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C-TAC 2015 National Summit on Advanced Illness Care - Master Slide Deck

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C-TAC 2015 National Summit on Advanced Illness Care - Master Slide Deck

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N a t i o n a l S u m m i t o n A d v a n c e d I l l n e s s C a r e D r i v i n g C h a n g e t h r o u g h L e a d e r s h i p , E v i d e n c e a n d A c t i o n
Welcome and Goals Leonard D. Schaeffer Judge Robert Maclay Widney Chair and Professor University of Southern California M a r c h 2 , 2 0 1 5
Conference Hosts • Bill Novelli: Board Co-Chair and Professor, McDonough School of Business, Georgetown University and former CEO, AARP • Tom Koutsoumpas: Board Co-Chair and President, Caring Foundations • Jon Broyles: Executive Director, C-TAC
C-TAC Vision All Americans with advanced illness, especially the sickest and most vulnerable, will receive comprehensive, high-quality, person- and family- centered care that is consistent with their goals and values and honors their dignity.
Advanced IllnessC-TAC’s Goal Chronic and Curative Care Healthy or with reversible illness Disease Progression Advance Directive Advance Care Planning Early onset, chronic conditions Progressive, frequent complications Hospice Eligible Palliative Care Hospice Phase 4Phase 3Phase 2Phase 1 All persons with advanced illness receive high quality care
Key C-TAC Initiatives • Comprehensive, Consensus-Based Policy Agenda: Guides C-TAC’s activities on the Hill and with Administration • Proof-in-Concept Community Action Pilot (Oakland, CA): Fosters partnerships between health systems and community organizations to fill gaps in care delivery • Advanced Care Project: Partnership with AHIP Foundation to engage health plans and health systems in implementing advanced illness care programs
Key C-TAC Initiatives • Serves as a guide for transforming advanced care illness across all disciplines • Analyzes key issues, challenges and solutions • Identifies action steps for achieving high-quality, advanced illness care • Provides a “Call to Action”
Conference Goals • Increase provider and consumer readiness to implement, evidence-based tools & approaches to AIC • Connect consumers, clinicians, health systems and health plans to deliver high quality, person-centered care and commit to improved performance • Disseminate information and support implementation of evidence-based AIC models
We’re here to learn what’s working and what’s not, and use these lessons to move forward • Identify gaps in evidence that need to be addressed to further the adoption of better AIC • Expand comparative effectiveness research to support transformational change in the field Conference Goals
How You Can Contribute Today One degree of change can make all the difference • Be candid about what’s working, what’s not, and why • Join in catalyzing action and energy around effective programs and ideas • Help identify programs and concepts with the greatest potential to improve AIC • Offer ideas on how to scale up what’s working
IOM (Institute of Medicine). 2014. Dying in America: Improving quality and honoring individual preferences near the end of life. Washington, DC: The National Academies Press. Introduction Please join me in welcoming: Victor Dzau, MD President, Institute of Medicine
A d v a n c e d I l l n e s s C a r e : T h e I O M P e r s p e c t i v e V i c t o r J . D z a u , M D P r e s i d e n t , I n s t i t u t e o f M e d i c i n e
Dr. Victor Dzau, MD President, Institute of Medicine Advanced Illness and End of Life Care: The IOM Perspective
Advanced Illness Care “Occurring when one or more conditions become serious enough that general health and functioning decline, and treatments begin to lose their impact. The process that continues to the end of life.” -Coalition to Transform Advanced Care
Trends & Background
Aging Americans over age 65 9% in 1960 20% in 2050 Growing ethnic and cultural diversity
Disease Burden Multiple chronic conditions 2/3 of people over 65 New cancer cases 45% increase from 2010 2030 Alzheimer’s disease and dementias 5.5 million in 2010  8.7 million in 2030 Parkinson’s disease Prevalence to double in the next 30 years.
Care People dying in acute care hospitals Deaths in nursing homes and hospice • # of Americans needing long-term care: more than double by 2050 • Medicare deaths in acute care hospitals: 33% 2000  25% in 2009 • Growing number of deaths in nursing homes • Hospice care: 1995, 17% of US deaths  2011, 45% • By 2011, 85% hospitals with 300+ beds had palliative care services
Costs Medicare spent 28 percent of 2011 spending, or about $170 billion, on patients’ last six months of life.
Decision-Making 40% of adult medical inpatients incapable of making their own treatment decisions Among nursing home residents, 44-69% cannot make their own medical decisions 70% of decedents aged 60 and older who faced treatment decisions in the final days of their lives were incapable of participating in these decisions
IOM’s Role Independent, Apolitical | Multidisciplinary | Evidence-based
Maintaining high quality of life until death Care Delivery Clinician- Patient Communication Policies and Payment Systems Professional Education Research and Information Sharing Public Education and Engagement
Care Delivery
Cover provisions for individuals nearing end of life Provide access to palliative care, with an integrated team Publically report quality and cost measures Comprehensive Care • Seamless, patient-centered, family-oriented, high- quality, integrated • Accessible 24/7 • Considers physical, emotional, social, and spiritual needs • Consistent with individuals’ values, goals, and informed preferences Care delivery organizations Government health insurers Care delivery organizations Care delivery organizations
Specifically for Children: • Need clinical practice guidelines and protocols for palliative, end-of-life, and bereavement care that meet the needs of children and families.
Proposed Core Components of Quality EoL Care • Frequent assessment of patient’s physical, emotional, social, and spiritual well-being • Management of emotional distress • Offer referral to expert-level palliative care • Offer referral to hospice if the patient has a prognosis of 6 months or less • Management of care and direct contact with patient and family for complex situations by a specialist level palliative care physician • Round-the-clock access to coordinated care and services • Management of pain and other symptoms • Counseling of patient and family • Family caregiver support • Attention to the patient’s social context and social needs • Attention to the patient’s spiritual and religious needs • Regular personalized revision of the care plan and access to services based on the changing needs of the patient and family
Clinician Patient Communication
In a national survey, clinicians asked for patients’ preferences in medical decisions only about ½ the time. 25% of patients reported that their clinician failed to share important information about their test results or medical history with others involved in their care
Develop Adopt Tie to reimbursement Facilitate tying to reimbursement, licensing, credentialing Quality Standards encouraging: • Individuals to participate in decision-making • Clinicians to initiate conversations • Clinicians to revisit discussions Professional Societies Professional Societies and others Payers Health care delivery organizations Payers
Specifically for Children: • Need better policies and procedures to ensure child’s involvement in treatment discussion and decisions. • Hospitals should not abruptly end contact with the family after the death.
IOM Roundtable on Value and Science Driven Health Care Evidence Communication Collaborative Good Communication Needs: • Respectful culture • Nurturing and secure decision making climates • Good clinician teamwork • Access to high-quality evidence for decision-making • Transparency and candidness around constraints and unknowns. Co-chaired by George Halverson & Bill Novelli
Policies and Payment Systems
Seek and enact legislation Implement Integrated Financing of medical and social services to support care at the end of life. • Financial incentives for coordinated care • EHR that incorporate advance care planning Administration, Congress Federal government and. its programs (e.g., Medicare, .Medicaid, VA), Other health care systems Federal, state, and.private insurance and care delivery programs Require public reporting on quality, cost, outcomes
Specifically for Children: • Clinicians should be reimbursed for fully informing and counseling parents. • Bereavement services for parents and siblings of children who die should be reimbursed.
Professional Education
Provide training throughout professional career Require education and experience in training programs Strengthened Knowledge and Skills • Palliative care • Communication skills • Interprofessional Collaboration • Symptom management Educational institutions Professional societies Accrediting organizations Certifying bodies State regulatory agencies Include in licensure requirements for health professionals, chaplains, social workers, etc. Create pathways to certification Entities that certify /specialty-level providers Care delivery organizations, medical centers, teaching hospitals Increase number of training positions for specialization
Research and Information Sharing
Research Needs • Prevalence and nature of care that is neither beneficial nor wanted. • Effect of palliative care on longevity. • Elements of palliative care likely to offer the greatest improvements in quality of life. • Evidence-based measures of quality end-of-life care. • Family caregivers’ roles, needs, behavior, health risks, success in performance, interaction with other members of the health care team, and use of respite care and other support services. • Reliable approaches to prognosis that start earlier in the disease trajectory, and assessment of whether more accurate prognoses. lead to improvements in quality of life and other outcomes of care. • Effects and value of specific types of clinical innovations in delivering end-of-life care.
Research needs for children • Comparative effectiveness studies of different approaches to symptom management and bereavement support. • Analyses of care received in emergency departments, outpatient settings, and hospices and through home health agencies. • Cohort studies examining the effect of palliative care on outcomes and on the patient experience. • Studies of how best to staff, manage, and finance hospital-based pediatric palliative and community-based pediatric hospice services.
Public Education and Engagement
People don’t speak with loved ones about end of life wishes because… Too many other things to worry about right now. Don’t want to think about death or dying. Family member did not want to discuss it.
Provide information, encourage dialogue Research consumer perception, test message effectiveness Encourage members to engage patients Engaged and Informed Constituents Civic leaders, governments, community organizations, …faith-based organizations, consumer groups, employers, care providers Health care professional societies Government agencies Payers
Moving Forward Wealth of knowledge  How do we act on it? Many roles  Need everyone to contribute
R E S E A R C H T H AT D R I V E S C H A N G E Joe V. Selby, MD MPH Executive Director Patient-Centered Outcomes Research Institute
W h a t D r i v e s C h a n g e ?
What Drives Change? • Getting the Research Question Right • Rigorous Research Methods • Community-led Dissemination Plan
Engagement is the key to finding the research question that leads to research that can be disseminated and implemented Evaluation Proposal Review; Design and Conduct of Research Topic Selection and Research Prioritization Dissemination and Implementation of Results
Rigorous methods - did the intervention really work – and would it work again? • Believable Benefit – or Bias? – Randomization – Multiple randomized Units • Compared to What? – Evaluation vs. research – Carefully specified, high quality usual care comparator
PCORI-funded Projects Health System Intervention to Improve Communication About End-of-Life Care for Vulnerable Patients – RCT – Washington State Improving Palliative and End-of-Life Care in Nursing Homes – RCT - Rochester NY Improving Advanced Cancer Patient-Centered Care by Enabling Goals of Care Discussions – RCT – New York City Computerized PAINRelieveIt Protocol for Cancer Pain Control in Hospice – RCT – Chicago Relapsed Childhood Neuroblastoma as a Model for Parental End-of-Life Decision-Making – Observational and qualitative – Boston MA Improving Communication in the Pediatric Intensive Care Unit for Patients Facing Life-Changing Decisions – RCT - Chicago
Pragmatic Clinical Studies Opportunity Snapshot • Number of cycles per year: two • Number of Anticipated Awards Per Funding Cycle: Six to Nine • Funds Available Per Cycle: Up to $90 Million • Maximum Project Duration: 5 Years • Costs per Project: Up to $10 million direct costs Seek to produce information that can be directly adopted by providers: • Compare two of more options for prevention, diagnosis, treatment, or management of a disease or symptom • Address critical clinical choices faced by patients, caregivers, clinicians, systems • Conducted in routine clinical settings • Protocols less complex than traditional trials • High-priority topics identified by: • PCORI’s Advisory Panels • Institute of Medicine CER 100 • Agency for Healthcare Research and Quality
Contact Us www.pcori.org info@pcori.org
E n g a g i n g M u l t i p l e G e n e r a t i o n s
E n g a g i n g M u l t i p l e G e n e r a t i o n s I n t r o d u c t i o n b y : M a r g a r e t M a g u i r e , J D , S V P C o r p o r a t e A c c o u n t a b i l i t y a n d C h i e f o f S t a f f C a m b i a H e a l t h S o l u t i o n s P r e s i d e n t a n d B o a r d C h a i r C a m b i a H e a l t h F o u n d a t i o n
Engaging Multiple Generations • Ellen Goodman, Moderator Co-Founder and Director The Conversation Project • Kenyon C. Burke, Ed.D. President Kenyon C. Burke Consulting • Rev. Rosemary Lloyd Advisor to the Faith-Based Community The Conversation Project • Lennon Flowers Co-Founder and Executive Director The Dinner Party
T h e I m p e r a t i v e f o r C h a n g e
The Imperative for Change • Rich Umbdenstock President and CEO American Hospital Association • Jeannine English, CPA, MBA President AARP
T h a n k Yo u
A Time for Caring Reception We look forward to seeing you at tonight’s reception, located at: The Four Seasons Hotel 2800 Pennsylvania Avenue, NW Washington DC 20007
N a t i o n a l S u m m i t o n A d v a n c e d I l l n e s s C a r e D r i v i n g C h a n g e t h r o u g h L e a d e r s h i p , E v i d e n c e a n d A c t i o n
Welcome and Recap Leonard D. Schaeffer Judge Robert Maclay Widney Chair and Professor University of Southern California M a r c h 3 , 2 0 1 5
Conference Hosts • Bill Novelli: Board Co-Chair and Professor, McDonough School of Business, Georgetown University and former CEO, AARP • Tom Koutsoumpas: Board Co-Chair, President and CEO, National Partnership for Hospice Innovation • Jon Broyles: Executive Director, C-TAC
C-TAC Vision All Americans with advanced illness, especially the sickest and most vulnerable, will receive comprehensive, high-quality, person- and family- centered care that is consistent with their goals and values and honors their dignity.
Recap From Day One • Where advanced illness care is heading • How to build urgency around change • How to effectively engage multiple generations in advanced illness care in community and clinical settings • How to build on successful innovations to achieve further progress Speaker themes included:
How You Can Contribute Today One degree of change can make all the difference • Be candid about what’s working, what’s not, and why • Join in catalyzing action and energy around effective programs and ideas • Help identify programs and concepts with the greatest potential to improve AIC • Offer ideas on how to scale up what’s working
Introductions Please join me in welcoming:  Karen Ignagni, President and CEO, America’s Health Insurance Plans  Jeff Burnich, MD, Senior Vice President Medical and Market Networks Sutter Health  Amy Berman, BS, RN, Senior Program Officer John A. Hartford Foundation
D r i v i n g C h a n g e
A C o m p r e h e n s i v e A p p r o a c h t o C a r e Tr a n s f o r m a t i o n : I n t e g r a t i n g C o m m u n i t y a n d C l i n i c a l M o d e l s
A Comprehensive Approach to Care Transformation • Rev. Diane C. Smalley Patient and Community Engagement Council, Saint Joseph Mercy Hospital, Trinity Health • Chris Dawe, Managing Director Evolent Health • Bud Hammes Director of Medical Humanities, Gunderson Health System • Daniel Johnson, MD, FAAHPM National Clinical Lead for Palliative Care, Care Management Institute, Kaiser Permanente • Rev. Cynthia Carter Hill, MPA Executive Director, Alameda County Care Alliance
H o w a S h a r e d - D e c i s i o n M a k i n g A p p r o a c h C a n C o n n e c t t h e C l i n i c a l a n d C o m m u n i t y B e r n a r d “ B u d ” H a m m e s , P h D G u n d e r s e n H e a l t h S y s t e m w w w . r e s p e c t i n g c h o i c e s . o r g
2014 IOM Report: Dying in America Shared decision making encompasses: • Eliciting and understanding the patient’s perspective; • Understanding the patient’s psychosocial and emotional context; • Developing a shared understanding of the clinical problem and its appropriate treatment, given the patient’s goals, preferences, and values; and • Empowerment, which is achieved through active involvement of patients in decision making. LeBlanc, T. W., and J. A. Tulsky. In press. Communication with the patient and family. In Oxford textbook of palliative medicine, 5th ed., edited by N. Cherney, M. Fallon, S. Kaasa, R. Portenoy, and D. Currow. Oxford, England: Oxford University Press.
This description is useful, but we need more detail for folks with advanced illness… To get to shared decision-making and planning requires (for persons with advanced illness)… 1. …a shift from a primary focus on goals of medical care, to a thoughtful exploration and clarification of personal goals and values; 2. …a specific exploration of fears and concerns as well as gaps in knowledge and understanding; 3. …a realization that this not just about the individual but also about the individual’s “family” and community relationships.
When Care Planning uses this person- centered, shared decision-making model, it can tie the clinical and the community together in two important, related ways… Through a common: 1. process and structure of planning and decision making; and, 2. ethical footing.
A Common Process and Structure for Share Decision-Making • Focused on the person and family perspectives, the planning and any decision that follow centers around a single, key question: How do the explored values and goals of the person and family, tied to the clinical realities, help define what it means to provide good care for this person? • To thoughtfully answer this question requires the intentional input and contribution of the person, those closest to this person, their broader community, and the clinical.
The Shared Ethical Basis: Care Relationships The ethical footing of this approach is the ethic of caring relationships: Relationship Ethical Value Health professional/patient Beneficence…acting in the best interest of the patient Individual/family or loved ones Love Individual/community Respect, Sanctity of Life
The Respecting Choices® Model This model is a systematic approach to care planning that uses person-centered, shared decision-making decision making and is designed to: 1. Provide a standardized process for care planning that may be used in both the clinical and community settings; 2. Build care planning into the routine of all care; 3. Create processes so care plans are stored, revisited, and communicated so that they are always available and up-to-date; 4. Prepare both patients and their appointed surrogates to make decisions when the time arises; 5. Improve care and outcomes for all involved.
Helping Community and Health Organizations Implement this Model • Respecting Choices has created a implementation pathway that provides a means for health organizations to develop this care planning approach so that it can become part of the routine of care and can be integrated into community engagement. • RC has been successfully implemented in 5 countries and over 120 health organizations in the USA.
