BON SECOURS HEALTH SYSTEM

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BON SECOURS HEALTH SYSTEM

• Integrating a Health System's Palliative Care
  Mission Into a Clinical-Quality-Data Management
• Patient Identification System
  Approach
• Maria Gatto, MA, APRN, BC-PCM, NP,HNP, Director
  Palliative Care
• Barbara Oot-Giromini, MS, RN, Director Care
  Management
• Amey Harvey, Performance Engineer, BSHSI,
  Premier, Inc.
• Michele Szukala, RN, MSE, Principal, Clinical
  Advisory Services, Premier, Inc.
• June 22th, 2006

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Objectives

• Review Mortality Study
• Define and Discuss Zero Preventable Deaths
• Define Palliative Care
• Review Palliative Care System Wide Assessment
• Present Palliative Care Electronic Trigger
  System Development and Process

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Bon Secours Health System Mission Statement The
Mission of Bon Secours Health System is to bring
compassion to health care and to be good help to
those in need, especially those who are poor and
dying. As a System of caregivers, we commit
ourselves to help bring people and communities to
health and wholeness as part of the healing
ministry of Jesus Christ and the Catholic
Church.
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Bon Secours Health System
A 2.2 billion not-for-profit Catholic health
system, Bon Secours owns, manages, or joint
ventures

• 20 Acute Care Hospitals
• 1 Psychiatric Hospital
• 6 Nursing Care Facilities
• 6 Assisted Living Facilities
• 2 Retirement Communities
• 6 Home Care and Hospice Providers

Bon Secours more than 19,000 caregivers help
people in 12 communities in 9 states
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Making an IMPACT on Mortality

• Mortality Review-Why do it?
• Raise the bar to establish the will to go beyond
  OK Performance
• Modify our thought process from
• Looking at mortality statistics
• to the focus of
• The emotion of the personal tragedy on
  eliminating avoidable deaths
• Look at ourselves realistically
• Develop strategies to deal with our findings

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Making an IMPACT on Mortality

• What is the problem?
• Large variability in quality and safety
• IHI analysis of mortality information and cases
  reveals 3 common themes
• Failure to plan (diagnosis, treatment appropriate
  care and end of life)
• Failure to communicate (between caregivers and
  covering physicians/consultants) inadequate
  documentation
• Failure to rescue/recognize (change in condition)
  
• pt on medical floor/telemetry instead of ICU,
  sepsis not recognized, pt who codes and show
  clear signs of deterioration and nothing done

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Achieving Zero Preventable Deaths

• Overarching aim of SPQ, Strategic Quality Plan
• Zero Preventable Deaths by 2009
• Goal achieved by
• Incorporating the IHI Mortality Reduction
  Strategy
• Need to further define Preventable Deaths by
  examining 3 categories of death
• Anticipated
• Unanticipated
• No Failure

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Achieving Zero Preventable Deaths

• Categories of Deaths
• Anticipated
• Occurs as a known natural consequence in the
  course of a disease process.
• Goal is early recognition, communication, and
  planning for patients addressing
• each stage of their chronic disease process until
  end-of-life. Rescue patients
• and family from unnecessary suffering during
  their life and at time of death.
• Unanticipated
• Result of a known or unknown variation in the
  patients plan of care. Goal is to
• intervene (100) to plan, communicate, recognize
  and, as necessary, rescue
• patients at risk of death.
• No Failure
• Occurs even though there were no variations in
  the plan, communication,
• recognition and/or rescue of the patient,
  including patients who choose to allow
• for a natural death. Goal is to deliver the best
  possible care and EBM treatment
• to support life according to the patients wishes.

