Replication of a HomeBased Palliative Care Program: A Multisite Study

1
Replication of a Home-Based Palliative Care
Program A Multi-site Study

• Susan Enguidanos, PhD
• Director, Research Center
• Partners in Care Foundation
• Assistant Professor
• Davis School of Gerontology
• University of Southern California
• sengui_at_aol.com

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Goals of Discussion

• Brief overview of End-of-Life Care
• Introduction to Home-based Palliative Care
• Evidence of Effectiveness
• Policy Implications
• Next Steps

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Definition of Terms

• Hospice Medicare benefit for last 6 months of
  life for those with terminal illness.
• Palliative Care pain and symptom relief provided
  for those with serious illness.

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Challenges in ProvidingEnd-of-Life Care

• Fragmentation of care
• Aging population
• Costs of medical care
• 25 of Medicare revenue is spent on 5 who die
  each year
• Average cost of care in last year of life is
  26,000 (1996 costs)
• Average cost of care in last 2 years 58,000

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A dichotomous intent
Curative / life-prolonging therapy
Presentation
Death
Relieve suffering (hospice)
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Barriers to Hospice

• Systemic
• Physician
• Patient

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Impact of Barriers

• Patients are referred late to Hospice
• Median length of stay22 days
• Patients often die in pain
• Patient EOL preferences are not considered
• Patients die in the hospital (60)

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Home Based Palliative Care Model

• Bridge traditional medical care and Hospice care
• In home end-of-life care for patients with one
  year life expectancy
• Blended model of care
• Shift focus of care from hospital to home

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Curative / remissive therapy
Presentation
Death
Hospice
Palliative care
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Core Components of Palliative Care

• Interdisciplinary team
• Physical, medical, psychological, social
  spiritual support
• Care provided in home
• Patient family education training
• Coordinated, patient-centered plan of care

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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
• 24 hour phone support, visits if necessary
• Volunteer bereavement services
• Transfer to hospice if appropriate

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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

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Progression ofIn Home Palliative Care Model

• Pilot study conducted in Kaiser Permanente (KP)
  Southern California in 1998
• Comparison group study KP Southern California in
  1999
• Won National KP Vohs Award for Quality in 2002

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Project Overview Funded by Garfield Memorial Fund

• Randomized controlled trial in Kaiser Permanente
  Colorado Hawaii (2002-2004)
• Study period 2 years (approximately 18 months of
  data collection)
• 310 patients recruited from 2 sites
• Colorado n150, Hawaii n160

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Data Collection

• Phone interviews at baseline and every 30 days up
  to 120 days
• Functional status
• Satisfaction
• At death or discharge from study
• Service utilization
• Medical care cost data
• Site of death

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Garfield Multisite Study Design
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Enrollment Criteria

• KP Health Plan Member
• Not receiving Hospice
• Diagnosis of congestive heart failure (CHF),
  chronic obstructive pulmonary disease (COPD), or
  cancer
• 1 or more emergency department/hospital visits in
  12 months
• Palliative Performance Scale 7 or less
• Life expectancy about 1 year
• Primary care physician would not be surprised
  if the patient died in the next year

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Study Groups

• Usual Care (UC)
• One visit by home health nurse to assess for
  further need
• Access to all usual medical care services
• Palliative Care (PC)
• Multiple home visits provided by
  interdisciplinary palliative team (physician,
  nurse, social worker, HHA, volunteers, pastor on
  request)
• Access to all usual medical care services

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Patient Flowchart
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Demographics of Study Participants

• Mean Age 74 (sd12)
• 77 of study participants were over 65. The age
  range spanned from 38-101
• 51 Male
• Primary Diagnosis
• 46.5 Cancer
• 32.7 CHF
• 20.8 COPD
• Mean of 2.5 major medical conditions (sd1.4)

• Marital Status
• 52.2 Married
• 29.3 Widowed
• 8.1 Single
• 6.7 Divorced
• 3.7 Unknown
• Ethnicity
• 63 Caucasian
• 16 Asian/Pacific Islanders
• 13 Hawaiian
• 5 Latino
• 2 African American
• 1 Other

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Baseline Group Comparisons

• No differences between study groups at enrollment
  in terms of
• Demographics ethnicity, age, gender, marital
  status, income level
• Palliative Performance Scale
• Palliative Care more satisfied with services at
  baseline
• Usual Care had significantly more days on service
  before death

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Baseline Variables
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Patient Satisfaction
Percent Very Satisfied at Enrollment (n277), 30
Days (n 216), 60 Days (n168) and 90 Days
Post-enrollment (n 149) by Study Group
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Adjusted Mean Satisfaction Scores at Enrollment
and 90 Days Post-enrollment by Study Group
P.004
P.4
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Acute Care Service Use (n297)
Plt.01
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Unadjusted Medical Service Use (n297)
Plt.01
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Total Service Costs
n292

• Adjusted costs of care for those in PC were 32.6
  less than those receiving UC
• Saves 7,551

plt.001 F16.66
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Average Cost Per Day
n292

• Adjusted average per day cost of care by study
  group based on the average days on service
• PC 95
• UC 213

plt.001
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Site of Death (n217)

• Studies show that most people prefer to die at
  home
• Patients enrolled in the Palliative Care program
  were significantly more likely to die at home
  (71 vs. 51 p.001)

P.013
(Townsend, Frank, Fermont, et al., 1990 Karlsen
Addington-Hall, 1998 Hays et al., 2001)
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Family Comments

• "We are so grateful our mother could participate
  in your Palliative Care Program.  What a gift! 
  It made possible an independent life until her
  death. Thank you for patience, devotion and
  capable care."
• But there were moments of stark beauty too.  A
  hospice priest counseled us about the freedom
  that comes from letting go of control.  My father
  thought quietly, then told me as I helped him
  back to bed that this realization had been a
  powerful assist, an emotional turning point. 
  Each day, he told my sister later, had become a
  gift, not a burden."

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Implications

• First rigorous study to examine the effectiveness
  of an in-home, community-based, palliative care
  program
• Provides strong clinical and financial evidence
  supporting the provision of palliative care in
  the home
• Tremendous implications for improving end of life
  care for terminally ill
• KP adapted as standard care throughout Southern
  CA moving to national

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Policy Implications

• Evidence provided here and in a previous study
  support the need for fundamental changes in the
  design of our health care system to bridge care
  between standard medical care and hospice care.
• Modification of Hospice benefit or development of
  a new pre-hospice benefit

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Future Studies

• Replicate within alternate funding structure,
  e.g., medical group
• Demonstration project to test benefited model of
  care, e.g., hospice
• Test similar chronic care model provided
  upstream, earlier in disease trajectory