A C o m p r e h e n s i v e A p p r o a c h t o C a r e Tr a n s f o r m a t i o n : T h e C l i n i c a l P e r s p e c t i v e D a n i e l J o h n s o n , M D , F A A H P M C a r e M a n a g e m e n t I n s t i t u t e K a i s e r P e r m a n e n t e
William • 77 y/o male • Advanced gastric cancer, diabetes, anemia, COPD • Prior surgery, XRT • Third line chemotherapy • Intractable nausea, pain • Recurrent bleeding • 3rd admission in 6 w • Two prior SNF stays • Request: “No death talk”
“What is spoken of as a “clinical picture” is not just a photograph of a man sick in bed; it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes and fears….” The Care of the Patient Francis W. Peabody, MD, JAMA 1927 Edvard Munch, The Sick Child, 1927
“The difficulty is that in the hospital one gets into the habit of using the oil immersion lens instead of the low power, and focuses too intently on the center of the field.” Francis W. Peabody, MD Daily Bread, Otto Betteman, 1936 Girls at the Piano, Renior, 1892
William – Through a Wider Lens • Needs transport help • Recurrent bleeding • Not filling meds ($$) • 3rd admission in 6 w • Greatest joy: dog Max • Two prior SNF stays • Hope: back to Iowa • “No death talk” • Fears: “quitting too soon”, questions: faith and God • 77 y/o male • Lives alone, friends help • Advanced gastric cancer, diabetes, COPD, anemia • Values independence • Prior surgery, XRT • Former US Veteran • On 3rd line chemo • Helping son “get sober” • Intractable nausea, pain • Increasingly anxious
About Kaiser Permanente…  Nation’s largest non-profit health plan  Integrated health care delivery system  9.1 million members  16,000+ physicians  174,000+ employees (including 48,000+ nurses)  Serving 8 states and the District of Columbia  38 hospitals  More than 600 medical offices  $53.1 billion operating revenue*  Scope includes ambulatory, inpatient, ACS, behavioral health, SNF, home health, hospice, pharmacy, imaging, laboratory, optical, dental, and insurance Mid-Atlantic Region Georgia Region Colorado Region Northern California Region Hawaii Region Northwest Region Southern California Region *Kaiser Permanente 2013 Press Release
KP-Colorado Slide 85 Multiple contracts and community partnerships:  Hospitals (2 core + others), SNF (25 facilities), LTACH (5)  Home Health, hospice (7 preferred, PC support) Integrated system serving over 600K members  Rocky Mountain Front Range  Insured pop: Commercial, Medicare Advantage (90K), Medicaid (50K), Duals (2K)  Case management (adult + kids)
Our Promises For us to achieve the “best care possible” for persons with serious illness we must: Deliver, for each individual, personalized “best care” Palliative and Community Support Discover, for each individual, what “best care” looks like Goal Setting and Care Planning AND
87 Building “Layers of Support” 1 2 3 4 Advance Care Planning (ACP) 10 PC 20 PC Increasing Complexity and Needs → Support→ LAYER KEY FEATURES Specialty PC Provide specialized support for most complex needs Primary PC Assess needs → personalize care; basic support ACP Assure systematic, competent discussions for all Population ID Identify risk groups, population-based care Leveraging Community Resources and Expertise
Foundational Studies of Palliative Support at Kaiser Permanente Three randomized control trials of palliative care in hospital, home and clinic settings – outcomes:  Improved patient-family satisfaction  Improved quality (communication, death at home)  Increased hospice admissions and LOS  Decreased hospital, ER utilization and costs Added matched- controlled analysis of inpatient PC:  Less hospital(40%), ICU (56%) and ER (24%) admissions  Higher hospice admissions (51%) and LOS (55%) Gade G et al. J Palliative Med, 2008. Brumley R. et al. J Palliative Med, 2003. Englehardt J. et al. J Managed Care, 2009. Bellows J, Johnson D et al, Kaiser Permanente, 2012
A Continuum of Specialty Support Hospital Home Assisted Living Long Term Care LTACSNF Primary Care Clinic Specialty Care Clinic Inpatient PC Home PC PC SW Clinic PC NH PC Hospice “One Stop Shop”
KPCO Specialty Palliative Care Services Service Setting Team #/year Access Model IPC Hospital MD, RN, SW, Chap, Pharm 1800 7 d/w with 24/7 call Hybrid staffing model – KP + hospital; referrals + alerts using LACE HBPC Home/ ALF MD, RN, SW, Chap, Pharm 500 7 d/w with 24/7 call Hybrid staffing model – KP + partner; referrals CBPC Clinic MD, RN, SW 400 5 d/w KP staff; referrals + integration pilots in high risk pulmonology and oncology PC-SW Clinic SW 300 5 d/w KP staff, referrals + integration pilots NH PC (KSS) SNF/LTC SW, RN or chap prn 400 5 d/w Contracted partners, referrals + integration in LTACH, NH Hospice All Full IDT 2000 7 d/w Contracted partners, Commercial and Medicare
What Elements Worked (or Not)? What Worked… A compelling “why” Evidence Invest – not just “stretch” Partnership (seek win-win) Layers and triage Embedded support Value team- and self-care Harness non-PC champions Think “learning system” …Not So Much Seeking perfection “Prove it” mentality Silos – thinking too narrowly Demands on referring MDs Failing to assess needs Failing to triage “Auto-referrals” Leaving out community Slow to standardize or
Examples of Positive Shared Outcomes Documented goals, values and care preferences More concordant care (i.e., delivery matches wishes) Care plan communication across care settings Increased access to specialty PC support More hospice use Less unwanted (by all) hospital, ER or ICU care Less total costs (for patients, family and system) Greater meaning around the work we do Asking and honoring “what matters most”
Rev. Cynthia Carter Hill, MPA Executive Director Alameda County Care Alliance
Alameda County Care Alliance Vision: All those in Alameda County living with advanced illness will receive person- and family-centered care that acknowledges their spiritual and cultural integrity, regardless of race, religion, origin, or creed. Mission: Build on community-based resources and health system partnerships to provide a new paradigm of care through: care coordination, spiritual care, and decision-making support for the person needing care, their family/caregiver.
ACCA: Who We Are A dynamic and collaborative partnership among faith- based and community organizations with long history of working together to transform the Alameda Community. Current focus - Advanced Care:  Launched in 2014  Represents 35,000+ people  Supported by Kaiser Permanente and California HealthCare Foundation.
ACCA HUB Partners Strategically located Community Partnerships : • Allen Temple Baptist Church • Glad Tidings Church of God in Christ • Family Bible Fellowship • Center of Hope • Greater St. John • Beebe Memorial • Community Organizations – Catholic Ecumenical & Asian Health Services
 Completed (2/15)  Training of pastors (3/18)  Training of navigators (3/18)  Patient and Caregiver enrollment (4/16) ACCA 18 Month Pilot Progress and Next Steps  Hub Church surveys  Pastoral training team & curriculum (Dr. Guess & team)  Navigator curriculum  Caregiver curriculum and partnerships (Family Caregiver Alliance)  Evaluation and key partnerships (UC Davis, UC Berkeley-Citris)
ACCA Proposed Outcomes: Process Strengthening community capacity for advanced care through: – Improved decision support for caregivers/and persons needing care – Trained clergy, community leaders, Care navigators – Identify and Increase access to care services for caregivers/patients
ACCA Proposed Outcomes: Impact – Increased care satisfaction among patients/families – Reduced caregiving burden for advanced illness – Reduced ER visits – Reduced readmission rates – Improved Quality of Life for ill person and caregivers
ACCA Finding #1: Build on Community Resources • Integrate current initiatives among faith communities through collective commitment and sharing resources such as trained volunteers across communities.
ACCA Finding #2: Build on Shared Outcomes Among Health Systems and Community Examples: • Reduced unwanted hospitalizations • Provide care in the community • Increased connection to spirituality • Improved quality of life
ACCA Finding #3: It’s Takes Time: Building Trusting Relationships between the Medical and Community Members • Honor the vast resources within churches and in community • Respect culture, spirituality, and traditions • Transparent communications amongst stakeholders
Transforming Care and Serving Most Vulnerable Whatever you do for one the least of these my brethren ones, you have done unto me. Matthew 25: 35-40
ACCA Firmly Believes That…..
Ta k i n g E v i d e n c e - B a s e d M o d e l s t o S c a l e J e f f S e l b e r g , M H A , E x e c u t i v e D i r e c t o r P e t e r s o n C e n t e r o n H e a l t h c a r e
M o r n i n g W o r k s h o p S e s s i o n s L e c t u r e R o o m : C o m m u n i t y a n d F a i t h - B a s e d P a r t n e r s h i p s R o o m 1 2 0 : M e t r i c s f o r S u c c e s s R o o m 1 2 5 : E n g a g i n g P a t i e n t s i n D i s s e m i n a t i o n a n d I m p l e m e n t a t i o n
C O M M U I T Y A N D FA I T H B A S E D PA RT N E R S H I P S
Te r e s a C u t t s , P h D A s s i s t a n t P r o f e s s o r, S o c i a l S c i e n c e s a n d H e a l t h y P o l i c y D i v o f P u b l i c H e a l t h a n d t h e M a y a A n g e l o u C e n t e r f o r H e a l t h E q u i t y Wa k e F o r e s t S c h o o l o f M e d i n c e
R e v . D r . T y r o n e P i t t s C o - C h a i r I n t e r f a i t h a n d D i v e r s i t y W o r k g r o u p , C - T A C
T h a n k y o u
M E T R I C S F O R S U C C E S S
Advanced Illness Care Coordination: A Case Study on Aetna Compassionate CareSM Program: What Metrics Can Demonstrate Randall Krakauer, MD VP, National Medical Director, Aetna
Geriatric Conditions and Quality Scores:1 How Does Advanced Illness Rate? Assessing Care of Vulnerable Elders (ACOVE) quality indicators: in 2000 identified significant quality and care gaps, and opportunities that might be addressed in managing care in Medicare populations 1Wenger NS, Solomon DH, Roth CP. et al. Annals of Internal Medicine. 2003; 139 (9) 740-747. Available at: www.mms.org/workilies/mmc services/geriatrics/Quality Medical Care Provided Vulnerable-Dwelling Older Patients.pdf. Accessed June 6, 2013. Geriatric conditions and quality indicators Condition % QIs Passed Malnutrition 47 Pressure ulcers 41 Dementia 35 Falls, mobility disorders 34 Urinary incontinence 29 End-of-life care 9
Variations In End-of-Life Care: Dartmouth Atlas of Health Care Percent of decedents enrolled in hospice during the last 6 months of life (2003-2007) Rates are adjusted for age, sex, race, primary chronic condition, and the presence of more than one chronic condition using ordinary least squares regression. Arizona: 54.5% New York: 23.8% • U.S. State
Variations In End-Of-Life Care: Dartmouth Atlas of Health Care Hospice days per decedent during the last 6 months of life (2003-2007) Rates are adjusted for age, sex, race, primary chronic condition, and the presence of more than one chronic condition using ordinary least squares regression. • Hospital Referral Region McAllen, TX 3.9 days Ogden, UT 35.5 days
Where are we? •Shortage of specialized expertise Compare: 1 oncologist to every 141 newly diagnosed cancer patients vs. 1 palliative medicine doctor to every 1,200 patients with serious or life-threatening illnesses.1 •Hospital-based palliative care — increasing access Since 2008, 19% increase in palliative care teams in hospitals. 85% of large (>300 beds) hospitals have teams.1 • Resources: Approximately 25-30% of Medicare costs incurred in last year of life; in last month, 80% of expenditures are for hospitalization.2 1 Center to Advance Palliative Care. America’s Care of Serious Illness: A State-by-State Report Card on Access to Palliative Care in Our Nation’s Hospitals. NY: 2011. Available at: reportcard.capc.org/pdf/state-by-state- reportcard.pdf. Accessed May 28, 2013. 2 Lubitz J, Riley GF. Trends in Medicare payments in the last year of life. New England Journal of Medicine 1993; 328 (15): 1092-1096. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC2838161/pdf/hesr0045- 0565.pdf. Accessed May 29, 2013.
Aetna Compassionate Care (ACCP) •Goals of the program: • Provide additional support to members • with advanced illness and their families/caregivers • Help them access optimal care • The goal is not to create or encourage hospice, although hospice can be a choice when appropriate and requested by the member.
Holistic, Member-Centric Case Management Help member understand options, with nurse case managers who are trained to: •Assess and manage members’ care in a culturally sensitive manner •Identify resources to make members as comfortable as possible, addressing pain and other symptoms •Help coordinate medical care, benefits and community-based services •Inform the member about treatment options, continuity of care and advanced care planning •Provide personal support •Consult and coordinate with the members’ treating physicians and staff (including other care coordinators where available)
Results: Member Discussion Example of Why Compassionate Care Shows Impact: Depth of Connection •Wife stated member passed away with hospice. Much emotional support given to spouse. She talked about what a wonderful life they had together, their children, all of the people's lives that he touched. They were married 49 years last Thursdayyand each year he would give her a piece of jewelry. On Tuesday, when she walked into his room, he had a gift and card laying on his chest, a beautiful ring that he had their daughter purchase. She was happy he gave it to her on Tuesday--- on Thursday, he was not alert. She stated that through his business he touched many peoples lives, and they all somehow knew he was sick, and he has received many flowers, meals, fruit, cake. She stated her lawn had become overgrow and the landscaper came and cleaned up the entire property, planted over 50 mums, placed cornstalks and pumpkins all around. She said she is so grateful for the outpouring of love. Also stated that hospice was wonderful, as well as everyone at the doctor’s office, and everyone here at Aetna. She tells all of her friends that "when you are part of Aetna, you have a lifeline.” Encouraged her to call CM with an issues or concerns. Closed to case management.
Results Favorable impact aligning patient goals with outcomes • 82% of engaged decedents choose hospice • 82% reduction in acute inpatient days • 77% reduction in emergency room visits • 86% reduction in intensive care unit days Improved quality of life for Aetna members and their families Data for 2010 Medicare Advantage members enrolled in Aetna’s Compassionate Care program. Resulting (in Medicare Advantage) in savings of over $12,500 per engaged member
Summary: Metrics Demonstrate Opportunity • Improving the quality of care for those with advanced illness represents a tremendous opportunity for the country’s health system, for individual patients, and for families and caregivers. • Programs that provide expert assistance such as Aetna Compassionate Care can increase awareness of the care options available to patients and caregivers, thereby aligning patient choice more closely with desired types of health services and care. • This care management program favorably impacts advanced illness, with very high rates of satisfaction. Metrics can demonstrate, particularly in Medicare, dramatic impact on Palliative Care and Hospice election, acute and intensive care utilization, cost and other metrics. • These metrics create an imperative that such services become more widely available.
Quality Measures as Drivers of Change National Summit on Advanced Illness Care Metrics for Success Workshop 122
Quality Results Making Hospital Safer
Quality Results Healing at Home
NQF Action Teams • Build on NQF’s role as an objective convener • Leverage NQF’s deep membership of 400+ organizations • Work collaboratively and in partnership to collectively impact health and healthcare quality • Promote uptake of existing NQF-endorsed performance measures • Influence important stakeholders to make meaningful and authentic commitments to action
NQF Maternity Action Team Results
Measurement Opportunities for Advanced Illness Care • Advanced Illness care generally does not follow patient goals and preferences • Palliative care can be used more broadly to alleviate suffering • Geriatrics finds that some of the most important care is outside of the traditional organ-system based clinical specialties. • Experience from caregivers as well as patients
Measurement Challenges for Advanced Illness Care • Individual condition-based guidelines often conflict for patients with multiple chronic diseases • Health affected by sociodemographic factors • Vulnerable populations may have difficulty accessing consistent source of care • Coordination of care among multiple sites/providers
NQF’s Aging Related Work Current Work: Prioritizing Measure Gaps: Alzheimer’s Disease and Related Dementias Measure Applications Partnership (MAP) Dual-eligibles beneficiary workgroup Post-acute care/long-term care workgroup Past Work: Multiple Chronic Conditions Framework Nursing home measures Home healthcare measures
Recent NQF Initiatives to Improve Care for Advanced Illnesses and Vulnerable Populations Current Work: • Prioritizing Measure Gaps: Alzheimer’s Disease and Related Dementias • Measure Applications Partnership (MAP) – Dual-eligibles beneficiary workgroup – Post-acute care/long-term care workgroup Past Work: • Multiple Chronic Conditions Framework • Nursing home measures • Home healthcare measures
Improving Care for Dual Eligible Beneficiaries • Considers the unique needs of population subgroups (e.g., individuals with ID/DD, frail elders) • Maintains a Family of Measures for Dual Eligible Beneficiaries • Gathers experience of state agencies, health plans, and other stakeholders in using MAP’s recommendations on measures to make them more accurate and actionable • Explores quality of life outcomes and how various system stakeholders share responsibility for supporting better outcomes for vulnerable beneficiaries
Big Opportunity Areas in Healthcare: What the Health System Needs Now Criteria for Impact Credible Timely Useable Meaningful Incubator Components  Concept  Technical expertise  Data sources  Analytics and feedback  Resources DATA ANALYTICS MEASURES INFORMATION IMPACT
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E N G A G I N G PAT I E N T S I N D I S S E M I N AT I O N A N D I M P L E M E N TAT I O N
P a t r i c i a A . G r a d y, R N , P h D FA A N , D i r e c t o r, N a t i o n a l I n s t i t u t e o f N u r s i n g R e s e a r c h
Research Translation General Public Educational InstitutionsPublic Interest Groups Federal Agencies State Agencies Local Agencies Professional Societies Industry Community Groups Patient Advocacy Groups Public Advisory Councils Health Professionals Volunteer Organizations Scientists Scientific Advisory Groups Stakeholders
NINR’s Areas of Research Scientific Focus Areas to Implement NINR’s Strategic Plan • Symptom Science • Wellness • Self-Management • End-of-Life and Palliative Care
Advanced Illness Care NINR Hosts NIH Briefing on IOM Report – Dying in America
Advanced Illness Care Hospice enrollment increases Medicare savings and decreases hospital usage Palliative Care Research Co-Operative (PCRC) o Comprehensive, multicenter resource o Developing structures and processes to enable and support end-of-life and palliative care research nationwide NINR-Supported Research to Improve / End-of-Life Care
Implementation and Dissemination
Research Support Selected NIH-Sponsored Funding Opportunities • Innovative Measurement Tools for Community Engaged Research Efforts • Development and testing of tools to measure trust, capacity, collaboration, empowerment, sustainability • Dissemination and Implementation Research in Health • Understanding and overcoming barriers to translating research discovery into clinical and community practice
www.ninr.nih.gov
R e g i n a G r e e r - S m i t h , M P H F A C H E
Guidance PCORI’s ENGAGEMENT RUBRIC PCOR GUIDING PRINCIPLES • Reciprocal Relationships • Co-Learning • Partnership • Trust, Transparency, Honesty DISSEMINATING THE STUDY RESULTS • “Patient partners are involved in plans for disseminating the study’s findings to patient, stakeholders, and research audiences so that the findings are communicated in understandable, usable ways.”
Developing Infastructure From Existing Relationships and Building Capacity Partnerships and Collaborations with Stakeholders For co-learning and trust-building Development of Programs and Initiatives to enable engagement activities Providing resources to empowering Priority Populations including: • Racial & Ethnic Minorities • LTBT • Persons with Disabilities • Low literary/numeracy • Rural populations More engagement resources at our website: http://www.healthcarera.com/
Develop Opportunities for Engagement, Dissemination & Implementation Exhibits and In-Person Presentations Social Media & Smartphones Use of Social Networking, Care Giver Support Groups & S.T.A.R. Initiative Engagement Clusters© Through partnerships and collaborations with patients, families, caregivers, faith-based partnerships, and all stakeholders
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A f t e r n o o n W o r k s h o p S e s s i o n s L e c t u r e R o o m : S h a r e d D e c i s i o n M a k i n g A u d i t o r i u m : T r a n s l a t i n g E v i d e n c e B a s e d P r a c t i c e I n t o C o m p e l l i n g M e s s a g e s R o o m 1 2 0 : F a m i l y C a r e g i v e r S u p p o r t R o o m 1 2 5 : B u i l d i n g t h e B u s i n e s s C a s e f o r A d v a n c e d I l l n e s s C a r e
S h a r e d D e c i s i o n M a k i n g : H o n o r i n g I n f o r m e d P a t i e n t C h o i c e
Practice Variation: Evidence for Poor Decisions 150 Red dots indicate HRRs served by U.S. News 50 Best Hospitals for Geriatric Care 2,500 3,500 4,500 5,500 6,500 7,500 8,500 ASRAdjustedMedicareSpending
Forces Sustaining Poor Quality 151
Patients & physicians view trade-offs differently Decision: Goal % top 3 Patient % top 3 Provider Surgery: Keep your breast 7% 71% Reconstruction: Look natural without clothes 59% 80% Chemotherapy: Live as long as possible 33% 96% Reconstruction: Avoid using prosthesis 33% 0% Sepucha K, et al. Patient Education and Counseling 2008 and Lee et al. 30th Annual Society for Medical Decision Making Conference, Philadelphia, 2008.