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Hospital Specific Mortality Rate (1998-2005)
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BSHSI Process Impact on Mortality Reduction
Reduction in unanticipated death goal HSMRlt75 or
25 reduction in unadjusted death
rates (Statistical significance)

• 100 Process In
• Planning
• Communication
• Recognition/rescue

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BSHSI System IHI Mortality 2x2 Table Summary
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Local System Intervention Process

• Best Practices Sharing
• IRIS
• Knowledge transfer
• SBAR Communication
• Clinical Initiatives from
• 100,000 Lives campaign
• Palliative Care
• Hospice Care

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Local System Summary IHI 2x2 Study

• Area of concern related to
• Lack of palliative care identification and timely
  intervention
• End of life discussions
• Occurring too late resulting in inappropriate
  transfer to ICU
• Potential intervention may not correlate with end
  of life
• progression/wishes of patient
• ICU Team discussions confirmed concerns and
  feedback
• Inappropriate patients, advanced palliative care
  end of life
• patients, transferred to ICU

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Local System Actions Related to 2x2 Findings
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Palliative Care Reflection

• Although the world is full of suffering, it is
  also full of the overcoming of it.
• Helen Keller, Optimism 1903

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Definitions

• Palliative Care
• Interdisciplinary care that seeks to relieve
  suffering, improve quality of life for
• patients/residents with chronic and/or
  life-threatening illness. Medical and evidence
• based model, offered simultaneously with
  appropriate medical treatment, along with
• curative therapies. Holistically focused
  physical, psycho-social-spiritual care for
• patient/resident/family. Involves the full
  continuum of care, to provide seamless
• supportive services.
• BSHSI QAPlan2004, NCP,2004
• Hospice Care
• A service delivery system for patients that have
  a live limiting expectancy,
• require comprehensive biomedical, psychosocial
  and spiritual support as they
• enter the terminal stage of an illness or
  condition. Supports family members
• coping with complex consequences of illness,
  disability and aging as death
• nears. Further addresses bereavement needs of the
  family following the death
• of a patient.
• Centers for Medicare and Medicaid in its proposed
  Hospice Conditions of Participation and adapted
  for the World Health
• Organization, 2002

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The Cure - Care Model The Old System
D E A T H
Palliative/ Hospice Care
Life Prolonging Care
Disease Progression
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NHWG Adapted from work of the Canadian
Palliative Care Association Frank Ferris, MD
A New Vision of Palliative Care
Modifying Therapy, Curative, restorative intent
Life Closure
Risk
Disease
Condition
Death Bereavement
Palliative and Hospice Care
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The Realty

• Palliative Care Is
• Excellent, evidence-based medical treatment
• Vigorous care of pain and symptoms throughout
  illness
• Care that patientswant at the same time as
  efforts to cure or prolong life

• Palliative Care Is Not
• Not giving up on a patient
• Not in place of curative or life-prolonging care
• Not the same as hospice

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Palliative Care is Evidenced Based Medicine

• Quality Outcomes
• Relieves/controls pain 95, distressing
  symptoms 92
• Support of QOL 89
• Improves transition management across continuum
• Satisfaction Outcomes
• Support for family stress, anxiety 84
• Manner of communication of terminal illness 88
• Supports re-evaluation of goals of care and
  difficult decision making
• Overall care provided by program 95

Campbell et al, Heart Lung, 1991 Campbell et al,
Crit Care Med, 1997 UC Davis Health System News
2002 Carr et al, Vitas Healthcare, 1995
Franklin Health, 2001 Dartmouth Atlas, 2000
Micklethwaite, 2002 Du Pen et al, J Clin Oncol,
1999 Finn et al, ASCO, 2002 Francke, Pat Educ
Couns, 2000 Advisory Board, 2001 Portenoy,
Seminars in Oncol, 1995 Ireland Cancer Center,
2002 Von Roenn et al, Ann Intern Med, 1993 Finn
J et al ASCO abstract. 2002 Manfredi et al JPSM
2001 Schneiderman et al. JAMA 2003 Higginson et
al JPSM 2002 2003 Smith et al. JCO 2002, JPM
2003 Coyne et al. JPSM 2002 www.capc.org. Post-D
ischarge/Death Family Satisfaction Interviews,
Mount Sinai Hospital, New York City, 2002
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Palliative Care Is Cost-Saving

