Iowa Health System Leadership Symposium

Palliative Care and Hospice

The “Final” Frontier

“I am not Dr. James Bell”

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.

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

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

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

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?

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

The Four Stages of Life

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 (40 th overall, 27th in life expectancy)

NYT.030109.Business section page 1

Target Population for Palliative Care

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

• 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

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

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

IHS Hospice Programs

AffiliateHospice

House/IPU2009 Admissions 2010 Admissions

Des Moines Y 712 702

Cedar Rapids N 482 506

Quad Cities Y 485 497

Fort Dodge Y 330 444

IHS Palliative Care Programs

Affiliate Inpatient 2010 Outpatient 2010 ER

Des Moines 867 397 Y

Cedar Rapids 598 128 Y

Quad Cities N/A 45 N

Fort Dodge 130 N/A N/A

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)

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

Cost Avoidance

$-

$5,000.00

$10,000.00

$15,000.00

$20,000.00

$25,000.00

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Day of Stay

Ho

sp

ital

Ch

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e

Usual Care

Day 7 Consult

Day 11 Consult

Day 14 Consult

Average hospital charge/day

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