153
154 23 Patient vs. 25 Physician States 2 Hybrids Patient Standard Physician Standard Hybrid (NM & MN)
Health Policy Relating to SDM SDM has become a standard part of the language of US health reform – AffordableCare Act – Definition requirement for MedicareACOs – Requirement for Comprehensive primary Care Initiatives – State-based health care reform – Meaningful use of HIT – InformedConsent – Professional societies, practice guidelines 155
WA State Passed Three Bills • Passed legislation in 2007 • Explicitly recognizes SDM is an enhanced informed consent for Preference-Sensitive Conditions if provider uses a “certified aid” • Led to Group Health demonstration project • 2009 Passed Bree Collaborative—SDM promoted • 2012 Passed legislation allowing CMO of HCA to “certify aids” moving forward with criteria • Payment of providers for SDM being considered 156
157 Involvement Values Concordance Decision Quality Knowledge Did the patient know what he or she needed to know? Did the decision reflect the patient’s goals and concerns? Did the patient know a decision was being made? Did the patient know the pros and cons of the treatment options? Did the provider elicit the patient’s preferences?
Health Policy Reasons for Adoption of SDM on Large Scale • Ethical imperative to do the right thing • Perfected Informed Consent-Aligning preferences, values and lifestyle with individual’s clinical decision • Bridging Health Disparities • Conservative Utilization of surgical interventions
W h a t M a t t e r s t o Yo u M a t t e r s t o U s H M S A’ s A C P V i d e o P r o j e c t R a e S e i t z , M D M a r c h 2 0 1 5
HMSA’s ACP Video Project • How the ACP Video Project advances HMSA’s mission and vision of keeping members at the center of, in control of, and responsible for their own well-being • Review some preliminary outcomes • The strategy applied to spreading the use of ACP video decision aids • What have we learned about ACP, what works and what challenges remain
0% 10% 20% 30% 40% 50% 4Q2012 1Q2013 2Q2013 3Q2013 4Q2013 1Q2014 2Q2014 Advance Care Planning at a Hospital “A” N=2668 across all time periods Percentage of Discharged with Completed POLSTS Percentage of Patients Discharged with Referral to Hospice Videos Introduced
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 4Q2013 1Q2014 2Q2014 POLST Completion Among Seriously Ill Patients N=845 across all time periods Conversation + Video vs Conversation Only
ACP Video Use in Palliative Care Pilot (n=56) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% PC Patient POLST Before POLST After 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Before After Life Prolonging Limited Comfort
Advance Care Planning Completion Rates for Members 75+ HMSA P4Q Measure 10/1/2013 to 9/30/2014 0% 10% 20% 30% 40% 50% Medicar Advantage PPO/HMO Using Video Not Using Video 37 Doctors identified using the videos; 250 doctors not using the video Denominator include 18000 for Medicare Advantage; 20,000 PPP/HMO Members
Our Approach Co- opetition Setting Standards Small Scale Testing & Spread Hospital/Ho spice/SNF Health Plans Primary Care Community
A new video campaign gives patients a voice on treatment options By Susan Essoyan
D i s c u s s i o n P o i n t s ?
ICU Code Order Changes After Patients/Families Watch ACP Videos n=14 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Pre-Video Post-Video Full Code Partial Code DNR
Advance Care Planning Outcomes ACP Outcomes Death at Home Hospice Use EOL ICU Days EOL Inpatie nt Use EOL ED Use Treatm ent at EOL EOL QOL FAMCA RE Decisio ns Honore d ACP Docum ents
Tr a n s l a t i n g E v i d e n c e - B a s e d P r a c t i c e s i n t o C o m p e l l i n g M e s s a g e s
Better Stories, Best Practices
successstartswiththestoryyoutell • stories change brains, beliefs and behaviors • stories are survival instruments • storytelling is a competitive sport • if you want to change your outcome, start by changing your narrative
Ithinkwe’regonnaneedabetternarrative
If we want to do better, first we have to feel better Change begins when you give people a new feeling about the issue. In this case, we want to replace fear of loss and helplessness with a promise of power, purpose and hope. Engage the Emotions
AIM Strategies 176 Engage the adversary: the revolving door The deep need: Reconnect with the “why”
Capital Caring Strategies 177 Envision our success: provide personal stories of positive outcomes Speak to identity: we are innovators
Stories are survival instruments. After you get the audience emotionally engaged, you have to give them practical tools to drive change. Stories are first and foremost survival instruments for a VUCA world. And advanced care - serious illness, the probable “third act” of life — is possibly the greatest VUCA of all. It requires that we come to terms with our ultimate mortality, life’s ultimate unknown, and it sets up a series of obstacles (financial, practical, emotional, physical) that make it hard for us to perform at the time we most need to. Empower Action
179 A new model: Built on patient experience and needs, not system structure Eliminate uncertainty: one way, one team AIM Strategies
180 Empower caregivers, Build confidence Capital Caring Strategies • allow autonomy with caregivers in implementing the program • build mastery: program builds confidence with caregivers • each positive interaction creates confidence and a better outcome
Build Resilience Stories are setbacks. The last act of life is not easy. There will be suffering. There will be sorrow. And no matter how powerful your program, there will be setbacks. People are often tempted to give up when they have a bad experience. Much of what we as leaders can do is to build resilience in ourselves and our communities, to help persevere through the hard times. The growth mindset is about getting people to recognize the truth that failure is a necessary stepping stone on the way to success.
182 Coach the growth mindset: “We’re all still learning how to do this.” Everyone worries about risk. The best strategy is to tell the truth. AIM Strategies
183 Openly share successes and setbacks - address issues Remember we are all learners and teachers Capital Caring Strategies • set clear, immediate metrics • be transparent in identifying what doesn’t work • be proud in reporting on what does
Capital Caring F o r n e a r l y 4 0 y e a r s , c o o r d i n a t e d , c o m p a s s i o n a t e c a r e w h e r e v e r o n e c a l l s h o m e
Capital Caring at a Glance • One of the nation’s oldest and largest non-profit providers of hospice and palliative care, Capital Caring cares for over 1,200 families each day. • Our service area includes The District of Columbia, Northern Virginia, and Prince George’s County, Maryland. • World-class, high quality care is at the heart of our business strategy. • Our mission? To simply improve care.
A commitment to people • In order to ‘simply improve care’- and with high- quality care at the heart of our strategy, Capital Caring’s key metrics allow us to measure and demonstrate improving care. - e.g. Capital Caring is committed to reducing a patient’s pain to a comfortable level within 48 hours; we achieve this in nearly every case. • We focus on culture, people development & training - Capital Caring instituted Standards – clear, impressive, and sustainable rules for achieving world-class care and results - We are committed to meeting 100% of our standards, 100% of the time
C a p i t a l C a r i n g : I n n o v a t i o n s i n C a r e Capital Caring is committed to innovation. • In 2014, we opened our state-of-the art Adler Center for Caring on the Van Metre Campus in Loudoun County, Virginia. This first-of-its-kind in the nation facility is home to Capital Caring’s Center for Pain and Palliative Care, a 21- bed world-class inpatient facility, Capital Caring’s home care team and palliative care. The Center even boasts a spa and gift shop. • Capital Caring’s Center for Pain and Palliative Care (CPPC) is on the forefront of innovation. The Center’s ability to perform procedures using state-of-the-art real-time imaging to alleviate debilitating pain on-site, complementing or even replacing pharmacotherapy, provides a vast improvement for patients dealing with pain associated with an advanced illness.
TeleCaring ™ • In 2011, Capital Caring launched TeleCaring™, an innovative care support program, where trained professionals, including nurses, place proactive, outbound calls to patients and caregivers. • TeleCaring™ is an extension of Capital Caring’s home care team that empowers caregivers—and provides rapid response to emerging issues or to answer questions. “I feel like every one of them is an extension of our family. Sometimes, when we have questions, when the Telecaring nurse calls, they take 5 minutes, 10 minutes to help me focus and address what matters most. The calls reassure me, and are a valuable extra layer of care.”----- Barry, Caregiver
Caring in the nation’s capital -By virtue of being in the nation’s capital, Capital Caring’s mission to simply improve care includes public education and advocacy to expand access to person-centered hospice care. -Since 2006, hospice utilization in D.C. has increased from 2% to over 30% in part because of our Hospice Comes to Washington awareness event. Our “In Good Faith” initiative has been instrumental in building trust among faith community leadership, their ‘parishioners’, and Capital Caring, in order to identify patients/families at risk in order to increase timely access to palliative care and hospice services. -Our program is centered on earlier, easier access to care with clearly defined standards and measurable quality of care as our business strategy.
Overview of AIM® Where we are today within Sutter Health • Betsy Gornet, FACHE • Sutter Health and Sutter Care at Home • March 3, 2015
“This publication was made possible by Grant Number 1C1CMS331005 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services.” "The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies." HEALTH CARE INNOVATIONS AWARDS
• Non-for-Profit health system serving Northern California • Includes 24 hospitals and over 5000 aligned physicians • Sutter Center for Integrated Care • Health care research, • 28 Home Care locations • AIM – System level; over 7300 Enrollments through Dec 2014; plus 1500 during pilot 192 SUTTER HEALTH AT A GLANCE Pending Luanch
Defining Advance Illness Management (AIM® ) AIM is a Care Management Model that Employs Evidence Based Principles of: Care Coordination & Transitions Management Palliative Care Patient Engagement Health Literacy Self Management Support 193
What Else Defines AIM? Improve Patient/Family/Caregiver Experience & Provider Experience; All payers, all diseases Fill in Gaps of Care – Between MD appointments and Between Home Health Care and Hospice Strengthen Relationship Between Patient & Physician Focus on Personal Goals and Revisiting Them as Illness Progresses Focus on Last 12- 18 Months of Life Coordinate Care Across all Sites of Care; Continuous; Team Navigation 194
• AIM Home Health (Skilled Episode) • AIM Transitions (Non-Skilled Care needs, short term) AIM In-Home Visit Based Care • Outbound, frequency acuity adjusted; Some inbound • Maintains MD Connection AIM In-Home Telesupport • Hospitalization • ED Visit • AIM Care Liaison AIM Acute Care Support • AIM Home Health (Skilled episode) • AIM Transitions (Non-Skilled Care needs, short term) AIM In-Home Visit Based Care Maintain Physician Communication and Connection with Patient; AIM Triage After Hours and Weekends IF Then cycle repeats CLOSER LOOK AT INTEGRATION
Advance Care Planning (Personal Goals) Dual Approach to Care: Curative + Palliative Red Flags & Symptom Management Plans Medication Management Follow Up Visits Patient Engagement & Self Management Support AIM Care Pillars 196 "The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies."
Key AIM Outcome Highlights Results not yet validated independently by CMMI Results July 2012- June 2014 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Q3 2014 74% 62% 91% Advance Care Plan (ACP) Documentation % of AIM Patients with ACPs at Enrollment % of AIM Patients with ACPs at Enrollment who Made Modifications to the ACP within 90 Days of Enrollment % of AIM Patients who had ACPs Documented Within 90 Days of Enrollment (Target = 90%) 0 200 400 600 800 1000 1200 1400 1600 1800 Hospitalizations ED Visits ICU Days Change in Utilization 90 Days Post AIM Enrollment 9 of 10 Sites Reporting; Q3 2013 - Q2 2014; n=1761 Results not yet validated independently by CMMI Pre Post 57% Reduction 22% Reduction 66% Reduction The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies."
Health Care Innovations Awards •“The project described was supported by Grant Number 1C1CMS331005 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services.”
B u i l d i n g t h e B u s i n e s s C a s e f o r A d v a n c e d I l l n e s s C a r e
Tr a n s f o r m i n g t h e C a r e o f S e r i o u s I l l n e s s : T h e B u s i n e s s C a s e Diane E. Meier, MD Director, Center to Advance Palliative Care diane.meier@mssm.edu www.capc.org www.getpalliativecare.org @dianeemeier
No Disclosures
Objectives • The case for integrated palliative care strategies • What works to improve quality and subsequently reduce costs for vulnerable people? • How to face outwards towards needs of: – Our patients, their families – Policymakers, payers, health system leadership
Concentration of Spending Distribution of Total Medicare Beneficiaries and Spending, 2011 10% 63% 37% 90% Total Number of FFS Beneficiaries: 37.5 million Total Medicare Spending: $417 billion Average per capita Medicare spending (FFS only): $8,554 Average per capita Medicare spending among top 10% (FFS only): $48,220 NOTE: FFS is fee-for-service. Includes noninstitutionalized and institutionalized Medicare fee-for-service beneficiaries, excluding Medicare managed care enrollees. SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost & Use file, 2011.
Concentration of Risk/$
Concentration of Risk/$
Value = Quality/Cost Because of the Concentration of Risk and Spending, and the Impact of Palliative Care on Quality and Cost, its Principles and Practices are Central to Improving Value
Mr. B • An 88 year old man with dementia admitted via the ED for management of back pain due to spinal stenosis and arthritis. • Pain is 8/10 on admission, for which he is taking 5 gm of acetaminophen/day. • Admitted 3 times in 2 months for pain (2x), falls, and altered mental status due to constipation. • His family (83 year old wife) is overwhelmed.
Mr. B • Mr. B: “Don’t take me to the hospital! Please!” • Mrs. B: “He hates being in the hospital, but what could I do? The pain was terrible and I couldn’t reach the doctor. I couldn’t even move him myself, so I called the ambulance. It was the only thing I could do.” Modified from and with thanks to Dave Casarett
Before and After Usual Care • 4 calls to 911 in a 3 month period, leading to • 4 ED visits and • 3 hospitalizations, leading to • Hospital acquired infection • Functional decline • Family distress Palliative Care • House calls referral • Pain management • 24/7 phone coverage • Support for caregiver • Meals on Wheels • Friendly visitor program • No 911 calls, ED visits, or hospitalizations in last 18 months
The Modern Death Ritual: The Emergency Department Half of older Americans visited ED in last month of life and 75% did so in their last 6 months of life. Smith AK et al. Health Affairs 2012;31:1277-85.
Who Are These Patients? • Functional Limitation • Frailty • Dementia • Exhausted overwhelmed family caregivers • +/- Serious illness(es)
Gómez-Batiste X, et al. BMJ Supportive & Palliative Care 2012;0:1–9. doi:10.1136/bmjspcare-2012-000211
Functional Limitations as a Predictor of Risk http://www.cahpf.org/docuserfiles/georgetown_trnsfrming_care.pdf
Dementia As A Predictor of Risk • Prospective • Cohort of community dwelling older adults • Callahan et al. JAGS 2012; 60:813-20. Dementia No Dementia Medicare SNF use 44.7% 11.4% Medicaid NH use 21% 1.4% Hospital use 76.2% 51.2% Home health use 55.7% 27.3% Transitions 11.2 3.8
Dementia And Total Spending • 2010: $215 billion/yr • By comparison: heart disease $102 billion; cancer $77 billion • 2040 estimates> $375 billion/yr Hurd MD et al. NEJM 2013;368:1326-34.
In case you are not already worried… The Future of Dementia Hospitalizations and Long Term Services+Supports 10 fold growth in dementia related hospitalizations projected between 2000 and 2050 to >7 million. Zilberberg and Tija. Arch Int Med 2011;171:1850. 3 fold increase in need for formal LTSS between now and 2050, from 9 to 27 million. Lynn and Satyarthi. Arch Int Med 2011;171:1852.
Why? Low Ratio of Social to Health Service Expenditures in U.S. Bradley E H et al. BMJ Qual Saf 2011;20:826-831 Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.
Surprise! Home and Community Based Services are High Value • Improves quality: Staying home is concordant with people’s goals. • Reduces spending: Based on 25 State reports, costs of Home and Community Based LTC Services less than 1/3rd the cost of Nursing Home care.
Study: Having meals delivered to home reduces need for nursing home 10/14/2013 | HealthDay News A study published today in Health Affairs found if all 48 contiguous states increased by 1% the number of elderly who got meals delivered to their homes, it would prevent 1,722 people on Medicaid from needing nursing home care. The Brown University study found 26 states would save money because lower Medicaid costs would more than offset the cost of providing the meals.
What is Palliative Care? • Specialized medical care for people with serious illness and their families • Focused on improving quality of life as defined by patients and families. • Provided by an interdisciplinary team that works with patients, families, and other healthcare professionals to provide an added layer of support. • Appropriate at any age, for any diagnosis, at any stage in a serious illness, and provided together with disease treatments. Definition from public opinion survey conducted by ACS CAN and CAPC http://www.capc.org/tools-for-palliative-care- programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdf
Conceptual Shift for Palliative Care
11% 49% 40% Costliest 5% of Patients IOM Dying in America Appendix E http://www.iom.edu/Reports/2014/Dying-In-America-Improving-Quality- and-Honoring-Individual-Preferences-Near-the-End-of-Life.aspx Last 12 months of life Short term high $ Persistent high $
Palliative Care Improves Value Quality improves – Symptoms – Quality of life – Length of life – Family satisfaction – Family bereavement outcomes – MD satisfaction Costs reduced – Hospital cost/day – Use of hospital, ICU, ED – 30 day readmissions – Hospitality mortality – Labs, imaging, pharmaceuticals
Palliative Care Improves Quality in Office Randomized trial simultaneous standard cancer care with palliative care co-management from diagnosis versus control group receiving standard cancer care only: – Improved quality of life – Reduced major depression – Reduced ‘aggressiveness’ (less chemo < 14d before death, more likely to get hospice, less likely to be hospitalized in last month) – Improved survival (11.6 mos. vs 8.9 mos., p<0.02) Temel et al. Early palliative care for patients with non-small-cell lung cancer NEJM2010;363:733-42.
Palliative Care at Home for the Chronically Ill Improves Quality, Markedly Reduces Cost RCT of Service Use Among Heart Failure, Chronic Obstructive Pulmonary Disease, or Cancer Patients While Enrolled in a Home Palliative Care Intervention or Receiving Usual Home Care, 1999–2000 13.2 11.1 2.3 9.4 4.6 35.0 5.3 0.9 2.4 0.9 0 10 20 30 40 Home health visits Physician office visits ER visits Hospital days SNF days Usual Medicare home care Palliative care intervention KP Study Brumley, R.D. et al. JAGS 2007
46 High Quality Studies 2002-11 Palliat Med 2014;28:130-50.
46 Studies: Across settings, patient populations, and palliative care delivery models, palliative care improves quality and in so doing, reduces costs.
What Do Patients Want? Survey of Senior Center and Assisted Living subjects, n=357, dementia excluded, no data on function. Asked to rank order what’s most important: 1st Independence (76% rank it most important) 2nd Pain and symptom relief 3rd Staying alive Fried et al. Arch Int Med 2011;171:1854
How Can We Help Families Help Patients Stay Home? Partner with our payers.