• Palliative care lowers costs (for hospitals and
  payers) by reducing hospital and ICU LOS,1 in 5,gt
  500,000, die in ICU or after ICU tx during
  terminal hosp admission) and direct (such as
  pharmacy) costs
• Medicare data Palliative Care Patients spent 357
  fewer days in Mount Sinai as compared to
  DRG-matched patients not followed by palliative
  care
• Cost savings from palliative care 866,806 per
  year for patients with LOS gt 21 days
• Palliative care improves continuity between
  settings and increases hospice/homecare/nursing
  home referral by supporting appropriate
  transition management
• Lilly et al, Am J Med, 2000 Dowdy et
  al, Crit Care Med, 1998 Carlson et al, JAMA,
  1988 Campbell et al, Heart Lung, 1991 Campbell
  et al, Crit Care Med, 1997 Bruera et al, J Pall
  Med, 2000 Finn et al, ASCO, 2002 Goldstein et
  al, Sup Care Cancer, 1996 Advisory Board 2002
  Project Safe Conduct 2002, Smeenk et al Pat Educ
  Couns 2000 Von Gunten JAMA 2002 Schneiderman et
  al JAMA 2003 Campbell and Guzman, Chest 2003
  Smith et al. JPM 2003 Smith, Hillner JCO 2002
  www.capc.org.

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Center for the Evaluative Clinical Sciences,
CECS, Dartmouth Atlas of Health Care Report

• 4.7 million Medicare enrollees who died between
  2000 and 2003 at 4,300
• hospitals across the country reported that
  patients with chronic disease we
• Hospitalized or admitted to an ICU in the last
  six months of life, five times higher at some
  academic medical centers as others
• LOS of Chronically Ill in final six months of
  life Highest, 32.1, national length of stay
  average, 13.9, palliative care leadership
  centers, 3.3
• Medicare 40 billion, (nearly 1/3rd spent for
  care over four years)
• Almost One-Third of Medicare Spending for
  Chronically Ill noted unnecessary
• Chronic illness accounts for more than 75 of all
  U.S. health care expenditures, indicating overuse
  and overspending is not just a Medicare problem
  - health care systems as a whole have not
  developed efficient, effective ways of caring for
  people with severe chronic illnesses
• Care of Patients with Severe Chronic Illness An
  Online Report on the Medicare Program by the
  Dartmouth Atlas \
• Project, The Dartmouth Atlas of Health Care 2006,
  The Center for the Evaluative Clinical Sciences,
  Dartmouth Medical
• School, http//www.dartmouthatlas.org/

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MYTH MORE IS BETTER

• More care is not by any means always better
  care, new technologies and
• hospital stays can sometime harm more than they
  help.
• Greater use of resources was associated with
  worse outcomes, poorer quality and lower
  satisfaction with care
• Regions with best quality and outcomes used fewer
  resources relative to their high-cost
  counterparts, not due to withholding needed care
• Falsely optimistic assumptions More aggressive
  treatment of people who are severely ill with
  medical conditions that must be managed but can't
  be cured
• Need to fundamentally re-design care for the
  millions of Americans with chronic illness
• Redirect resources away from acute care and
  invest in an
• infrastructure that can better coordinate and
  integrate
• Donald M. Berwick, M.D., M.P.P., President, CEO,
  Institute for Healthcare Improvement, leading
  national authority
• on health care quality and improvement issues
  HPCCANNY, HNN Newsletter, Dartmouth 2006
• John E. Wennberg, M.D., M.P.H. , Principle
  Investigator, CES, Dartmouth, 2006

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CECS Dartmouth Palliative Care

• Palliative care's ability to expertly
  communicate
• with patients and families, as well as control
  their
• pain, symptoms and other suffering, prevents
• patients from over treatment and inappropriate
• treatment. This improves quality of life, and
  overall
• care for patients thereby reducing length of
  stay
• and costs for hospitals.
• Care of Patients with Severe Chronic Illness An
  Online Report on the Medicare Program by the
  Dartmouth Atlas Project,
• The Dartmouth Atlas of Health Care 2006, The
  Center for the Evaluative Clinical Sciences,
  Dartmouth Medical ,
• http//www.dartmouthatlas.org/

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Palliative Care System Wide Assessment

• Goal
• Identify a baseline measurement of palliative
• care services system wide across the
• continuum of care

