from ICU) • Change of Payer (Transition to HMB)

42. Strategy: Financial Management Reduce variable costs and LOS by transferring ↑ ICU patients earlier Create net income contribution ↑direct admissions to APCU’s freeing ICU beds and ending ED diversion Reduce variable costs through improved coordination of care and discharge planning Meet payer requirements by documenting need for inpatient care and DRG coding Maintain efficient, properly documented billing by palliative physicians

44. Palliative Care Benchmarks

45. Minimum Standard: Acute Palliative Care Consult service regularly available in hospital to facilitate palliative evaluation and management of symptom burden Supported by Interdisciplinary Process

46. Stepwise Approach toward achieving Palliative Benchmarks • Minimum Standard • Increased Presence, Breadth and Depth of Services • Routine Identification of Appropriate Patients in ED, ICU • Routine Advance Care Planning from hospital admission through inpatient course • Coherent System of Palliative Care from primary care through hospitalization, to discharge destination

47. Sharpening the SawExample: ACP Preliminary Discussion Formal ACP session by trained professionals Use of Valid, Reliable, Standardized Tool System in place to process/ accomodate choices Repository for storing and updating Directives L Bierbach. St Vincent Health System, Billings Montana ,

48. Benchmark Processes and Timing • Timing/frequency of rounding assessment • Timing of post assessment intervention • Timing of ICU Intervention and Transfer • Timing of ED Palliative Triage and Intervention • Timing of Initial Advance Care Planning Assessment and follow-up discussions • Extent to which Family is involved • Valid, Reliable Measurement of Symptoms

49. Patient/Proxy/Family Satisfaction % Timing/ frequency of Hospice Transfers Timing Palliative Care Recommendations Implemented

50. Palliative Care Benchmarks/Timing Patient status assessed within x days of admission Pain and Symptoms measured numerically Pain and Symptoms reduced within 48 hours Discharge Planning by day x Psychosocial Assessment by SW by day x Family Meeting by day x University Health Systems Palliative Care Benchmark Field Book 2004 Unpublished