Innovative Payer Toolkit • Talk to your payers! • But first, read this: • Predictors of successful payer- ACO-provider initiatives • Case studies • Checklists • Worksheets • Resources 231 www.capc.org/payertoolkit
Payers Are Bringing Palliative Care Home
www.theatlantic.com 02.25.13 MA Full Risk PMPM contract with HealthCare Partners/DaVita 15%+margin. >700K patients “Now instead of 30-40 patients/day, Dr. Dougher sees 6-8.”
Treating the person beyond the disease
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F a m i l y C a r e g i v e r S u p p o r t
F a m i l y C a r e g i v e r S u p p o r t Susan C. Reinhard, R.N., Ph. D., FAAN
Family Caregivers Taking On More Complex Tasks • Partnership between the AARP Public Policy Institute and the United Hospital Fund • Funded by The John A. Hartford Foundation
Almost Half of Family Caregivers Perform Medical/Nursing Tasks
Medical/Nursing Tasks
Caregiver Advise, Record, Enable (CARE) Act What does the CARE Act Do? • Designation – Record the name of the family caregiver upon admission into the hospital • Notification – Contact the family caregiver(s) prior to discharge to another facility or home • Consultation – Hospital consults with caregiver on discharge plan, taking into account the caregiver’s capabilities and limitations • Training – Hospital gives caregiver the opportunity to receive instruction on all after- care tasks included in the discharge plan to be performed by the caregiver
Caregiver Advise, Record, Enable (CARE) Act • Gives support to nurses and other health and social service professionals to do what professional standards of practice require them to do • Stimulates new thinking on how to anticipate patient and family questions and pro-actively support them • Reduce hospital re-
Caregiver Advise, Record, Enable (CARE) Act Passed and signed in… It has been introduced in sixteen states (CT, HI, IN, KS, MA, MD, MN, MS, NH, NM, NY, ND, PR, VA, WI, WV).
Reimbursement for Educating Family Caregivers? • 2010 Invitational meeting with CMS (Centers for Medicare & Medicaid Services) and other stakeholders Focus: – Participants included leaders from nursing and social work professions, family caregiver advocacy organizations, and federal government agencies – The agenda explored policies around caregiver assessment and reimbursement for caregiver counseling. – Goal was to provide participants with relevant data on the use of Medicare reimbursement codes for the counseling of family caregivers of Medicare recipients.
Reimbursement for Educating Family Caregivers? • AARP Public Policy Institute worked with CMS to provide data on use of existing reimbursement codes. – Determine the past and current use of the reimbursement codes, – What healthcare professionals (Physicians, Nurse Practitioners, etc.) were using codes – If usage was low, why? – What regions of the country were codes used
Reimbursement for Educating Family Caregivers? • Data run not completed due to regulations around privacy of Medicare beneficiary and provider data
Medicare Payment for Clinicians • The following provide payment for clinicians doing care coordination including family caregivers – Chronic Care Management Fee – Post-Discharge Transitional Care Management – Home Health Services for Caregivers of Alzheimer’s Patients – Patient-Centered Medical Home (Advanced Primary Care Practices) – Medicare Community-Based Care Transition Program
Care Recipient Family Caregiver CARE TRIANGLE Healthcare Professional “It will take a movement to join the three corners of the care triangle: people who need care, families who care for and about their members, and people who give care for a living.” Deborah Stone, The Nation, March 13, 2008
Questions? Susan Reinhard SReinhard@aarp.org @susanpolicy 202-434-3840
F a m i l y C a r e g i v e r S u p p o r t Gail Gibson Hunt President and CEO National Alliance for Care Giving
About Alliance  Non-profit coalition of over 50 national organizations focused on family caregiving issues  Established in 1996 to support family caregivers and the professionals who work with them  NAC Activities:  Conduct research and policy analysis;  Develop national programs;  Strengthen state and local coalitions;  Increase public awareness;  International work and awareness.
Demographics of Care Giving  65.7 million caregivers make up 29% of the US adult population and 31% of households  48.9 million care for only adult recipients, including people with disabilities  Portrait of Caregiver:  48-year-old woman who works and cares  Average of 20.4 hours of care per week for her mother for an average of 4.6 years  34% care for two or more people  86% provide care for a relative
Who Are Caregivers?
Caregiver Financial Burden  Caregiving costs U.S. employers between $17.1 and $33.6 billion in lost productivity annually  Over $5,500 out of pocket expenses  Seven in 10 working caregivers make workplace accommodations  Loss of wages, pension, Social Security: $324,044—women; $283,716—men  43% of caregivers were affected financially (AHA/ASA 2005)
PCORI End of Life Research  Several studies from PCORI on end-of-life care and caregiving  Includes cancer and heart failure treatment  Pediatric end-of-life care received grants to examine care preferences and communication on care  Shared decision making with patients, families and medical professionals  Impact on caregivers: • Caregiver burden • Decision-making (aggressiveness of care, etc.) • Reduce caregiver conflict/regret
Federal Caregiving Legislation  Previously introduced legislation – yet to be introduced in current term  “FAMILY Act” – Family And Medical Insurance Leave Act of 2013, would create a self-sustaining insurance fund through a payroll tax to provide paid family and medical leave similar to the California Paid Leave program.  Caregiver Corps Act of 2014 (Sen. Casey-PA) and the National Care Corps Act (Rep. Grisham-NM), propose to create volunteer corps to help support families that do not have caregivers to meet long-term care needs  Mental Health Support for Veteran Families and Caregivers Act of 2013 (Sen. Sanders), would have created educational programs to support caregivers and vets with mental health disorders through the VA’s vet centers  In Home CARE Act (Sen. Booker-NJ, Rep. Pascrell-NJ), would have provided in- home caregiver education and training and an assessment with referral to resources for physical and mental Health for both the caregiver and the care recipient
Active Caregiving Initiatives  White House Conference on Aging  Older Americans Act Reauthorization  21st Century Cures • Accelerates innovation for diseases with unmet needs  President’s Budget • Proposed increases in NFCSP and Lifespan Respite, among others • New ACL Family Support Program ($15,000,000)
Thank you Gail Gibson Hunt President & CEO National Alliance for Caregiving 4720 Montgomery Lane, Suite 205 Bethesda, MD 20814 gailhunt@caregiving.org 301-718-8444 www.caregiving.org
T h a n k y o u
T h e C o n t i n u u m o f C a r e : P a n e l D i s c u s s i o n
The Continuum of Care: Panel Discussion • Brad Stuart, MD C-TAC • Samira K. Beckwith, President and CEO, Hope Healthcare Services • Robert Sowislo, Board and Government Affairs U.S. Medical Management • Jean Kutner, MD, MSPH, CMO Professor of Medicine and Associate Dean for Clinical Affairs University of Colorado School of Medicine Past President AAHPM • Cheryl Phillips, MD, SVP Advocacy and Public Policy, Leading Age • Randy Axelrod, MD, EVP Clinical and Patient Services, Providence Health Services
M o d e r a t o r : B r a d S t u a r t , M D C - T A C
Toward A Person-Centered Continuum of Care Person Community HH, Hospice Health System Medical Group Agencies Church Private Payers LT Care Government Physician Hospital
H o s p i c e A s A n A g e n t f o r C l i n i c a l I n t e g r a t i o n S a m i r a K . B e c k w i t h P r e s i d e n t a n d C E O H o p e H e a l t h c a r e S e r v i c e s
Hope Comfort Care Hope PACE Hope Healing Hearts Hope Hospice Hope Visiting Nurses Hope Connections Hope Parkinson Program Hope Kids Care Patients and Families
USMM / VPA H o m e B a s e d P r i m a r y C a r e C o n t i n u u m o f C a r e R o b e r t S o w i s l o E V P A d v o c a c y / G o v e r n m e n t A f f a i r s
Who We Are… USMM is the nation's largest physician led provider of in- home medical services for high-risk populations: • Provide 15% of all in-home physician visits nationally • Serve over 50,000 complex patients on an annual basis • Operate >100 local offices across 14 States Delivers a physician- driven, fully- integrated continuum of care model ~ 225 full time Physicians, NPs and PAs Engage in over 400,000 physician house call visits, 39,000 podiatric house call visits, 139,000 home health visits, and 380,000 hospice patient days annually Centralized administrative, data management, and call center operations 24x7 response to urgent escalations in illness and medical crises
Shared Savings Programs Provide enhanced access to health services and quality of life for complex populations by removing barriers to receiving care Pioneer ACO Independence at Home 30% 30% 50% Top Decile Top Quintile 17% / year Not Published • Reduction in All-Cause 30-Day Readmissions • Reduction in Hospital Admissions for Ambulatory-Care Sensitive Conditions • Reduction in ER Visits for Ambulatory-Care Sensitive Conditions • Patient Satisfaction Scores (CAHPS) • Quality Scores (ACO Measures / IAH Quality Metrics) • Cost Reduction (Pioneer 3 Yrs. Experience / IAH Year 1 Not Published) Results and Outcomes • Opportunity to expand shared savings participation to remaining FFS population through current CMS MSSP ACO program (First Home Based Primary Care ACO in the U.S.) • Launched in January 2015; enrolled 20,000+ beneficiaries out of existing USMM/VPA USMM Accountable Care Partners, LLC
J e a n K u n t e r , M D , M S P H , C M O P r o f e s s o r o f M e d i c i n e a n d A s s o c i a t e D e a n f o r C l i n i c a l A f f a i r s U n i v e r s i t y o f C o l o r a d o S c h o o l o f M e d i c i n e P a s t P r e s i d e n t , A A H P M
L o n g - t e r m C a r e a n d C o m m u n i t y C o n n e c t i o n s C h e r y l P h i l l i p s , M D S V P, A d v o c a c y a n d P u b l i c P o l i c y L e a d i n g A g e
I n t e g r a t e d H e a l t h S y s t e m s R a n d y A x e l r o d , M D E V P, C l i n i c a l a n d P a t i e n t S e r v i c e s , P r o v i d e n c e H e a l t h a n d S e r v i c e s
A Snapshot of Providence Caregivers (all employees) 73,018 Employed physicians 3,389 Employed advanced practice clinicians 923 Registered nurses 25,478 Physician clinics 475 Acute care hospitals 34 Acute care beds (licensed) 7,932 Providence Health Plan members 390,596 Hospice and home health programs 19 Home health visits 633,364 Hospice days 640,409 Assisted living and long-term care facilities (free standing and co-located) 22 Supportive housing Facilities: 14 Units: 693 Unique patients served 2,483,462 Community benefit and charity care costs $951 million Data is consolidated for Providence and its affiliates based on financial reporting. 272
Question & Answer Panel Discussion
F e d e r a l I n i t i a t i v e s t o D r i v e C h a n g e
Federal Initiatives to Drive Change • Tom Daschle, Former U.S. Senator (D-SD) Founder and CEO, The Daschle Group
CMS Innovation and Health Care Delivery System Reform Dr. Patrick Conway, M.D., MSc CMS Chief Medical Officer and Deputy Administrator for Innovation and Quality Director, Center for Medicare and Medicaid innovation Director, Center for Clinical Standards and Quality
Better Care, Smarter Spending, Healthier People  In three words, our vision for improving health delivery is about better, smarter, healthier.  If we find better ways to deliver care, pay providers, and distribute information, we can receive better care, spend our dollars more wisely, and have healthier communities, a healthier economy, and a healthier country.  We understand that it’s our role and responsibility to lead … and we will.  What we won’t do – and can’t do – is go it alone. Patients, providers, government, and business all stand to benefit if we get this right, and this shared purpose calls out for deeper partnership.  So we will continue to work across sectors for the goals we share: better care, smarter spending, and healthier people.
Overview Early Results CMS Innovation Center Delivery System Reform and Our Goals
CMS Support of Health Care Delivery System Reform Will Result in Better Care, Smarter Spending, and Healthier People Historical state Key characteristics  Producer-centered  Incentives for volume  Unsustainable  Fragmented Care Systems and Policies  Fee-For-Service Payment Systems Evolving future state Key characteristics  Patient-centered  Incentives for outcomes  Sustainable  Coordinated care Systems and Policies  Value-based purchasing  Accountable Care Organizations  Bundled payments  Medical Homes  Quality/cost transparency  Population-based payments Public and private sectors
Improving the way providers are incentivized, the way care is delivered, and the way information is distributed will help provide better care at lower cost across the health care system.  Encourage the integration and coordination of clinical and support services  Improve population health  Promote patient engagement through shared decision making Pay Providers  Create transparency on cost and quality information  Bring electronic health information to the point of care for meaningful use Focus Areas Description Deliver Care Distribute Information  Promote value-based payment systems – Test alternative payment models – Increase linkage of Medicaid, Medicare FFS, and other payments to value  Bring proven alternative payment models to scale Delivery System Reform Requires Focusing On the Way We Pay Providers, Deliver Care, and Distribute Information Source: Burwell SM. Setting Value-Based Payment Goals ─ HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online first.
CMS Has Adopted a Framework That Categorizes Payments to Providers Description Medicare Fee-for- Service examples  Payments are based on volume of services and not linked to quality or efficiency Category 1: Fee for Service – No Link to Value Category 2: Fee for Service – Link to Quality Category 3: Alternative Payment Models Built on Fee-for- Service Architecture Category 4: Population-Based Payment  At least a portion of payments vary based on the quality or efficiency of health care delivery  Some payment is linked to the effective management of a population or an episode of care  Payments still triggered by delivery of services, but opportunities for shared savings or 2-sided risk  Payment is not directly triggered by service delivery so volume is not linked to payment  Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (e.g., ≥1 year)  Limited in Medicare fee- for-service  Majority of Medicare payments now are linked to quality  Hospital value- based purchasing  Physician Value Modifier  Readmissions / Hospital Acquired Condition Reduction Program  Accountable Care Organizations  Medical homes  Bundled payments  Comprehensive Primary Care initiative  Comprehensive ESRD  Medicare-Medicaid Financial Alignment Initiative Fee-For- Service Model  Eligible Pioneer Accountable Care Organizations in years 3-5  Maryland hospitals Source: Rajkumar R, Conway PH, Tavenner M. CMS ─ engaging multiple payers in payment reform. JAMA 2014; 311: 1967-8.
During January 2015, HHS Announced Goals for Value-Based Payments Within the Medicare FFS System  30% of Medicare payments are tied to quality or value through alternative payment models (categories 3-4) by the end of 2016, and 50% by the end of 2018  85% of all Medicare fee-for-service payments are tied to quality or value (categories 2-4) by the end of 2016, and 90% by the end of 2018 Goals Purpose  Set internal goals for HHS  Invite private sector payers and Medicaid to match or exceed HHS goals Stakeholders  Consumers  Businesses/Purchasers  Payers  Providers  State partners (including Medicaid programs) Next steps  Testing of new models and expansion of existing models is critical to reaching incentive goals  Creation of the Health Care Payment Learning and Action Network to align incentives and identify best practices
50% Target Percentage of Payments in ‘FFS Linked to Quality’ and ‘Alternative Payment Models’ by 2016 and 2018 ~20 0%
CMS Increasingly Linking FFS Payments to Quality or Value 1 2 2 1 2 2 1 2 1.75 2 3 2 3 2 2
CMS is Aligning with Private Sector and States to Drive Delivery System Reform Convening Stakeholders  Convened payers in 7 markets in Comprehensive Primary Care  Convening payers, providers, employers, consumers, and public partners through the Health Care Payment Learning and Action Network CMS Strategies for Aligning with Private Sector and States Incentivizing Providers  Pioneer ACOs agreements required 50% of the ACO’s business to be in value- based contracts by the end of the second program year Partnering with States  The State Innovation Models Initiative funds testing awards and model design awards for states implementing comprehensive delivery system reform  The Maryland All-Payer Model tests the effectiveness of an all- payer rate system for hospital payments
Early Results CMS Innovation Center Delivery System Reform and Our Goals
Source: CMS Office of the Actuary 9.24% 5.99% 4.63% 7.64% 7.16% *27.59% 1.98% 4.91% 4.15% 1.36% 2.25% 1.13% 0.35% 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Medicare Per Capita Growth Medical CPI Growth *Medicare Part D prescription drug benefit implementation, Jan 2006 28% 27% Results: Per Capita Spending Growth at Historic Lows
Pioneer ACOS were designed for organizations with experience in coordinated care and ACO-like contracts Pioneer ACOs showed improved quality outcomes Quality outperformed published benchmarks in 15/15 clinical quality measures and 4/4 patient experience measures in year 1 and improved in year 2 Mean quality score of 85.2% in 2013 compared to 71.8% in 2012 Average performance score improved in 28 of 33 (85%) quality measures Pioneer ACOs generated savings for 2nd year in a row  $384M in program savings combined for two years†  Average savings per ACO increased from $2.7 million in PY1 to $4.2 million in PY2‡ Pioneer ACOs Provided Higher Quality and Lower Cost Care to Medicare Beneficiaries in Their First Two Performance Years  19 ACOs operating in 12 states (AZ, CA, IA, IL, MA, ME, MI, MN, NH, NY, VT, WI) reaching over 600,000 Medicare fee-for-service beneficiaries  Duration of model test: January 2012 – December 2014; 19 ACOs extended for 2 additional years † Results from regression based analysis ‡ Results from actuarial analysis
 CMS convenes Medicaid and commercial payers to support primary care practice transformation through enhanced, non-visit-based payments, data feedback, and learning systems  Across all 7 regions, CPC reduced Medicare Part A and B expenditures per beneficiary by $14 or 2%*  Reductions appear to be driven by initiative-wide impacts on hospitalizations, ED visits, and unplanned 30-day readmissions Comprehensive Primary Care (CPC) is Showing Early Positive Results  7 regions (AR, OR, NJ, CO, OK, OH/KY, NY) encompassing 31 payers, nearly 500 practices, and approximately 2.5 million multi-payer patients  Duration of model test: Oct 2012 – Dec 2016 * Reductions relative to a matched comparison group and do not include the care management fees (~$20
Spotlight: Comprehensive Primary Care, SAMA Healthcare SAMA Healthcare Services is an independent four-physician family practice located located in El Dorado, a town in rural southeast Arkansas “A lot of the things we’re doing now are things we wanted to do in the past… We needed the front-end investment of start-up money to develop our teams and our processes” -Practice Administrator Services made possible by CPC investment  Care management  Each Care Team consists of a doctor, a nurse practitioner, a care coordinator, and three nurses  Teams drive proactive preventive care for approximately 19,000 patients  Teams use Allscripts’ Clinical Decision Support feature to alert the team to missing screenings and lab work  Risk stratification  The practice implemented the AAFP six- level risk stratification tool  Nurses mark records before the visit and physicians confirm stratification during the patient encounter
Partnership for Patients Contributes to Quality Improvements and Cost Savings Ventilator- Associated Pneumonia Early Elective Delivery Central Line- Associated Blood Stream Infections Venous thromboembolic complications Re- admissions 62.4% ↓ 70.4% ↓ 12.3% ↓ 14.2% ↓ 7.3% ↓  Data shows a 17% reduction in hospital acquired conditions across all measures from 2010 – 2013 ‒ 50,000 lives saved ‒ 1.3 million patient harm events avoided ‒ $12 billion in savings  Many areas of harm dropping dramatically – patient safety improving Leading Indicators, change from 2010 to 2013
Medicare All-Cause, 30-day Hospital Readmission Rate is Declining Legend: CL: control limit; UCL: upper control limit; LCL: lower control limit ReadmissionRate
Beneficiaries Move to MA Plans with High Quality Scores  Sent prompt to beneficiaries enrolled in plans with 2.5 star rating or lower  Letters only sent to beneficiaries in consistently low-rated plans  Switch rate 44% (prompt) v. 21% (no prompt) 9% 9%9% 2012 20% 61% 29% 57% 20142013 9% 5% 45% 45% 1% 5-star 4-star 3-star 2-star Medicare Advantage (MA) Enrollment Rating Distribution 29 % 71 % 37 % 63 % 55 % 45 % % 4 or 5 star % 2 or 3 star
Early Results CMS Innovation Center Delivery System Reform and Our Goals
The CMS Innovation Center Was Created By the Affordable Care Act to Develop, Test, and Implement New Payment and Delivery Models
The Innovation Center Portfolio Aligns With Delivery System Reform Focus Areas
CMS Has Engaged the Health Care Delivery System and Invested in Innovation Across the Country Models run at the state levelSites where innovation models are being tested Source: CMS Innovation Center website, January 2015
Accountable Care Organizations: Participation in Medicare ACOs Growing Rapidly ACO-Assigned Beneficiaries by County 424 ACOs have been established in the MSSP and Pioneer ACO programs 7.8 million assigned beneficiaries This includes 89 new ACOS covering 1.6 million beneficiaries assigned to the shared saving program in 2015
 The bundled payment model targets 48 conditions with a single payment for an episode of care  Incentivizes providers to take accountability for both cost and quality of care  Four Models - Model 1: Retrospective acute care hospital stay only - Model 2: Retrospective acute care hospital stay plus post-acute care - Model 3: Retrospective post-acute care only - Model 4: Acute care hospital stay only  102 Awardees and 167 episode initiators in phase 2 as of January 2015  85 new awardees and 373 new episode initiators will enter phase 2 in April 2015 Bundled Payments for Care Improvement is Also Growing Rapidly  Duration of model is scheduled for 3 years:  Model 1: April 2013 to present  Models 2,3,4: October 2013 to present * Current as of January 2015
 CMS is testing the ability of state governments to utilize policy and regulatory levers to accelerate health care transformation  Primary objectives include  Improving the quality of care delivered  Improving population health  Increasing cost efficiency and expand value-based payment State Innovation Model Grants Have Been Awarded in Two Rounds  Six round 1 model test states  Eleven round 2 model test states  Twenty one round 2 model design states
Round 1 States Are Testing and Round 2 States Are Designing and Implementing Comprehensive Reform Plans Round 1 States testing APMs Arkansas Maine Massachuset ts Minnesota Oregon Vermont Patient centered medical homes Accounta ble care Episodes  Near term CMMI objectives  Establish project milestones and success metrics  Support development of states’ stakeholder engagement plan  Onboard states to Technical Assistance Solution Center and SIMergy Collaboration site  Launch State HIT Resource Center and CDC support for Population Health Plans Round 2 States designing interventions
 Maryland is the nation’s only all-payer hospital rate regulation system  Model will test whether effective accountability for both cost and quality can be achieved within all-payer system based upon per capita total hospital cost growth  Quality of care will be measured through  Readmissions  Hospital Acquired Conditions  Population Health Maryland is Testing an Innovative All-Payer Payment Model  Maryland has ~6 million residents*  Hospitals began moving into All-Payer Global Budgets in July 2014 - 95% of Maryland hospital revenue will be in global budgets - All 46 MD hospitals have signed agreements  Model was initiated in January 2014; Five year test period * US census bureau estimate for 2013
C-TAC 2015 National Summit on Advanced Illness Care - Master Slide Deck
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C-TAC 2015 National Summit on Advanced Illness Care - Master Slide Deck

  • 1. N a t i o n a l S u m m i t o n A d v a n c e d I l l n e s s C a r e D r i v i n g C h a n g e t h r o u g h L e a d e r s h i p , E v i d e n c e a n d A c t i o n
  • 2. Welcome and Goals Leonard D. Schaeffer Judge Robert Maclay Widney Chair and Professor University of Southern California M a r c h 2 , 2 0 1 5
  • 3. Conference Hosts • Bill Novelli: Board Co-Chair and Professor, McDonough School of Business, Georgetown University and former CEO, AARP • Tom Koutsoumpas: Board Co-Chair and President, Caring Foundations • Jon Broyles: Executive Director, C-TAC
  • 4. C-TAC Vision All Americans with advanced illness, especially the sickest and most vulnerable, will receive comprehensive, high-quality, person- and family- centered care that is consistent with their goals and values and honors their dignity.