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Palliative Care Baseline Assessment

• Evaluation Tool
• 12 Elements from BSHSI Palliative Care Quality
  Business Plan
• Baseline Process Rating
• 3.0Present/Green
• 2.0Partially Present/Yellow
• 1.0Not Present/Red
• 28 health care sites assessed across the
  continuum
• 14 Hospitals
• 7 Nursing Homes
• 5 Assisted Living Facilities
• 2 Home Health Care Agencies
• System Wide Median Score 1.90

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5 TOP ISSUES

• Lack of palliative care teams
• Inadequate education, certification program
  development
• Inconsistent palliative care policies
  standards
• No established palliative care metrics or
• measurement system
• Lack of integration of palliative care services
  across the continuum of care

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BSHSIs FY07 Strategic Quality Plan
Key Strategies
Goal
Outcomes
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Palliative Care Dashboard Indicator
Determination and Reference Base

• Benchmarking indicators limited due to
• New specialty
• Research data limited - none
• CAPC The Center to Advance Palliative Care
• National initiative supported by The Robert Wood
  Johnson Foundation, named national leader, Mount
  Sinai School of Medicine, (NY)
• Only national organization to establish accepted
  benchmark
• Estimated number of potential palliative care
  patients based on an estimated 5 of annual
  discharges
• Assumed potential of palliative care patients
  based on experience of palliative care program
  increasing over time
• BSHSIs First Year Trial 1.0
  
  
  
  
• http//www.capc.org/ http//www.capc.org/about-c
  apc/faqs
• http//www.capc.org/impact_calculator_basic/
• http//www.capc.org/impact_calculator_detailed/

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Palliative Care Patients Identified

• Known Supportive Processes
• Establishing palliative care services,
  collaborative relationships, trust
• Increased staff education
• Daily Huddles
• Attending Care Management Rounds
• Known Barriers
• Culture change difficult
• Lack of education Hospital staff, community,
  patients/family
• Limited staff, time, resources
• New service development
• Poor communication Departmental silos,
  fragmented care
• Lack of identification on admission,
  re-admission, and late referrals

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Challenge Create New Processes

• Palliative Care Electronic Trigger System
• Need identified, concept developed
• Project Team Created HSO/Local Clinical,
  Operational, IT Systems
• Current Manual Tool Based CAPC Screening Tool,
  Palliative Care ICD9/DRG Codes used as starting
  point
• Criteria developed
• Process map under development
• Multiple system interface identified Softmed,
  Treadstar, CDMP, HIM, Premier
• Pilot site determined Hampton Roads Mary View
  Medical Center
• Test run mock reports generated from software
  programs to review criteria credibility,
  reliability, potential reporting capability and
  process outcomes, revisions for more efficient,
  effective, accurate streamline process

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Palliative Care Process Map
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Pilot Report Development Summary

• Established palliative care trigger criteria
  (PCTC)
• Palliative care ICD-9/DRGs codes from CAPC
  screening tool
• Admission source SNF or ED, Age gt 18
• Removed symptom codes (i.e. N/V, SOB, pain
  codes) - overwhelming number of potential
  palliative care cases
• Narrowed list by high volume diagnosis specific
  to pilot hospital
• Added levels for priority
• Level 1 patients with ICD-9 code in finalized
  list
• Level 2 patients with ICD-9 code in finalized
  list, LOS gt5 days, and age gt to 65
• Results
• Level 1 Average of 246 potential patients per
  month
• Level 2 Average of 93 potential patients per
  month
• Pilot hospital is a 466 bed hospital

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Interfacing Clinical Information Systems

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ALERT
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Level 1
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Level 1 cont.
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Level 2
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Level 2 cont.
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CAPC Screening Tool
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Worklist
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Premiers Clinical Advisor Program for Palliative
Care

• Value of Clinical Advisor in Palliative Care
• Evaluate Program Demand
• Broad survey of potential palliative care
  patients to support program strategies and
  development
• Check and Balance
• Retrospective identification of candidate
  palliative care patients as audit of real-time
  data systems
• Ongoing Program Performance Monitor
• Evaluate clinical outcomes and resources through
  comparative benchmarks
• Determine program ROI

