palliative care in the nursing home · 1/29/2015 4 mortality and los in ltcf o 25% americans die in...
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Palliative Care in the Nursing HomeJanet Bull, MD FAAHPM, HMDC
Objectives
o Understand nursing home environments, the impact of healthcare reform, and the alignment of palliative care services
o Identify ingredients of a successful palliative care program
o Discuss CMS Innovations model of care
o Define tools, process and outcome metrics that are useful in improving care, and demonstrating success
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What Keeps You Up at Night?
NH Administrators
o Occupancy
o Decreased reimbursement
o Dealing with multiple payer sources – MA plans
o Partnerships
o Star ratings
o Staff turnover
o Case mix
o Readmissions
Trendso Overall number of nursing facilities decreased by .7% to
15,643
o Occupancy decreased from 85.6 to 83% with decrease in patients from 1.6 to 1.3 million
o Increase in For‐Profits => 69%
o Majority of ≥ 65 yo => need LTCF for average of 3 years, and by 85 yo, 20% for 5 years
Kaiser Foundation Overview of Nursing Facility Capacity, Financing, and Ownership in the United States in 2011
Peter Kemper et al., “Long‐Term Care Over an Uncertain Future: What Can Current Retirees Expect?,” Inquiry, 42 (2005): 335‐350
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Expected Growth in Nursing Homes
Understanding Nursing Home Environmento Strict regulatory requirements
o Salaries tend to be lower
o Reimbursement declining – tight margin
o Understaffing in RN and CNA positions
o Sicker patients secondary to shortened hospital stays
o High staff turnover
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Mortality and LOS in LTCF
o 25% Americans die in LTCF
• Half of these died within 5 months
• 65% died within 12 months
• ALOS – 14 months (other data – 2 years)
• Males and higher financial worth had shorter prognosis
Kelly, A J Am Geriatr Soc 58:1701–1706, 2010. Length of Stay for Older Adults Residing in Nursing Homes at the End of Life
Dementia in LTCF
o Accounts for up to 2/3 of all admissions
o Death rate doubled from 1996 to 2007
o Behavioral issues often drive NH admissions
o Staff often ill equipped to handle
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Bereavement Surveys ‐ LTCF
o 32% patients have pain
o 24% patients dyspnea
o 60% inadequate emotional support
o Only 42% rated quality of care as excellent, as compared to 71% with hospice care at home
Teno JM, Family perspectives on end‐of‐life care at the last place of care. JAMA 2004; 291:88.
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Affordable Care Act – Triple Aim
Palliative Care
At least 1/3 of LTCF patients are appropriate for palliative care at time
of admission!
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Times are Changing
Fee for Service
Pay for Performance
Risk‐sharing/
ACOs
Quality Demonstration
*Cost/quality‐directed decision making
*Group Accountability
*Outcomes‐directed decision making*Physician Accountability
*Physician choice
*Physician Accountability
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Accountable Care Organizationso Population health
o Redesign care processes
o Focus on post acute continuum
o Infrastructure development
• Health information exchange
• Coordination across care settings
5 Star Ratings for Nursing Home
o Health inspections – last 3 years
o Staffing
o Quality Measures
Each category has 5 star category and is designed to help consumers compare LTCF
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Quality Measures – Long Stay
• falls
• physically restrained
• UTIs
• need help ADLs
• Mod – severe pain
• depressive symptoms
• pressure ulcers
• influenza vaccine
• Incontinence
• pneumococcal vaccine
• catheter
• antipsychotic meds
• weight loss
http://www.medicare.gov/NursingHomeCompare/About/Long‐Stay‐Residents.html
Quality Clinical Measures
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Quality Measures – Short Stay
• Mod – severe pain