  • 5. Advanced IllnessC-TAC’s Goal Chronic and Curative Care Healthy or with reversible illness Disease Progression Advance Directive Advance Care Planning Early onset, chronic conditions Progressive, frequent complications Hospice Eligible Palliative Care Hospice Phase 4Phase 3Phase 2Phase 1 All persons with advanced illness receive high quality care
  • 6. Key C-TAC Initiatives • Comprehensive, Consensus-Based Policy Agenda: Guides C-TAC’s activities on the Hill and with Administration • Proof-in-Concept Community Action Pilot (Oakland, CA): Fosters partnerships between health systems and community organizations to fill gaps in care delivery • Advanced Care Project: Partnership with AHIP Foundation to engage health plans and health systems in implementing advanced illness care programs
  • 7. Key C-TAC Initiatives • Serves as a guide for transforming advanced care illness across all disciplines • Analyzes key issues, challenges and solutions • Identifies action steps for achieving high-quality, advanced illness care • Provides a “Call to Action”
  • 8. Conference Goals • Increase provider and consumer readiness to implement, evidence-based tools & approaches to AIC • Connect consumers, clinicians, health systems and health plans to deliver high quality, person-centered care and commit to improved performance • Disseminate information and support implementation of evidence-based AIC models
  • 9. We’re here to learn what’s working and what’s not, and use these lessons to move forward • Identify gaps in evidence that need to be addressed to further the adoption of better AIC • Expand comparative effectiveness research to support transformational change in the field Conference Goals
  • 10. How You Can Contribute Today One degree of change can make all the difference • Be candid about what’s working, what’s not, and why • Join in catalyzing action and energy around effective programs and ideas • Help identify programs and concepts with the greatest potential to improve AIC • Offer ideas on how to scale up what’s working
  • 11. IOM (Institute of Medicine). 2014. Dying in America: Improving quality and honoring individual preferences near the end of life. Washington, DC: The National Academies Press. Introduction Please join me in welcoming: Victor Dzau, MD President, Institute of Medicine
  • 12. A d v a n c e d I l l n e s s C a r e : T h e I O M P e r s p e c t i v e V i c t o r J . D z a u , M D P r e s i d e n t , I n s t i t u t e o f M e d i c i n e
  • 13. Dr. Victor Dzau, MD President, Institute of Medicine Advanced Illness and End of Life Care: The IOM Perspective
  • 14. Advanced Illness Care “Occurring when one or more conditions become serious enough that general health and functioning decline, and treatments begin to lose their impact. The process that continues to the end of life.” -Coalition to Transform Advanced Care
  • 16. Aging Americans over age 65 9% in 1960 20% in 2050 Growing ethnic and cultural diversity
  • 17. Disease Burden Multiple chronic conditions 2/3 of people over 65 New cancer cases 45% increase from 2010 2030 Alzheimer’s disease and dementias 5.5 million in 2010  8.7 million in 2030 Parkinson’s disease Prevalence to double in the next 30 years.
  • 18. Care People dying in acute care hospitals Deaths in nursing homes and hospice • # of Americans needing long-term care: more than double by 2050 • Medicare deaths in acute care hospitals: 33% 2000  25% in 2009 • Growing number of deaths in nursing homes • Hospice care: 1995, 17% of US deaths  2011, 45% • By 2011, 85% hospitals with 300+ beds had palliative care services
  • 19. Costs Medicare spent 28 percent of 2011 spending, or about $170 billion, on patients’ last six months of life.
  • 20. Decision-Making 40% of adult medical inpatients incapable of making their own treatment decisions Among nursing home residents, 44-69% cannot make their own medical decisions 70% of decedents aged 60 and older who faced treatment decisions in the final days of their lives were incapable of participating in these decisions
  • 21. IOM’s Role Independent, Apolitical | Multidisciplinary | Evidence-based
  • 22.
  • 23. Maintaining high quality of life until death Care Delivery Clinician- Patient Communication Policies and Payment Systems Professional Education Research and Information Sharing Public Education and Engagement
  • 25. Cover provisions for individuals nearing end of life Provide access to palliative care, with an integrated team Publically report quality and cost measures Comprehensive Care • Seamless, patient-centered, family-oriented, high- quality, integrated • Accessible 24/7 • Considers physical, emotional, social, and spiritual needs • Consistent with individuals’ values, goals, and informed preferences Care delivery organizations Government health insurers Care delivery organizations Care delivery organizations
  • 26. Specifically for Children: • Need clinical practice guidelines and protocols for palliative, end-of-life, and bereavement care that meet the needs of children and families.
  • 27. Proposed Core Components of Quality EoL Care • Frequent assessment of patient’s physical, emotional, social, and spiritual well-being • Management of emotional distress • Offer referral to expert-level palliative care • Offer referral to hospice if the patient has a prognosis of 6 months or less • Management of care and direct contact with patient and family for complex situations by a specialist level palliative care physician • Round-the-clock access to coordinated care and services • Management of pain and other symptoms • Counseling of patient and family • Family caregiver support • Attention to the patient’s social context and social needs • Attention to the patient’s spiritual and religious needs • Regular personalized revision of the care plan and access to services based on the changing needs of the patient and family
  • 29. In a national survey, clinicians asked for patients’ preferences in medical decisions only about ½ the time. 25% of patients reported that their clinician failed to share important information about their test results or medical history with others involved in their care
  • 30. Develop Adopt Tie to reimbursement Facilitate tying to reimbursement, licensing, credentialing Quality Standards encouraging: • Individuals to participate in decision-making • Clinicians to initiate conversations • Clinicians to revisit discussions Professional Societies Professional Societies and others Payers Health care delivery organizations Payers
  • 31. Specifically for Children: • Need better policies and procedures to ensure child’s involvement in treatment discussion and decisions. • Hospitals should not abruptly end contact with the family after the death.
  • 32. IOM Roundtable on Value and Science Driven Health Care Evidence Communication Collaborative Good Communication Needs: • Respectful culture • Nurturing and secure decision making climates • Good clinician teamwork • Access to high-quality evidence for decision-making • Transparency and candidness around constraints and unknowns. Co-chaired by George Halverson & Bill Novelli
  • 34. Seek and enact legislation Implement Integrated Financing of medical and social services to support care at the end of life. • Financial incentives for coordinated care • EHR that incorporate advance care planning Administration, Congress Federal government and. its programs (e.g., Medicare, .Medicaid, VA), Other health care systems Federal, state, and.private insurance and care delivery programs Require public reporting on quality, cost, outcomes
  • 35. Specifically for Children: • Clinicians should be reimbursed for fully informing and counseling parents. • Bereavement services for parents and siblings of children who die should be reimbursed.
  • 37. Provide training throughout professional career Require education and experience in training programs Strengthened Knowledge and Skills • Palliative care • Communication skills • Interprofessional Collaboration • Symptom management Educational institutions Professional societies Accrediting organizations Certifying bodies State regulatory agencies Include in licensure requirements for health professionals, chaplains, social workers, etc. Create pathways to certification Entities that certify /specialty-level providers Care delivery organizations, medical centers, teaching hospitals Increase number of training positions for specialization
  • 39. Research Needs • Prevalence and nature of care that is neither beneficial nor wanted. • Effect of palliative care on longevity. • Elements of palliative care likely to offer the greatest improvements in quality of life. • Evidence-based measures of quality end-of-life care. • Family caregivers’ roles, needs, behavior, health risks, success in performance, interaction with other members of the health care team, and use of respite care and other support services. • Reliable approaches to prognosis that start earlier in the disease trajectory, and assessment of whether more accurate prognoses. lead to improvements in quality of life and other outcomes of care. • Effects and value of specific types of clinical innovations in delivering end-of-life care.
  • 40. Research needs for children • Comparative effectiveness studies of different approaches to symptom management and bereavement support. • Analyses of care received in emergency departments, outpatient settings, and hospices and through home health agencies. • Cohort studies examining the effect of palliative care on outcomes and on the patient experience. • Studies of how best to staff, manage, and finance hospital-based pediatric palliative and community-based pediatric hospice services.
  • 41. Public Education and Engagement
  • 42. People don’t speak with loved ones about end of life wishes because… Too many other things to worry about right now. Don’t want to think about death or dying. Family member did not want to discuss it.
  • 43. Provide information, encourage dialogue Research consumer perception, test message effectiveness Encourage members to engage patients Engaged and Informed Constituents Civic leaders, governments, community organizations, …faith-based organizations, consumer groups, employers, care providers Health care professional societies Government agencies Payers
  • 44. Moving Forward Wealth of knowledge  How do we act on it? Many roles  Need everyone to contribute
  • 45. R E S E A R C H T H AT D R I V E S C H A N G E Joe V. Selby, MD MPH Executive Director Patient-Centered Outcomes Research Institute
  • 46. W h a t D r i v e s C h a n g e ?
  • 47. What Drives Change? • Getting the Research Question Right • Rigorous Research Methods • Community-led Dissemination Plan
  • 48. Engagement is the key to finding the research question that leads to research that can be disseminated and implemented Evaluation Proposal Review; Design and Conduct of Research Topic Selection and Research Prioritization Dissemination and Implementation of Results
  • 49. Rigorous methods - did the intervention really work – and would it work again? • Believable Benefit – or Bias? – Randomization – Multiple randomized Units • Compared to What? – Evaluation vs. research – Carefully specified, high quality usual care comparator
  • 50. PCORI-funded Projects Health System Intervention to Improve Communication About End-of-Life Care for Vulnerable Patients – RCT – Washington State Improving Palliative and End-of-Life Care in Nursing Homes – RCT - Rochester NY Improving Advanced Cancer Patient-Centered Care by Enabling Goals of Care Discussions – RCT – New York City Computerized PAINRelieveIt Protocol for Cancer Pain Control in Hospice – RCT – Chicago Relapsed Childhood Neuroblastoma as a Model for Parental End-of-Life Decision-Making – Observational and qualitative – Boston MA Improving Communication in the Pediatric Intensive Care Unit for Patients Facing Life-Changing Decisions – RCT - Chicago
  • 51. Pragmatic Clinical Studies Opportunity Snapshot • Number of cycles per year: two • Number of Anticipated Awards Per Funding Cycle: Six to Nine • Funds Available Per Cycle: Up to $90 Million • Maximum Project Duration: 5 Years • Costs per Project: Up to $10 million direct costs Seek to produce information that can be directly adopted by providers: • Compare two of more options for prevention, diagnosis, treatment, or management of a disease or symptom • Address critical clinical choices faced by patients, caregivers, clinicians, systems • Conducted in routine clinical settings • Protocols less complex than traditional trials • High-priority topics identified by: • PCORI’s Advisory Panels • Institute of Medicine CER 100 • Agency for Healthcare Research and Quality
  • 53. E n g a g i n g M u l t i p l e G e n e r a t i o n s
  • 54. E n g a g i n g M u l t i p l e G e n e r a t i o n s I n t r o d u c t i o n b y : M a r g a r e t M a g u i r e , J D , S V P C o r p o r a t e A c c o u n t a b i l i t y a n d C h i e f o f S t a f f C a m b i a H e a l t h S o l u t i o n s P r e s i d e n t a n d B o a r d C h a i r C a m b i a H e a l t h F o u n d a t i o n
  • 55. Engaging Multiple Generations • Ellen Goodman, Moderator Co-Founder and Director The Conversation Project • Kenyon C. Burke, Ed.D. President Kenyon C. Burke Consulting • Rev. Rosemary Lloyd Advisor to the Faith-Based Community The Conversation Project • Lennon Flowers Co-Founder and Executive Director The Dinner Party
  • 56. T h e I m p e r a t i v e f o r C h a n g e
  • 57. The Imperative for Change • Rich Umbdenstock President and CEO American Hospital Association • Jeannine English, CPA, MBA President AARP
  • 58. T h a n k Yo u
  • 59. A Time for Caring Reception We look forward to seeing you at tonight’s reception, located at: The Four Seasons Hotel 2800 Pennsylvania Avenue, NW Washington DC 20007
  • 60. N a t i o n a l S u m m i t o n A d v a n c e d I l l n e s s C a r e D r i v i n g C h a n g e t h r o u g h L e a d e r s h i p , E v i d e n c e a n d A c t i o n
  • 61. Welcome and Recap Leonard D. Schaeffer Judge Robert Maclay Widney Chair and Professor University of Southern California M a r c h 3 , 2 0 1 5
  • 62. Conference Hosts • Bill Novelli: Board Co-Chair and Professor, McDonough School of Business, Georgetown University and former CEO, AARP • Tom Koutsoumpas: Board Co-Chair, President and CEO, National Partnership for Hospice Innovation • Jon Broyles: Executive Director, C-TAC
  • 63. C-TAC Vision All Americans with advanced illness, especially the sickest and most vulnerable, will receive comprehensive, high-quality, person- and family- centered care that is consistent with their goals and values and honors their dignity.
  • 64. Recap From Day One • Where advanced illness care is heading • How to build urgency around change • How to effectively engage multiple generations in advanced illness care in community and clinical settings • How to build on successful innovations to achieve further progress Speaker themes included:
  • 65. How You Can Contribute Today One degree of change can make all the difference • Be candid about what’s working, what’s not, and why • Join in catalyzing action and energy around effective programs and ideas • Help identify programs and concepts with the greatest potential to improve AIC • Offer ideas on how to scale up what’s working
  • 66. Introductions Please join me in welcoming:  Karen Ignagni, President and CEO, America’s Health Insurance Plans  Jeff Burnich, MD, Senior Vice President Medical and Market Networks Sutter Health  Amy Berman, BS, RN, Senior Program Officer John A. Hartford Foundation
  • 67. D r i v i n g C h a n g e
  • 68. A C o m p r e h e n s i v e A p p r o a c h t o C a r e Tr a n s f o r m a t i o n : I n t e g r a t i n g C o m m u n i t y a n d C l i n i c a l M o d e l s
  • 69. A Comprehensive Approach to Care Transformation • Rev. Diane C. Smalley Patient and Community Engagement Council, Saint Joseph Mercy Hospital, Trinity Health • Chris Dawe, Managing Director Evolent Health • Bud Hammes Director of Medical Humanities, Gunderson Health System • Daniel Johnson, MD, FAAHPM National Clinical Lead for Palliative Care, Care Management Institute, Kaiser Permanente • Rev. Cynthia Carter Hill, MPA Executive Director, Alameda County Care Alliance
  • 70.