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Potential Palliative Care Patients Survey Report

• List Clinical Advisor patients that met
  palliative care trigger criteria
• Identifies potential patients that did not
  receive palliative care services

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Patient Outcomes Selected DRGs

• Received palliative care

• Did not receive palliative care

• Preliminary observations
• ALOS 45 greater (additional 4.9 days/case) when
  criteria met, no palliative care
• Average cost/case tracks to ALOS, 45 greater
  when criteria met, no palliative care
• Readmission rate (30-day) not reliable due to
  short time period of sample

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Next Steps

• Rapid test of change methodology to validate
  steps and modify the
• process prior to full implementation
• Project team to evaluate results, action items
  determined
• Project timeline and implementation work plan
  developed
• Project team roles and responsibilities defined,
  assigned, coordinated
• Policy and procedure development
• Departmental wide in-servicing and educational
  plan developed
• Continue team calls to discuss weekly progress
  and refine processes as needed determined by
  local system feedback
• Set standard process in place
• Sharing best practice and support system-wide
  engagement Train the Trainer to spread
  Systemness

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Lessons Learned

• Identification
• IHI Mortality Tool 2x2 Use for baseline
  measurement opportunity
• Box 3 4 Ask if there were planning failures
  and did these include palliative care
  opportunities
• Assessment of palliative care need using internal
  review of processes and services
• Presentation and communication of results to
  system leaders
• Education
• Increase healthcare teams education to the
  broader definition of palliative care and
  differentiation from hospice
• Run Test of Change
• Run your 5 day LOS patients, review plan of care
  with team for palliative care opportunities
• Make daily rounds, especially the ICU for
  potential palliative care patients
• Use the data abstraction process outlined to
  identify potential cases to be referred on
  admission
• Develop a trigger process for your palliative
  care consults

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How can you replicate?

• Establish a cross-functional Palliative Care
  Trigger Team
• Palliative Care staff
• HIS / DSS staff
• Care Management
• Determine where in your system a trigger would be
  appropriate and establish the flag (i.e. HIS,
  SoftMed, DSS, etc.)
• Establish a process map for ongoing
  identification of palliative care patients
  (Appendix)
• Set trigger criteria
• Use the PCTC established as a starting point
  (Appendix)
• Modify based on your hospitals volume to
  identify a manageable patient set.
• Pre-populate flag based on historical data using
  criteria
• Train all staff indicated in process map on the
  new process and palliative care definitions

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Palliative Cares New Reflection Realized.

Pictured here is Treva with all of her children
three days before she passed on . Those days of
sharing together were precious. This time of
being with Treva as she was dying was a very
meaningful experience.
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Palliative Care Current Best Practices Future
Directions

• Team and Panel Recognition
• Q A
• Open Discussion

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Appendix
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CAPC Screening Tool Central Baptist Hospital
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Achieving Zero Preventable Deaths
DEATHS
Anticipated Expedite palliative and hospice care
Unanticipated (Preventable plus natural history
of disease with current best treatment e.g.. EBM)
Failures to plan, communicate, recognize and
rescue (higher number of preventable deaths)
Decreased Failures
No failure to plan communicate, recognize and
rescue (low number of preventable deaths)
Interventions
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BSHSI Goal Developing a Statistical Model
2006
2009
x rate of deaths
y rate of deaths
95 confidence interval
95 confidence interval
0
0
Deaths without fully implemented Planning,
Communication, Recognition and Rescue
Deaths without fully implemented Planning,
Communication, Recognition and Rescue
A separate model can be developed for
preventable deaths, depending on accuracy of
definition and number of events.
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Palliative Care Trigger Criteria Pilot Hospital
Customized criteria based on volume for the pilot
hospital
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Palliative Care Trigger Process Map
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Palliative Care Trigger Process Map (cont)
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Palliative Care Trigger Process Map (cont)
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Palliative Care Trigger Files

• PCTC full ICD listing
• PCTC customized for pilot hospital
• Palliative Care Trigger Process Map