• New Pressure ulcers
• Influenza vaccine
• Pneumococcal vaccine
• Antipsychotic med
http://www.medicare.gov/NursingHomeCompare/About/Short‐Stay‐Residents.html
Goals for 2015
o Dementia patients on antipsychotics
• Goal from 20.3% 19%
o Pressure ulcer rate
• Goal from 6.7% 6.6%
20.30% 19.00%
6.70% 6.60%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
Goal‐ Patients on Antipsychotics Goal ‐ Pressure Ulcer Rate
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Quality Metrics for Nursing Homes
o Pay for Performance
o None of the QM pertain to end of life
o 2 Proposed additional EOL measures
• Place of death
• Hospice enrollment prior to death
Mukamel,J Palliat Med. Apr 2012; 15(4): 438–446., End of Life Quality‐of‐Care Measures for Nursing Homes: Place of Death and Hospice
NH Value Based Purchasing Pilot
o Pay for Performance
o Pilot – Virginia, New York, Wisconsin
o Staffing, QM, Survey Deficiencies, Hospitalizations
o Top 20% ‐ participate in shared savings
http://innovation.cms.gov/initiatives/Nursing‐Home‐Value‐Based‐Purchasing/
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Nursing Home Compare
http://www.medicare.gov/nursinghomecompare
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Readmissions
o 25% Medicare patients readmitted within 30 days to the hospital
o 2/3 of transfers are considered avoidable
o NHs will soon be penalized
• HHS proposal to decrease payments by up to 3% by 2017 for NH with high readmission rates
o 2018 – HHS proposes bundled payment system
Readmission Rates ‐ Benchmarkso 21% readmitted within 30 days
• 25.5% ‐ worst ranking facilities
• 19.8% ‐ best ranking
o 4.3% died within 30 days
o Lower readmissions correlated with better staffing ratio, but not quality indicators
Neuman, JAMA. 2014;312(15):1542‐1551 Association Between Skilled Nursing Facility Quality Indicators and Hospital Readmissions
o American Health Care Association (AHCA) recommends reduction to <15%
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Dying in America: Improving Quality and
Honoring Individual Preferences Near the End of Life
IOM (Institute of Medicine) 2014.
IOM Report Recommendations
o Palliative Care Training/Education
• Symptom Management
• Effective Communication
• Advance Care Planning
• Goal based Care
• Continuity across settings
o Covering Patient’s Social Needs
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A Shifting Paradigm…
Traditional Care Transformational Care
Physician led Team led
Acute clinical needs Goal directed care
Silo care ‐ specialists Coordinated health teams
Fee for service Value based purchasingBundled payments
Going From Macro To Micro…
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Opportunities for Palliative Care
o Projected 40% of all deaths in NH by 2020
o Poor pain and symptom management
o High degree of social and spiritual isolation
o Inadequate physician involvement in care
o Exclusion of resident/family in treatment decisions
Benefits of Palliative Careo Palliative care –improves quality of care
o Coordinated care
o Higher completion of Advance Care Planning
o Reduce hospital transfers
o Higher family and patient satisfaction
o Improved staff satisfaction with education component and availability of providers
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Miller, Lima, Intrator, Martin, Bull, Hanson, 2015, Brown School of Public Health, preliminary research results.
Screening Tool for PCo Completed by MDS/admissions coordinator on all NH
admissions
o Identifies all patients with a cancer diagnosis
o Identifies all patients with end stage disease, such as CHF, COPD, dementia, ESRD
o Identifies patients without Advance Directives
o Identifies patients with pain or symptom needs
o Identifies multiple hospitalizations
o If positive screen, call is placed to attending for PC consult
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Defining Eligibility
o Define your program parameters. Don’t try to be all things to all people. It is better to under promise and over deliver.