  • 71. H o w a S h a r e d - D e c i s i o n M a k i n g A p p r o a c h C a n C o n n e c t t h e C l i n i c a l a n d C o m m u n i t y B e r n a r d “ B u d ” H a m m e s , P h D G u n d e r s e n H e a l t h S y s t e m w w w . r e s p e c t i n g c h o i c e s . o r g
  • 72. 2014 IOM Report: Dying in America Shared decision making encompasses: • Eliciting and understanding the patient’s perspective; • Understanding the patient’s psychosocial and emotional context; • Developing a shared understanding of the clinical problem and its appropriate treatment, given the patient’s goals, preferences, and values; and • Empowerment, which is achieved through active involvement of patients in decision making. LeBlanc, T. W., and J. A. Tulsky. In press. Communication with the patient and family. In Oxford textbook of palliative medicine, 5th ed., edited by N. Cherney, M. Fallon, S. Kaasa, R. Portenoy, and D. Currow. Oxford, England: Oxford University Press.
  • 73. This description is useful, but we need more detail for folks with advanced illness… To get to shared decision-making and planning requires (for persons with advanced illness)… 1. …a shift from a primary focus on goals of medical care, to a thoughtful exploration and clarification of personal goals and values; 2. …a specific exploration of fears and concerns as well as gaps in knowledge and understanding; 3. …a realization that this not just about the individual but also about the individual’s “family” and community relationships.
  • 74. When Care Planning uses this person- centered, shared decision-making model, it can tie the clinical and the community together in two important, related ways… Through a common: 1. process and structure of planning and decision making; and, 2. ethical footing.
  • 75. A Common Process and Structure for Share Decision-Making • Focused on the person and family perspectives, the planning and any decision that follow centers around a single, key question: How do the explored values and goals of the person and family, tied to the clinical realities, help define what it means to provide good care for this person? • To thoughtfully answer this question requires the intentional input and contribution of the person, those closest to this person, their broader community, and the clinical.
  • 76. The Shared Ethical Basis: Care Relationships The ethical footing of this approach is the ethic of caring relationships: Relationship Ethical Value Health professional/patient Beneficence…acting in the best interest of the patient Individual/family or loved ones Love Individual/community Respect, Sanctity of Life
  • 77. The Respecting Choices® Model This model is a systematic approach to care planning that uses person-centered, shared decision-making decision making and is designed to: 1. Provide a standardized process for care planning that may be used in both the clinical and community settings; 2. Build care planning into the routine of all care; 3. Create processes so care plans are stored, revisited, and communicated so that they are always available and up-to-date; 4. Prepare both patients and their appointed surrogates to make decisions when the time arises; 5. Improve care and outcomes for all involved.
  • 78. Helping Community and Health Organizations Implement this Model • Respecting Choices has created a implementation pathway that provides a means for health organizations to develop this care planning approach so that it can become part of the routine of care and can be integrated into community engagement. • RC has been successfully implemented in 5 countries and over 120 health organizations in the USA.
  • 79. A C o m p r e h e n s i v e A p p r o a c h t o C a r e Tr a n s f o r m a t i o n : T h e C l i n i c a l P e r s p e c t i v e D a n i e l J o h n s o n , M D , F A A H P M C a r e M a n a g e m e n t I n s t i t u t e K a i s e r P e r m a n e n t e
  • 80. William • 77 y/o male • Advanced gastric cancer, diabetes, anemia, COPD • Prior surgery, XRT • Third line chemotherapy • Intractable nausea, pain • Recurrent bleeding • 3rd admission in 6 w • Two prior SNF stays • Request: “No death talk”
  • 81. “What is spoken of as a “clinical picture” is not just a photograph of a man sick in bed; it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes and fears….” The Care of the Patient Francis W. Peabody, MD, JAMA 1927 Edvard Munch, The Sick Child, 1927
  • 82. “The difficulty is that in the hospital one gets into the habit of using the oil immersion lens instead of the low power, and focuses too intently on the center of the field.” Francis W. Peabody, MD Daily Bread, Otto Betteman, 1936 Girls at the Piano, Renior, 1892
  • 83. William – Through a Wider Lens • Needs transport help • Recurrent bleeding • Not filling meds ($$) • 3rd admission in 6 w • Greatest joy: dog Max • Two prior SNF stays • Hope: back to Iowa • “No death talk” • Fears: “quitting too soon”, questions: faith and God • 77 y/o male • Lives alone, friends help • Advanced gastric cancer, diabetes, COPD, anemia • Values independence • Prior surgery, XRT • Former US Veteran • On 3rd line chemo • Helping son “get sober” • Intractable nausea, pain • Increasingly anxious
  • 84. About Kaiser Permanente…  Nation’s largest non-profit health plan  Integrated health care delivery system  9.1 million members  16,000+ physicians  174,000+ employees (including 48,000+ nurses)  Serving 8 states and the District of Columbia  38 hospitals  More than 600 medical offices  $53.1 billion operating revenue*  Scope includes ambulatory, inpatient, ACS, behavioral health, SNF, home health, hospice, pharmacy, imaging, laboratory, optical, dental, and insurance Mid-Atlantic Region Georgia Region Colorado Region Northern California Region Hawaii Region Northwest Region Southern California Region *Kaiser Permanente 2013 Press Release
  • 85. KP-Colorado Slide 85 Multiple contracts and community partnerships:  Hospitals (2 core + others), SNF (25 facilities), LTACH (5)  Home Health, hospice (7 preferred, PC support) Integrated system serving over 600K members  Rocky Mountain Front Range  Insured pop: Commercial, Medicare Advantage (90K), Medicaid (50K), Duals (2K)  Case management (adult + kids)
  • 86. Our Promises For us to achieve the “best care possible” for persons with serious illness we must: Deliver, for each individual, personalized “best care” Palliative and Community Support Discover, for each individual, what “best care” looks like Goal Setting and Care Planning AND
  • 87. 87 Building “Layers of Support” 1 2 3 4 Advance Care Planning (ACP) 10 PC 20 PC Increasing Complexity and Needs → Support→ LAYER KEY FEATURES Specialty PC Provide specialized support for most complex needs Primary PC Assess needs → personalize care; basic support ACP Assure systematic, competent discussions for all Population ID Identify risk groups, population-based care Leveraging Community Resources and Expertise
  • 88. Foundational Studies of Palliative Support at Kaiser Permanente Three randomized control trials of palliative care in hospital, home and clinic settings – outcomes:  Improved patient-family satisfaction  Improved quality (communication, death at home)  Increased hospice admissions and LOS  Decreased hospital, ER utilization and costs Added matched- controlled analysis of inpatient PC:  Less hospital(40%), ICU (56%) and ER (24%) admissions  Higher hospice admissions (51%) and LOS (55%) Gade G et al. J Palliative Med, 2008. Brumley R. et al. J Palliative Med, 2003. Englehardt J. et al. J Managed Care, 2009. Bellows J, Johnson D et al, Kaiser Permanente, 2012
  • 89. A Continuum of Specialty Support Hospital Home Assisted Living Long Term Care LTACSNF Primary Care Clinic Specialty Care Clinic Inpatient PC Home PC PC SW Clinic PC NH PC Hospice “One Stop Shop”
  • 90. KPCO Specialty Palliative Care Services Service Setting Team #/year Access Model IPC Hospital MD, RN, SW, Chap, Pharm 1800 7 d/w with 24/7 call Hybrid staffing model – KP + hospital; referrals + alerts using LACE HBPC Home/ ALF MD, RN, SW, Chap, Pharm 500 7 d/w with 24/7 call Hybrid staffing model – KP + partner; referrals CBPC Clinic MD, RN, SW 400 5 d/w KP staff; referrals + integration pilots in high risk pulmonology and oncology PC-SW Clinic SW 300 5 d/w KP staff, referrals + integration pilots NH PC (KSS) SNF/LTC SW, RN or chap prn 400 5 d/w Contracted partners, referrals + integration in LTACH, NH Hospice All Full IDT 2000 7 d/w Contracted partners, Commercial and Medicare
  • 91. What Elements Worked (or Not)? What Worked… A compelling “why” Evidence Invest – not just “stretch” Partnership (seek win-win) Layers and triage Embedded support Value team- and self-care Harness non-PC champions Think “learning system” …Not So Much Seeking perfection “Prove it” mentality Silos – thinking too narrowly Demands on referring MDs Failing to assess needs Failing to triage “Auto-referrals” Leaving out community Slow to standardize or
  • 92. Examples of Positive Shared Outcomes Documented goals, values and care preferences More concordant care (i.e., delivery matches wishes) Care plan communication across care settings Increased access to specialty PC support More hospice use Less unwanted (by all) hospital, ER or ICU care Less total costs (for patients, family and system) Greater meaning around the work we do Asking and honoring “what matters most”
  • 93. Rev. Cynthia Carter Hill, MPA Executive Director Alameda County Care Alliance
  • 94. Alameda County Care Alliance Vision: All those in Alameda County living with advanced illness will receive person- and family-centered care that acknowledges their spiritual and cultural integrity, regardless of race, religion, origin, or creed. Mission: Build on community-based resources and health system partnerships to provide a new paradigm of care through: care coordination, spiritual care, and decision-making support for the person needing care, their family/caregiver.
  • 95. ACCA: Who We Are A dynamic and collaborative partnership among faith- based and community organizations with long history of working together to transform the Alameda Community. Current focus - Advanced Care:  Launched in 2014  Represents 35,000+ people  Supported by Kaiser Permanente and California HealthCare Foundation.
  • 96. ACCA HUB Partners Strategically located Community Partnerships : • Allen Temple Baptist Church • Glad Tidings Church of God in Christ • Family Bible Fellowship • Center of Hope • Greater St. John • Beebe Memorial • Community Organizations – Catholic Ecumenical & Asian Health Services
  • 97.  Completed (2/15)  Training of pastors (3/18)  Training of navigators (3/18)  Patient and Caregiver enrollment (4/16) ACCA 18 Month Pilot Progress and Next Steps  Hub Church surveys  Pastoral training team & curriculum (Dr. Guess & team)  Navigator curriculum  Caregiver curriculum and partnerships (Family Caregiver Alliance)  Evaluation and key partnerships (UC Davis, UC Berkeley-Citris)
  • 98. ACCA Proposed Outcomes: Process Strengthening community capacity for advanced care through: – Improved decision support for caregivers/and persons needing care – Trained clergy, community leaders, Care navigators – Identify and Increase access to care services for caregivers/patients
  • 99. ACCA Proposed Outcomes: Impact – Increased care satisfaction among patients/families – Reduced caregiving burden for advanced illness – Reduced ER visits – Reduced readmission rates – Improved Quality of Life for ill person and caregivers
  • 100. ACCA Finding #1: Build on Community Resources • Integrate current initiatives among faith communities through collective commitment and sharing resources such as trained volunteers across communities.
  • 101. ACCA Finding #2: Build on Shared Outcomes Among Health Systems and Community Examples: • Reduced unwanted hospitalizations • Provide care in the community • Increased connection to spirituality • Improved quality of life
  • 102. ACCA Finding #3: It’s Takes Time: Building Trusting Relationships between the Medical and Community Members • Honor the vast resources within churches and in community • Respect culture, spirituality, and traditions • Transparent communications amongst stakeholders
  • 103. Transforming Care and Serving Most Vulnerable Whatever you do for one the least of these my brethren ones, you have done unto me. Matthew 25: 35-40
  • 104. ACCA Firmly Believes That…..
  • 105. Ta k i n g E v i d e n c e - B a s e d M o d e l s t o S c a l e J e f f S e l b e r g , M H A , E x e c u t i v e D i r e c t o r P e t e r s o n C e n t e r o n H e a l t h c a r e
  • 106. M o r n i n g W o r k s h o p S e s s i o n s L e c t u r e R o o m : C o m m u n i t y a n d F a i t h - B a s e d P a r t n e r s h i p s R o o m 1 2 0 : M e t r i c s f o r S u c c e s s R o o m 1 2 5 : E n g a g i n g P a t i e n t s i n D i s s e m i n a t i o n a n d I m p l e m e n t a t i o n
  • 107. C O M M U I T Y A N D FA I T H B A S E D PA RT N E R S H I P S
  • 108. Te r e s a C u t t s , P h D A s s i s t a n t P r o f e s s o r, S o c i a l S c i e n c e s a n d H e a l t h y P o l i c y D i v o f P u b l i c H e a l t h a n d t h e M a y a A n g e l o u C e n t e r f o r H e a l t h E q u i t y Wa k e F o r e s t S c h o o l o f M e d i n c e
  • 109. R e v . D r . T y r o n e P i t t s C o - C h a i r I n t e r f a i t h a n d D i v e r s i t y W o r k g r o u p , C - T A C
  • 110. T h a n k y o u
  • 111. M E T R I C S F O R S U C C E S S
  • 112. Advanced Illness Care Coordination: A Case Study on Aetna Compassionate CareSM Program: What Metrics Can Demonstrate Randall Krakauer, MD VP, National Medical Director, Aetna
  • 113. Geriatric Conditions and Quality Scores:1 How Does Advanced Illness Rate? Assessing Care of Vulnerable Elders (ACOVE) quality indicators: in 2000 identified significant quality and care gaps, and opportunities that might be addressed in managing care in Medicare populations 1Wenger NS, Solomon DH, Roth CP. et al. Annals of Internal Medicine. 2003; 139 (9) 740-747. Available at: www.mms.org/workilies/mmc services/geriatrics/Quality Medical Care Provided Vulnerable-Dwelling Older Patients.pdf. Accessed June 6, 2013. Geriatric conditions and quality indicators Condition % QIs Passed Malnutrition 47 Pressure ulcers 41 Dementia 35 Falls, mobility disorders 34 Urinary incontinence 29 End-of-life care 9
  • 114. Variations In End-of-Life Care: Dartmouth Atlas of Health Care Percent of decedents enrolled in hospice during the last 6 months of life (2003-2007) Rates are adjusted for age, sex, race, primary chronic condition, and the presence of more than one chronic condition using ordinary least squares regression. Arizona: 54.5% New York: 23.8% • U.S. State
  • 115. Variations In End-Of-Life Care: Dartmouth Atlas of Health Care Hospice days per decedent during the last 6 months of life (2003-2007) Rates are adjusted for age, sex, race, primary chronic condition, and the presence of more than one chronic condition using ordinary least squares regression. • Hospital Referral Region McAllen, TX 3.9 days Ogden, UT 35.5 days
  • 116. Where are we? •Shortage of specialized expertise Compare: 1 oncologist to every 141 newly diagnosed cancer patients vs. 1 palliative medicine doctor to every 1,200 patients with serious or life-threatening illnesses.1 •Hospital-based palliative care — increasing access Since 2008, 19% increase in palliative care teams in hospitals. 85% of large (>300 beds) hospitals have teams.1 • Resources: Approximately 25-30% of Medicare costs incurred in last year of life; in last month, 80% of expenditures are for hospitalization.2 1 Center to Advance Palliative Care. America’s Care of Serious Illness: A State-by-State Report Card on Access to Palliative Care in Our Nation’s Hospitals. NY: 2011. Available at: reportcard.capc.org/pdf/state-by-state- reportcard.pdf. Accessed May 28, 2013. 2 Lubitz J, Riley GF. Trends in Medicare payments in the last year of life. New England Journal of Medicine 1993; 328 (15): 1092-1096. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC2838161/pdf/hesr0045- 0565.pdf. Accessed May 29, 2013.
  • 117. Aetna Compassionate Care (ACCP) •Goals of the program: • Provide additional support to members • with advanced illness and their families/caregivers • Help them access optimal care • The goal is not to create or encourage hospice, although hospice can be a choice when appropriate and requested by the member.
  • 118. Holistic, Member-Centric Case Management Help member understand options, with nurse case managers who are trained to: •Assess and manage members’ care in a culturally sensitive manner •Identify resources to make members as comfortable as possible, addressing pain and other symptoms •Help coordinate medical care, benefits and community-based services •Inform the member about treatment options, continuity of care and advanced care planning •Provide personal support •Consult and coordinate with the members’ treating physicians and staff (including other care coordinators where available)
  • 119. Results: Member Discussion Example of Why Compassionate Care Shows Impact: Depth of Connection •Wife stated member passed away with hospice. Much emotional support given to spouse. She talked about what a wonderful life they had together, their children, all of the people's lives that he touched. They were married 49 years last Thursdayyand each year he would give her a piece of jewelry. On Tuesday, when she walked into his room, he had a gift and card laying on his chest, a beautiful ring that he had their daughter purchase. She was happy he gave it to her on Tuesday--- on Thursday, he was not alert. She stated that through his business he touched many peoples lives, and they all somehow knew he was sick, and he has received many flowers, meals, fruit, cake. She stated her lawn had become overgrow and the landscaper came and cleaned up the entire property, planted over 50 mums, placed cornstalks and pumpkins all around. She said she is so grateful for the outpouring of love. Also stated that hospice was wonderful, as well as everyone at the doctor’s office, and everyone here at Aetna. She tells all of her friends that "when you are part of Aetna, you have a lifeline.” Encouraged her to call CM with an issues or concerns. Closed to case management.
  • 120. Results Favorable impact aligning patient goals with outcomes • 82% of engaged decedents choose hospice • 82% reduction in acute inpatient days • 77% reduction in emergency room visits • 86% reduction in intensive care unit days Improved quality of life for Aetna members and their families Data for 2010 Medicare Advantage members enrolled in Aetna’s Compassionate Care program. Resulting (in Medicare Advantage) in savings of over $12,500 per engaged member
  • 121. Summary: Metrics Demonstrate Opportunity • Improving the quality of care for those with advanced illness represents a tremendous opportunity for the country’s health system, for individual patients, and for families and caregivers. • Programs that provide expert assistance such as Aetna Compassionate Care can increase awareness of the care options available to patients and caregivers, thereby aligning patient choice more closely with desired types of health services and care. • This care management program favorably impacts advanced illness, with very high rates of satisfaction. Metrics can demonstrate, particularly in Medicare, dramatic impact on Palliative Care and Hospice election, acute and intensive care utilization, cost and other metrics. • These metrics create an imperative that such services become more widely available.
