Palliative Care Benchmarking: Timing is Everything

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Palliative Care Benchmarking Timing is
Everything

• Mary Ann Gill, RNMA
• Executive Director, Palliative Care Services
• Project Manager, Palliative Care Leadership
  Center
• mgill_at_mchs.com

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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
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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
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Outline

• Palliative Care Mount Carmels history and
  evolution
• Infrastructure, Models
• Strategies to achieve Quality
• Establishing Benchmarks

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Mount Carmel Multi-Hospital System with
Vertical Integration

• Serving Columbus, Ohio, for gt125 years
• Three hospitals -- 53,000 inpatient admissions
• Care Continuum-- Hospice, Homehealth,
• College of Nursing, Medical Education
• ASCs and UCCs
• Owned Physician Practices
• Medicare Choice Product
• Member, Trinity Health System

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Mount Carmel Health System Table of Organization
and APCS
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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

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Mount Carmel Palliative Care Services

• Palliative Care
• Hospice Acute Palliative
  Care
• Consult Service APC
  Units

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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

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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

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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

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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

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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

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Background Sources of Evidence

• SUPPORT Study
• Dartmouth Studies
• National Concensus Project,
• JCAHO

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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

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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
• gt50 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.

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Strategy Articulate a Vision

• Optimal pain and symptom management (physical,
  emotional, spiritual) for hospitalized patients
  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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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?

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Data Contd

• PPS
• CMI
• Variable Cost Savings
• Contribution to Overhead
• transferred to hospices
• Hospice ALOS

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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

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Sample Diagnosis Types

• Primary Diagnosis
• Cancer 38.6
• Non Cancer 61.4
• Cardiac 17.0
• Pulmonary 15.3
• CVA 9.6

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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

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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

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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

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Hospital Costs Rev vs LOS
ICU _at_ 750 /day Cost

LOSSES!
Cost per day
LOS (Days in acute care bed)
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Strategy Palliative Financial Management

• LOS ReductionICU Palliative Consultation at day
  X
• Variable Cost Reduction Earlier Transfer from
  ICU
• Direct Admissions Avoiding ICU, Control LOS
• Consultation Team Productivity Standards

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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

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Strategy Manage Payers

• Education of Commercial Payers
• Coordination with Provider Relations
• Challenge denials

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Challenges

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

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How APCS Controls Costs

• Coordination of Services
• Reduce LOS (Early Discharge)
• Change of setting (Transition from ICU)
• Change of Payer (Transition to HMB)

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Strategy Financial Management

• Reduce variable costs and LOS by transferring ?
  ICU patients earlier
• Create net income contribution ?direct admissions
  to APCUs 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

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• Palliative Care Benchmarks

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Minimum Standard Acute Palliative Care

• Consult service regularly available in hospital
  to facilitate palliative evaluation and
  management of symptom burden
• Supported by Interdisciplinary Process

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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

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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 ,

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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

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• Patient/Proxy/Family Satisfaction
• Timing/ frequency of Hospice Transfers
• Timing Palliative Care Recommendations Implemented

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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

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Predictors of Success

• Strong Advocate for System Change
• Physician buy in
• Partnership with accessible and flexible Hospice
• Consistent presence of Palliative Physicians,
  Nurse experts to mentor, teach
• Commitment to Data collection/analysis
• Commitment to Quality Improvement
• Commitment to Financial Management
• Openness to learning hospital culture

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Questions