o Eligibility criteria – patients with serious or life‐limiting illnesses
o Excluded – chronic pain, i.e., quadriplegic• post surgical• substance abuse• acute pain (orthopedic)
Risk Stratification
o Demographics
o Diseases
o Clinical signs and symptoms (ADLs, cognitive and nutritional decline)
o Adverse events (hospitalizations, ER)
Porock,D. Journal of Gerontology, 2005, Vol. 60A, No. 4, 491–498
Predicting Death in the Nursing Home: Development and Validation of the 6‐Month Minimum Data Set Mortality Risk Index
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Prognosis – NH Patients
o MDS Mortality Rating Index
o Scoring system based on 10 factors and ADLs assistance
Porock,D. Journal of Gerontology, 2005, Vol. 60A, No. 4, 491–498
Predicting Death in the Nursing Home: Development and Validation of the 6‐Month Minimum Data Set Mortality Risk Index
http://eprognosis.ucsf.edu/porock.php
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Developing Referral Sources
o RELATIONSHIPS o Physician and facility preference listso Developing your message – how do you benefit them with
your services? o Humble attitude in a host environmento Plan for educating their staffo “Rounding” tool – communicate frequentlyo Create a win‐win situation
Key Nursing Home Personnel
o Director of nursingo Charge floor nurseso MDS coordinatoro Admissions coordinatoro MD directoro Ancillary staff (dietary, PT, OT)o Nursing home administrator
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INTERACT o Communication
o Care paths or clinical protocols
o Advance Care Planning
o Available for LTCF, ALF, home health, and ACO (under development)
http://interact2.net/tools.html
Interventions to reduce acute care transfers
INTERACT – Communication Tools
o SBAR tool
o Medication Reconciliation
o Stop and Watch – early warning on changes with residents
o Transfer forms/checklist
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INTERACT Care Pathso Fever
o Dehydration
o Dyspnea
o CHF
o GI sx – nausea, vomiting, diarrhea
o Respiratory Illness
o Altered mental status
o Change in behavior
o UTI
Advance Care Planning Tools
o ACP tracking tool
o Communication guide
o Comfort care order sets
o Decision about hospitalization
o Feeding tube education
o CPR
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QTC – Quality Transitional Care Pilot
o Coordination with hospital discharge planners, primary care providers, home heath, NH, and ALF’s
o RN contacts pt/families within 48 hours of discharge
• Medication reconciliation
• Patient education
• Symptom assessment – QDACT Tool
• Schedules PC visit based on acuity
o RN case manager in facility < 2x week
Results
0
5
10
15
20
25
30
35
40
45
Readmission BeforeQTC
Readmission AfterQTC
196 Patients – Within 30 days
4%
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CMMI – Round 2 Innovation Grant
o The Innovation Models are organized into seven categories.• Accountable Care
• Bundled Payments for Care Improvement
• Primary Care Transformation
• Initiatives Focused on the Medicaid and CHIP Population
• Initiatives Focused on the Medicare‐Medicaid Enrollees
• Initiatives to Speed the Adoption of Best Practices
• Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models
Palliative Care Teamso PC Admin (scheduling, HIM, billing)
o PC NP (1:100)
o PC RN (1:300)
o PC SW
o PC MD/DO ‐ oversight for team
All patients have QDACT Assessment
Eligibility: ≥ 65 yo, Medicare
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Palliative care in the SNF
o Staffing ratios
• Caseload – NP caseload ‐ 100 patients
• Productivity – 6‐8 visits/day
o Billing
• Intensity > Time based billing
o Support Staff
• Scheduling, HIM, IT, Billing, Admin
Role of the Nurse Practitionero Understands nursing home environment and spends time
with relationship building
o Understand state and federal regulations
o Responsible for risk stratification
o Assigned to 1‐2 nursing homes to keep consistent care
o Provide formal education quarterly with rounding tools daily
o Available by phone 24/7
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Palliative Care Progress Noteo Written with the MDS in mindo Document:
• Pain scores and interventions• Symptom assessment• Continence issues• Cognitive status• Behavioral issues and need for antipsychotics• Oral intake/weight and interventions • Patient/family goals• Progress or lack thereof of PT/OT• Coordination with NH plan of care
Align with NH Quality Metrics
o Patients prefer to avoid hospital deaths
o Hospice patients quality of care
o Better pain control
o Less physical restraints
o Lower use of feeding tubes
o Higher patient/family satisfaction
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Building a system – QDACT v 2
Metrics to Tracko Hospice Transitions
• LOS average and mean
o Hospital Readmissions
o Symptom Scores
o ACP
o Patient/family Satisfaction
o Billing
• Intensity > Time based billing