  • 122. Quality Measures as Drivers of Change National Summit on Advanced Illness Care Metrics for Success Workshop 122
  • 125. NQF Action Teams • Build on NQF’s role as an objective convener • Leverage NQF’s deep membership of 400+ organizations • Work collaboratively and in partnership to collectively impact health and healthcare quality • Promote uptake of existing NQF-endorsed performance measures • Influence important stakeholders to make meaningful and authentic commitments to action
  • 126. NQF Maternity Action Team Results
  • 127. Measurement Opportunities for Advanced Illness Care • Advanced Illness care generally does not follow patient goals and preferences • Palliative care can be used more broadly to alleviate suffering • Geriatrics finds that some of the most important care is outside of the traditional organ-system based clinical specialties. • Experience from caregivers as well as patients
  • 128. Measurement Challenges for Advanced Illness Care • Individual condition-based guidelines often conflict for patients with multiple chronic diseases • Health affected by sociodemographic factors • Vulnerable populations may have difficulty accessing consistent source of care • Coordination of care among multiple sites/providers
  • 129. NQF’s Aging Related Work Current Work: Prioritizing Measure Gaps: Alzheimer’s Disease and Related Dementias Measure Applications Partnership (MAP) Dual-eligibles beneficiary workgroup Post-acute care/long-term care workgroup Past Work: Multiple Chronic Conditions Framework Nursing home measures Home healthcare measures
  • 130. Recent NQF Initiatives to Improve Care for Advanced Illnesses and Vulnerable Populations Current Work: • Prioritizing Measure Gaps: Alzheimer’s Disease and Related Dementias • Measure Applications Partnership (MAP) – Dual-eligibles beneficiary workgroup – Post-acute care/long-term care workgroup Past Work: • Multiple Chronic Conditions Framework • Nursing home measures • Home healthcare measures
  • 131. Improving Care for Dual Eligible Beneficiaries • Considers the unique needs of population subgroups (e.g., individuals with ID/DD, frail elders) • Maintains a Family of Measures for Dual Eligible Beneficiaries • Gathers experience of state agencies, health plans, and other stakeholders in using MAP’s recommendations on measures to make them more accurate and actionable • Explores quality of life outcomes and how various system stakeholders share responsibility for supporting better outcomes for vulnerable beneficiaries
  • 132. Big Opportunity Areas in Healthcare: What the Health System Needs Now Criteria for Impact Credible Timely Useable Meaningful Incubator Components  Concept  Technical expertise  Data sources  Analytics and feedback  Resources DATA ANALYTICS MEASURES INFORMATION IMPACT
  • 133. T h a n k y o u
  • 134. E N G A G I N G PAT I E N T S I N D I S S E M I N AT I O N A N D I M P L E M E N TAT I O N
  • 135. P a t r i c i a A . G r a d y, R N , P h D FA A N , D i r e c t o r, N a t i o n a l I n s t i t u t e o f N u r s i n g R e s e a r c h
  • 136. Research Translation General Public Educational InstitutionsPublic Interest Groups Federal Agencies State Agencies Local Agencies Professional Societies Industry Community Groups Patient Advocacy Groups Public Advisory Councils Health Professionals Volunteer Organizations Scientists Scientific Advisory Groups Stakeholders
  • 137. NINR’s Areas of Research Scientific Focus Areas to Implement NINR’s Strategic Plan • Symptom Science • Wellness • Self-Management • End-of-Life and Palliative Care
  • 138. Advanced Illness Care NINR Hosts NIH Briefing on IOM Report – Dying in America
  • 139. Advanced Illness Care Hospice enrollment increases Medicare savings and decreases hospital usage Palliative Care Research Co-Operative (PCRC) o Comprehensive, multicenter resource o Developing structures and processes to enable and support end-of-life and palliative care research nationwide NINR-Supported Research to Improve / End-of-Life Care
  • 141. Research Support Selected NIH-Sponsored Funding Opportunities • Innovative Measurement Tools for Community Engaged Research Efforts • Development and testing of tools to measure trust, capacity, collaboration, empowerment, sustainability • Dissemination and Implementation Research in Health • Understanding and overcoming barriers to translating research discovery into clinical and community practice
  • 143. R e g i n a G r e e r - S m i t h , M P H F A C H E
  • 144. Guidance PCORI’s ENGAGEMENT RUBRIC PCOR GUIDING PRINCIPLES • Reciprocal Relationships • Co-Learning • Partnership • Trust, Transparency, Honesty DISSEMINATING THE STUDY RESULTS • “Patient partners are involved in plans for disseminating the study’s findings to patient, stakeholders, and research audiences so that the findings are communicated in understandable, usable ways.”
  • 145. Developing Infastructure From Existing Relationships and Building Capacity Partnerships and Collaborations with Stakeholders For co-learning and trust-building Development of Programs and Initiatives to enable engagement activities Providing resources to empowering Priority Populations including: • Racial & Ethnic Minorities • LTBT • Persons with Disabilities • Low literary/numeracy • Rural populations More engagement resources at our website: http://www.healthcarera.com/
  • 146. Develop Opportunities for Engagement, Dissemination & Implementation Exhibits and In-Person Presentations Social Media & Smartphones Use of Social Networking, Care Giver Support Groups & S.T.A.R. Initiative Engagement Clusters© Through partnerships and collaborations with patients, families, caregivers, faith-based partnerships, and all stakeholders
  • 147. T h a n k y o u
  • 148. A f t e r n o o n W o r k s h o p S e s s i o n s L e c t u r e R o o m : S h a r e d D e c i s i o n M a k i n g A u d i t o r i u m : T r a n s l a t i n g E v i d e n c e B a s e d P r a c t i c e I n t o C o m p e l l i n g M e s s a g e s R o o m 1 2 0 : F a m i l y C a r e g i v e r S u p p o r t R o o m 1 2 5 : B u i l d i n g t h e B u s i n e s s C a s e f o r A d v a n c e d I l l n e s s C a r e
  • 149. S h a r e d D e c i s i o n M a k i n g : H o n o r i n g I n f o r m e d P a t i e n t C h o i c e
  • 150. Practice Variation: Evidence for Poor Decisions 150 Red dots indicate HRRs served by U.S. News 50 Best Hospitals for Geriatric Care 2,500 3,500 4,500 5,500 6,500 7,500 8,500 ASRAdjustedMedicareSpending
  • 151. Forces Sustaining Poor Quality 151
  • 152. Patients & physicians view trade-offs differently Decision: Goal % top 3 Patient % top 3 Provider Surgery: Keep your breast 7% 71% Reconstruction: Look natural without clothes 59% 80% Chemotherapy: Live as long as possible 33% 96% Reconstruction: Avoid using prosthesis 33% 0% Sepucha K, et al. Patient Education and Counseling 2008 and Lee et al. 30th Annual Society for Medical Decision Making Conference, Philadelphia, 2008.
  • 153. 153
  • 154. 154 23 Patient vs. 25 Physician States 2 Hybrids Patient Standard Physician Standard Hybrid (NM & MN)
  • 155. Health Policy Relating to SDM SDM has become a standard part of the language of US health reform – AffordableCare Act – Definition requirement for MedicareACOs – Requirement for Comprehensive primary Care Initiatives – State-based health care reform – Meaningful use of HIT – InformedConsent – Professional societies, practice guidelines 155
  • 156. WA State Passed Three Bills • Passed legislation in 2007 • Explicitly recognizes SDM is an enhanced informed consent for Preference-Sensitive Conditions if provider uses a “certified aid” • Led to Group Health demonstration project • 2009 Passed Bree Collaborative—SDM promoted • 2012 Passed legislation allowing CMO of HCA to “certify aids” moving forward with criteria • Payment of providers for SDM being considered 156
  • 157. 157 Involvement Values Concordance Decision Quality Knowledge Did the patient know what he or she needed to know? Did the decision reflect the patient’s goals and concerns? Did the patient know a decision was being made? Did the patient know the pros and cons of the treatment options? Did the provider elicit the patient’s preferences?
  • 158. Health Policy Reasons for Adoption of SDM on Large Scale • Ethical imperative to do the right thing • Perfected Informed Consent-Aligning preferences, values and lifestyle with individual’s clinical decision • Bridging Health Disparities • Conservative Utilization of surgical interventions
  • 159. W h a t M a t t e r s t o Yo u M a t t e r s t o U s H M S A’ s A C P V i d e o P r o j e c t R a e S e i t z , M D M a r c h 2 0 1 5
  • 160. HMSA’s ACP Video Project • How the ACP Video Project advances HMSA’s mission and vision of keeping members at the center of, in control of, and responsible for their own well-being • Review some preliminary outcomes • The strategy applied to spreading the use of ACP video decision aids • What have we learned about ACP, what works and what challenges remain
  • 161.
  • 162. 0% 10% 20% 30% 40% 50% 4Q2012 1Q2013 2Q2013 3Q2013 4Q2013 1Q2014 2Q2014 Advance Care Planning at a Hospital “A” N=2668 across all time periods Percentage of Discharged with Completed POLSTS Percentage of Patients Discharged with Referral to Hospice Videos Introduced
  • 163. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 4Q2013 1Q2014 2Q2014 POLST Completion Among Seriously Ill Patients N=845 across all time periods Conversation + Video vs Conversation Only
  • 164. ACP Video Use in Palliative Care Pilot (n=56) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% PC Patient POLST Before POLST After 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Before After Life Prolonging Limited Comfort
  • 165. Advance Care Planning Completion Rates for Members 75+ HMSA P4Q Measure 10/1/2013 to 9/30/2014 0% 10% 20% 30% 40% 50% Medicar Advantage PPO/HMO Using Video Not Using Video 37 Doctors identified using the videos; 250 doctors not using the video Denominator include 18000 for Medicare Advantage; 20,000 PPP/HMO Members
  • 167. A new video campaign gives patients a voice on treatment options By Susan Essoyan
  • 168. D i s c u s s i o n P o i n t s ?
  • 169. ICU Code Order Changes After Patients/Families Watch ACP Videos n=14 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Pre-Video Post-Video Full Code Partial Code DNR
  • 170. Advance Care Planning Outcomes ACP Outcomes Death at Home Hospice Use EOL ICU Days EOL Inpatie nt Use EOL ED Use Treatm ent at EOL EOL QOL FAMCA RE Decisio ns Honore d ACP Docum ents
  • 171. Tr a n s l a t i n g E v i d e n c e - B a s e d P r a c t i c e s i n t o C o m p e l l i n g M e s s a g e s
  • 173. successstartswiththestoryyoutell • stories change brains, beliefs and behaviors • stories are survival instruments • storytelling is a competitive sport • if you want to change your outcome, start by changing your narrative
  • 175. If we want to do better, first we have to feel better Change begins when you give people a new feeling about the issue. In this case, we want to replace fear of loss and helplessness with a promise of power, purpose and hope. Engage the Emotions
  • 176. AIM Strategies 176 Engage the adversary: the revolving door The deep need: Reconnect with the “why”
  • 177. Capital Caring Strategies 177 Envision our success: provide personal stories of positive outcomes Speak to identity: we are innovators
  • 178. Stories are survival instruments. After you get the audience emotionally engaged, you have to give them practical tools to drive change. Stories are first and foremost survival instruments for a VUCA world. And advanced care - serious illness, the probable “third act” of life — is possibly the greatest VUCA of all. It requires that we come to terms with our ultimate mortality, life’s ultimate unknown, and it sets up a series of obstacles (financial, practical, emotional, physical) that make it hard for us to perform at the time we most need to. Empower Action
  • 179. 179 A new model: Built on patient experience and needs, not system structure Eliminate uncertainty: one way, one team AIM Strategies
  • 180. 180 Empower caregivers, Build confidence Capital Caring Strategies • allow autonomy with caregivers in implementing the program • build mastery: program builds confidence with caregivers • each positive interaction creates confidence and a better outcome
  • 181. Build Resilience Stories are setbacks. The last act of life is not easy. There will be suffering. There will be sorrow. And no matter how powerful your program, there will be setbacks. People are often tempted to give up when they have a bad experience. Much of what we as leaders can do is to build resilience in ourselves and our communities, to help persevere through the hard times. The growth mindset is about getting people to recognize the truth that failure is a necessary stepping stone on the way to success.
  • 182. 182 Coach the growth mindset: “We’re all still learning how to do this.” Everyone worries about risk. The best strategy is to tell the truth. AIM Strategies
  • 183. 183 Openly share successes and setbacks - address issues Remember we are all learners and teachers Capital Caring Strategies • set clear, immediate metrics • be transparent in identifying what doesn’t work • be proud in reporting on what does
  • 184. Capital Caring F o r n e a r l y 4 0 y e a r s , c o o r d i n a t e d , c o m p a s s i o n a t e c a r e w h e r e v e r o n e c a l l s h o m e
  • 185. Capital Caring at a Glance • One of the nation’s oldest and largest non-profit providers of hospice and palliative care, Capital Caring cares for over 1,200 families each day. • Our service area includes The District of Columbia, Northern Virginia, and Prince George’s County, Maryland. • World-class, high quality care is at the heart of our business strategy. • Our mission? To simply improve care.
  • 186. A commitment to people • In order to ‘simply improve care’- and with high- quality care at the heart of our strategy, Capital Caring’s key metrics allow us to measure and demonstrate improving care. - e.g. Capital Caring is committed to reducing a patient’s pain to a comfortable level within 48 hours; we achieve this in nearly every case. • We focus on culture, people development & training - Capital Caring instituted Standards – clear, impressive, and sustainable rules for achieving world-class care and results - We are committed to meeting 100% of our standards, 100% of the time
  • 187. C a p i t a l C a r i n g : I n n o v a t i o n s i n C a r e Capital Caring is committed to innovation. • In 2014, we opened our state-of-the art Adler Center for Caring on the Van Metre Campus in Loudoun County, Virginia. This first-of-its-kind in the nation facility is home to Capital Caring’s Center for Pain and Palliative Care, a 21- bed world-class inpatient facility, Capital Caring’s home care team and palliative care. The Center even boasts a spa and gift shop. • Capital Caring’s Center for Pain and Palliative Care (CPPC) is on the forefront of innovation. The Center’s ability to perform procedures using state-of-the-art real-time imaging to alleviate debilitating pain on-site, complementing or even replacing pharmacotherapy, provides a vast improvement for patients dealing with pain associated with an advanced illness.
  • 188. TeleCaring ™ • In 2011, Capital Caring launched TeleCaring™, an innovative care support program, where trained professionals, including nurses, place proactive, outbound calls to patients and caregivers. • TeleCaring™ is an extension of Capital Caring’s home care team that empowers caregivers—and provides rapid response to emerging issues or to answer questions. “I feel like every one of them is an extension of our family. Sometimes, when we have questions, when the Telecaring nurse calls, they take 5 minutes, 10 minutes to help me focus and address what matters most. The calls reassure me, and are a valuable extra layer of care.”----- Barry, Caregiver
  • 189. Caring in the nation’s capital -By virtue of being in the nation’s capital, Capital Caring’s mission to simply improve care includes public education and advocacy to expand access to person-centered hospice care. -Since 2006, hospice utilization in D.C. has increased from 2% to over 30% in part because of our Hospice Comes to Washington awareness event. Our “In Good Faith” initiative has been instrumental in building trust among faith community leadership, their ‘parishioners’, and Capital Caring, in order to identify patients/families at risk in order to increase timely access to palliative care and hospice services. -Our program is centered on earlier, easier access to care with clearly defined standards and measurable quality of care as our business strategy.
  • 190. Overview of AIM® Where we are today within Sutter Health • Betsy Gornet, FACHE • Sutter Health and Sutter Care at Home • March 3, 2015
  • 191. “This publication was made possible by Grant Number 1C1CMS331005 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services.” "The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies." HEALTH CARE INNOVATIONS AWARDS
  • 192. • Non-for-Profit health system serving Northern California • Includes 24 hospitals and over 5000 aligned physicians • Sutter Center for Integrated Care • Health care research, • 28 Home Care locations • AIM – System level; over 7300 Enrollments through Dec 2014; plus 1500 during pilot 192 SUTTER HEALTH AT A GLANCE Pending Luanch
  • 193. Defining Advance Illness Management (AIM® ) AIM is a Care Management Model that Employs Evidence Based Principles of: Care Coordination & Transitions Management Palliative Care Patient Engagement Health Literacy Self Management Support 193
  • 194. What Else Defines AIM? Improve Patient/Family/Caregiver Experience & Provider Experience; All payers, all diseases Fill in Gaps of Care – Between MD appointments and Between Home Health Care and Hospice Strengthen Relationship Between Patient & Physician Focus on Personal Goals and Revisiting Them as Illness Progresses Focus on Last 12- 18 Months of Life Coordinate Care Across all Sites of Care; Continuous; Team Navigation 194
  • 195. • AIM Home Health (Skilled Episode) • AIM Transitions (Non-Skilled Care needs, short term) AIM In-Home Visit Based Care • Outbound, frequency acuity adjusted; Some inbound • Maintains MD Connection AIM In-Home Telesupport • Hospitalization • ED Visit • AIM Care Liaison AIM Acute Care Support • AIM Home Health (Skilled episode) • AIM Transitions (Non-Skilled Care needs, short term) AIM In-Home Visit Based Care Maintain Physician Communication and Connection with Patient; AIM Triage After Hours and Weekends IF Then cycle repeats CLOSER LOOK AT INTEGRATION
  • 196. Advance Care Planning (Personal Goals) Dual Approach to Care: Curative + Palliative Red Flags & Symptom Management Plans Medication Management Follow Up Visits Patient Engagement & Self Management Support AIM Care Pillars 196 "The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies."
  • 197. Key AIM Outcome Highlights Results not yet validated independently by CMMI Results July 2012- June 2014 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Q3 2014 74% 62% 91% Advance Care Plan (ACP) Documentation % of AIM Patients with ACPs at Enrollment % of AIM Patients with ACPs at Enrollment who Made Modifications to the ACP within 90 Days of Enrollment % of AIM Patients who had ACPs Documented Within 90 Days of Enrollment (Target = 90%) 0 200 400 600 800 1000 1200 1400 1600 1800 Hospitalizations ED Visits ICU Days Change in Utilization 90 Days Post AIM Enrollment 9 of 10 Sites Reporting; Q3 2013 - Q2 2014; n=1761 Results not yet validated independently by CMMI Pre Post 57% Reduction 22% Reduction 66% Reduction The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies."
  • 198. Health Care Innovations Awards •“The project described was supported by Grant Number 1C1CMS331005 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services.”
  • 199. B u i l d i n g t h e B u s i n e s s C a s e f o r A d v a n c e d I l l n e s s C a r e
  • 200. Tr a n s f o r m i n g t h e C a r e o f S e r i o u s I l l n e s s : T h e B u s i n e s s C a s e Diane E. Meier, MD Director, Center to Advance Palliative Care diane.meier@mssm.edu www.capc.org www.getpalliativecare.org @dianeemeier
  • 202. Objectives • The case for integrated palliative care strategies • What works to improve quality and subsequently reduce costs for vulnerable people? • How to face outwards towards needs of: – Our patients, their families – Policymakers, payers, health system leadership
  • 203. Concentration of Spending Distribution of Total Medicare Beneficiaries and Spending, 2011 10% 63% 37% 90% Total Number of FFS Beneficiaries: 37.5 million Total Medicare Spending: $417 billion Average per capita Medicare spending (FFS only): $8,554 Average per capita Medicare spending among top 10% (FFS only): $48,220 NOTE: FFS is fee-for-service. Includes noninstitutionalized and institutionalized Medicare fee-for-service beneficiaries, excluding Medicare managed care enrollees. SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost & Use file, 2011.
  • 206. Value = Quality/Cost Because of the Concentration of Risk and Spending, and the Impact of Palliative Care on Quality and Cost, its Principles and Practices are Central to Improving Value
  • 207. Mr. B • An 88 year old man with dementia admitted via the ED for management of back pain due to spinal stenosis and arthritis. • Pain is 8/10 on admission, for which he is taking 5 gm of acetaminophen/day. • Admitted 3 times in 2 months for pain (2x), falls, and altered mental status due to constipation. • His family (83 year old wife) is overwhelmed.
  • 208. Mr. B • Mr. B: “Don’t take me to the hospital! Please!” • Mrs. B: “He hates being in the hospital, but what could I do? The pain was terrible and I couldn’t reach the doctor. I couldn’t even move him myself, so I called the ambulance. It was the only thing I could do.” Modified from and with thanks to Dave Casarett
  • 209. Before and After Usual Care • 4 calls to 911 in a 3 month period, leading to • 4 ED visits and • 3 hospitalizations, leading to • Hospital acquired infection • Functional decline • Family distress Palliative Care • House calls referral • Pain management • 24/7 phone coverage • Support for caregiver • Meals on Wheels • Friendly visitor program • No 911 calls, ED visits, or hospitalizations in last 18 months
  • 210. The Modern Death Ritual: The Emergency Department Half of older Americans visited ED in last month of life and 75% did so in their last 6 months of life. Smith AK et al. Health Affairs 2012;31:1277-85.
  • 211. Who Are These Patients? • Functional Limitation • Frailty • Dementia • Exhausted overwhelmed family caregivers • +/- Serious illness(es)
  • 212. Gómez-Batiste X, et al. BMJ Supportive & Palliative Care 2012;0:1–9. doi:10.1136/bmjspcare-2012-000211
  • 213. Functional Limitations as a Predictor of Risk http://www.cahpf.org/docuserfiles/georgetown_trnsfrming_care.pdf
  • 214. Dementia As A Predictor of Risk • Prospective • Cohort of community dwelling older adults • Callahan et al. JAGS 2012; 60:813-20. Dementia No Dementia Medicare SNF use 44.7% 11.4% Medicaid NH use 21% 1.4% Hospital use 76.2% 51.2% Home health use 55.7% 27.3% Transitions 11.2 3.8
  • 215. Dementia And Total Spending • 2010: $215 billion/yr • By comparison: heart disease $102 billion; cancer $77 billion • 2040 estimates> $375 billion/yr Hurd MD et al. NEJM 2013;368:1326-34.
  • 216. In case you are not already worried… The Future of Dementia Hospitalizations and Long Term Services+Supports 10 fold growth in dementia related hospitalizations projected between 2000 and 2050 to >7 million. Zilberberg and Tija. Arch Int Med 2011;171:1850. 3 fold increase in need for formal LTSS between now and 2050, from 9 to 27 million. Lynn and Satyarthi. Arch Int Med 2011;171:1852.
  • 217. Why? Low Ratio of Social to Health Service Expenditures in U.S. Bradley E H et al. BMJ Qual Saf 2011;20:826-831 Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.
  • 218. Surprise! Home and Community Based Services are High Value • Improves quality: Staying home is concordant with people’s goals. • Reduces spending: Based on 25 State reports, costs of Home and Community Based LTC Services less than 1/3rd the cost of Nursing Home care.
  • 219. Study: Having meals delivered to home reduces need for nursing home 10/14/2013 | HealthDay News A study published today in Health Affairs found if all 48 contiguous states increased by 1% the number of elderly who got meals delivered to their homes, it would prevent 1,722 people on Medicaid from needing nursing home care. The Brown University study found 26 states would save money because lower Medicaid costs would more than offset the cost of providing the meals.
  • 220. What is Palliative Care? • Specialized medical care for people with serious illness and their families • Focused on improving quality of life as defined by patients and families. • Provided by an interdisciplinary team that works with patients, families, and other healthcare professionals to provide an added layer of support. • Appropriate at any age, for any diagnosis, at any stage in a serious illness, and provided together with disease treatments. Definition from public opinion survey conducted by ACS CAN and CAPC http://www.capc.org/tools-for-palliative-care- programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdf
  • 221. Conceptual Shift for Palliative Care
  • 222. 11% 49% 40% Costliest 5% of Patients IOM Dying in America Appendix E http://www.iom.edu/Reports/2014/Dying-In-America-Improving-Quality- and-Honoring-Individual-Preferences-Near-the-End-of-Life.aspx Last 12 months of life Short term high $ Persistent high $
  • 223. Palliative Care Improves Value Quality improves – Symptoms – Quality of life – Length of life – Family satisfaction – Family bereavement outcomes – MD satisfaction Costs reduced – Hospital cost/day – Use of hospital, ICU, ED – 30 day readmissions – Hospitality mortality – Labs, imaging, pharmaceuticals
  • 224.
  • 225. Palliative Care Improves Quality in Office Randomized trial simultaneous standard cancer care with palliative care co-management from diagnosis versus control group receiving standard cancer care only: – Improved quality of life – Reduced major depression – Reduced ‘aggressiveness’ (less chemo < 14d before death, more likely to get hospice, less likely to be hospitalized in last month) – Improved survival (11.6 mos. vs 8.9 mos., p<0.02) Temel et al. Early palliative care for patients with non-small-cell lung cancer NEJM2010;363:733-42.
  • 226. Palliative Care at Home for the Chronically Ill Improves Quality, Markedly Reduces Cost RCT of Service Use Among Heart Failure, Chronic Obstructive Pulmonary Disease, or Cancer Patients While Enrolled in a Home Palliative Care Intervention or Receiving Usual Home Care, 1999–2000 13.2 11.1 2.3 9.4 4.6 35.0 5.3 0.9 2.4 0.9 0 10 20 30 40 Home health visits Physician office visits ER visits Hospital days SNF days Usual Medicare home care Palliative care intervention KP Study Brumley, R.D. et al. JAGS 2007
  • 227. 46 High Quality Studies 2002-11 Palliat Med 2014;28:130-50.
  • 228. 46 Studies: Across settings, patient populations, and palliative care delivery models, palliative care improves quality and in so doing, reduces costs.
  • 229. What Do Patients Want? Survey of Senior Center and Assisted Living subjects, n=357, dementia excluded, no data on function. Asked to rank order what’s most important: 1st Independence (76% rank it most important) 2nd Pain and symptom relief 3rd Staying alive Fried et al. Arch Int Med 2011;171:1854
  • 230. How Can We Help Families Help Patients Stay Home? Partner with our payers.
  • 231. Innovative Payer Toolkit • Talk to your payers! • But first, read this: • Predictors of successful payer- ACO-provider initiatives • Case studies • Checklists • Worksheets • Resources 231 www.capc.org/payertoolkit
  • 232. Payers Are Bringing Palliative Care Home
  • 233. www.theatlantic.com 02.25.13 MA Full Risk PMPM contract with HealthCare Partners/DaVita 15%+margin. >700K patients “Now instead of 30-40 patients/day, Dr. Dougher sees 6-8.”
  • 234. Treating the person beyond the disease
  • 235. T h a n k y o u
  • 236. F a m i l y C a r e g i v e r S u p p o r t
  • 237. F a m i l y C a r e g i v e r S u p p o r t Susan C. Reinhard, R.N., Ph. D., FAAN
  • 238. Family Caregivers Taking On More Complex Tasks • Partnership between the AARP Public Policy Institute and the United Hospital Fund • Funded by The John A. Hartford Foundation
  • 239. Almost Half of Family Caregivers Perform Medical/Nursing Tasks
  • 241. Caregiver Advise, Record, Enable (CARE) Act What does the CARE Act Do? • Designation – Record the name of the family caregiver upon admission into the hospital • Notification – Contact the family caregiver(s) prior to discharge to another facility or home • Consultation – Hospital consults with caregiver on discharge plan, taking into account the caregiver’s capabilities and limitations • Training – Hospital gives caregiver the opportunity to receive instruction on all after- care tasks included in the discharge plan to be performed by the caregiver
  • 242. Caregiver Advise, Record, Enable (CARE) Act • Gives support to nurses and other health and social service professionals to do what professional standards of practice require them to do • Stimulates new thinking on how to anticipate patient and family questions and pro-actively support them • Reduce hospital re-
  • 243. Caregiver Advise, Record, Enable (CARE) Act Passed and signed in… It has been introduced in sixteen states (CT, HI, IN, KS, MA, MD, MN, MS, NH, NM, NY, ND, PR, VA, WI, WV).
  • 244. Reimbursement for Educating Family Caregivers? • 2010 Invitational meeting with CMS (Centers for Medicare & Medicaid Services) and other stakeholders Focus: – Participants included leaders from nursing and social work professions, family caregiver advocacy organizations, and federal government agencies – The agenda explored policies around caregiver assessment and reimbursement for caregiver counseling. – Goal was to provide participants with relevant data on the use of Medicare reimbursement codes for the counseling of family caregivers of Medicare recipients.
  • 245. Reimbursement for Educating Family Caregivers? • AARP Public Policy Institute worked with CMS to provide data on use of existing reimbursement codes. – Determine the past and current use of the reimbursement codes, – What healthcare professionals (Physicians, Nurse Practitioners, etc.) were using codes – If usage was low, why? – What regions of the country were codes used
  • 246. Reimbursement for Educating Family Caregivers? • Data run not completed due to regulations around privacy of Medicare beneficiary and provider data
  • 247. Medicare Payment for Clinicians • The following provide payment for clinicians doing care coordination including family caregivers – Chronic Care Management Fee – Post-Discharge Transitional Care Management – Home Health Services for Caregivers of Alzheimer’s Patients – Patient-Centered Medical Home (Advanced Primary Care Practices) – Medicare Community-Based Care Transition Program
  • 248. Care Recipient Family Caregiver CARE TRIANGLE Healthcare Professional “It will take a movement to join the three corners of the care triangle: people who need care, families who care for and about their members, and people who give care for a living.” Deborah Stone, The Nation, March 13, 2008
  • 250. F a m i l y C a r e g i v e r S u p p o r t Gail Gibson Hunt President and CEO National Alliance for Care Giving
  • 251. About Alliance  Non-profit coalition of over 50 national organizations focused on family caregiving issues  Established in 1996 to support family caregivers and the professionals who work with them  NAC Activities:  Conduct research and policy analysis;  Develop national programs;  Strengthen state and local coalitions;  Increase public awareness;  International work and awareness.
  • 252. Demographics of Care Giving  65.7 million caregivers make up 29% of the US adult population and 31% of households  48.9 million care for only adult recipients, including people with disabilities  Portrait of Caregiver:  48-year-old woman who works and cares  Average of 20.4 hours of care per week for her mother for an average of 4.6 years  34% care for two or more people  86% provide care for a relative
  • 254. Caregiver Financial Burden  Caregiving costs U.S. employers between $17.1 and $33.6 billion in lost productivity annually  Over $5,500 out of pocket expenses  Seven in 10 working caregivers make workplace accommodations  Loss of wages, pension, Social Security: $324,044—women; $283,716—men  43% of caregivers were affected financially (AHA/ASA 2005)
  • 255. PCORI End of Life Research  Several studies from PCORI on end-of-life care and caregiving  Includes cancer and heart failure treatment  Pediatric end-of-life care received grants to examine care preferences and communication on care  Shared decision making with patients, families and medical professionals  Impact on caregivers: • Caregiver burden • Decision-making (aggressiveness of care, etc.) • Reduce caregiver conflict/regret
  • 256. Federal Caregiving Legislation  Previously introduced legislation – yet to be introduced in current term  “FAMILY Act” – Family And Medical Insurance Leave Act of 2013, would create a self-sustaining insurance fund through a payroll tax to provide paid family and medical leave similar to the California Paid Leave program.  Caregiver Corps Act of 2014 (Sen. Casey-PA) and the National Care Corps Act (Rep. Grisham-NM), propose to create volunteer corps to help support families that do not have caregivers to meet long-term care needs  Mental Health Support for Veteran Families and Caregivers Act of 2013 (Sen. Sanders), would have created educational programs to support caregivers and vets with mental health disorders through the VA’s vet centers  In Home CARE Act (Sen. Booker-NJ, Rep. Pascrell-NJ), would have provided in- home caregiver education and training and an assessment with referral to resources for physical and mental Health for both the caregiver and the care recipient
  • 257. Active Caregiving Initiatives  White House Conference on Aging  Older Americans Act Reauthorization  21st Century Cures • Accelerates innovation for diseases with unmet needs  President’s Budget • Proposed increases in NFCSP and Lifespan Respite, among others • New ACL Family Support Program ($15,000,000)
  • 258. Thank you Gail Gibson Hunt President & CEO National Alliance for Caregiving 4720 Montgomery Lane, Suite 205 Bethesda, MD 20814 gailhunt@caregiving.org 301-718-8444 www.caregiving.org
  • 259. T h a n k y o u
  • 260. T h e C o n t i n u u m o f C a r e : P a n e l D i s c u s s i o n
  • 261. The Continuum of Care: Panel Discussion • Brad Stuart, MD C-TAC • Samira K. Beckwith, President and CEO, Hope Healthcare Services • Robert Sowislo, Board and Government Affairs U.S. Medical Management • Jean Kutner, MD, MSPH, CMO Professor of Medicine and Associate Dean for Clinical Affairs University of Colorado School of Medicine Past President AAHPM • Cheryl Phillips, MD, SVP Advocacy and Public Policy, Leading Age • Randy Axelrod, MD, EVP Clinical and Patient Services, Providence Health Services
  • 262. M o d e r a t o r : B r a d S t u a r t , M D C - T A C
  • 263. Toward A Person-Centered Continuum of Care Person Community HH, Hospice Health System Medical Group Agencies Church Private Payers LT Care Government Physician Hospital
  • 264. H o s p i c e A s A n A g e n t f o r C l i n i c a l I n t e g r a t i o n S a m i r a K . B e c k w i t h P r e s i d e n t a n d C E O H o p e H e a l t h c a r e S e r v i c e s
  • 266. USMM / VPA H o m e B a s e d P r i m a r y C a r e C o n t i n u u m o f C a r e R o b e r t S o w i s l o E V P A d v o c a c y / G o v e r n m e n t A f f a i r s
  • 267. Who We Are… USMM is the nation's largest physician led provider of in- home medical services for high-risk populations: • Provide 15% of all in-home physician visits nationally • Serve over 50,000 complex patients on an annual basis • Operate >100 local offices across 14 States Delivers a physician- driven, fully- integrated continuum of care model ~ 225 full time Physicians, NPs and PAs Engage in over 400,000 physician house call visits, 39,000 podiatric house call visits, 139,000 home health visits, and 380,000 hospice patient days annually Centralized administrative, data management, and call center operations 24x7 response to urgent escalations in illness and medical crises
  • 268. Shared Savings Programs Provide enhanced access to health services and quality of life for complex populations by removing barriers to receiving care Pioneer ACO Independence at Home 30% 30% 50% Top Decile Top Quintile 17% / year Not Published • Reduction in All-Cause 30-Day Readmissions • Reduction in Hospital Admissions for Ambulatory-Care Sensitive Conditions • Reduction in ER Visits for Ambulatory-Care Sensitive Conditions • Patient Satisfaction Scores (CAHPS) • Quality Scores (ACO Measures / IAH Quality Metrics) • Cost Reduction (Pioneer 3 Yrs. Experience / IAH Year 1 Not Published) Results and Outcomes • Opportunity to expand shared savings participation to remaining FFS population through current CMS MSSP ACO program (First Home Based Primary Care ACO in the U.S.) • Launched in January 2015; enrolled 20,000+ beneficiaries out of existing USMM/VPA USMM Accountable Care Partners, LLC
  • 269. J e a n K u n t e r , M D , M S P H , C M O P r o f e s s o r o f M e d i c i n e a n d A s s o c i a t e D e a n f o r C l i n i c a l A f f a i r s U n i v e r s i t y o f C o l o r a d o S c h o o l o f M e d i c i n e P a s t P r e s i d e n t , A A H P M
  • 270. L o n g - t e r m C a r e a n d C o m m u n i t y C o n n e c t i o n s C h e r y l P h i l l i p s , M D S V P, A d v o c a c y a n d P u b l i c P o l i c y L e a d i n g A g e
  • 271. I n t e g r a t e d H e a l t h S y s t e m s R a n d y A x e l r o d , M D E V P, C l i n i c a l a n d P a t i e n t S e r v i c e s , P r o v i d e n c e H e a l t h a n d S e r v i c e s
  • 272. A Snapshot of Providence Caregivers (all employees) 73,018 Employed physicians 3,389 Employed advanced practice clinicians 923 Registered nurses 25,478 Physician clinics 475 Acute care hospitals 34 Acute care beds (licensed) 7,932 Providence Health Plan members 390,596 Hospice and home health programs 19 Home health visits 633,364 Hospice days 640,409 Assisted living and long-term care facilities (free standing and co-located) 22 Supportive housing Facilities: 14 Units: 693 Unique patients served 2,483,462 Community benefit and charity care costs $951 million Data is consolidated for Providence and its affiliates based on financial reporting. 272
  • 273. Question & Answer Panel Discussion
  • 274. F e d e r a l I n i t i a t i v e s t o D r i v e C h a n g e
  • 275. Federal Initiatives to Drive Change • Tom Daschle, Former U.S. Senator (D-SD) Founder and CEO, The Daschle Group
  • 276. CMS Innovation and Health Care Delivery System Reform Dr. Patrick Conway, M.D., MSc CMS Chief Medical Officer and Deputy Administrator for Innovation and Quality Director, Center for Medicare and Medicaid innovation Director, Center for Clinical Standards and Quality
  • 277. Better Care, Smarter Spending, Healthier People  In three words, our vision for improving health delivery is about better, smarter, healthier.  If we find better ways to deliver care, pay providers, and distribute information, we can receive better care, spend our dollars more wisely, and have healthier communities, a healthier economy, and a healthier country.  We understand that it’s our role and responsibility to lead … and we will.  What we won’t do – and can’t do – is go it alone. Patients, providers, government, and business all stand to benefit if we get this right, and this shared purpose calls out for deeper partnership.  So we will continue to work across sectors for the goals we share: better care, smarter spending, and healthier people.
  • 278. Overview Early Results CMS Innovation Center Delivery System Reform and Our Goals
  • 279. CMS Support of Health Care Delivery System Reform Will Result in Better Care, Smarter Spending, and Healthier People Historical state Key characteristics  Producer-centered  Incentives for volume  Unsustainable  Fragmented Care Systems and Policies  Fee-For-Service Payment Systems Evolving future state Key characteristics  Patient-centered  Incentives for outcomes  Sustainable  Coordinated care Systems and Policies  Value-based purchasing  Accountable Care Organizations  Bundled payments  Medical Homes  Quality/cost transparency  Population-based payments Public and private sectors
  • 280. Improving the way providers are incentivized, the way care is delivered, and the way information is distributed will help provide better care at lower cost across the health care system.  Encourage the integration and coordination of clinical and support services  Improve population health  Promote patient engagement through shared decision making Pay Providers  Create transparency on cost and quality information  Bring electronic health information to the point of care for meaningful use Focus Areas Description Deliver Care Distribute Information  Promote value-based payment systems – Test alternative payment models – Increase linkage of Medicaid, Medicare FFS, and other payments to value  Bring proven alternative payment models to scale Delivery System Reform Requires Focusing On the Way We Pay Providers, Deliver Care, and Distribute Information Source: Burwell SM. Setting Value-Based Payment Goals ─ HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online first.
  • 281. CMS Has Adopted a Framework That Categorizes Payments to Providers Description Medicare Fee-for- Service examples  Payments are based on volume of services and not linked to quality or efficiency Category 1: Fee for Service – No Link to Value Category 2: Fee for Service – Link to Quality Category 3: Alternative Payment Models Built on Fee-for- Service Architecture Category 4: Population-Based Payment  At least a portion of payments vary based on the quality or efficiency of health care delivery  Some payment is linked to the effective management of a population or an episode of care  Payments still triggered by delivery of services, but opportunities for shared savings or 2-sided risk  Payment is not directly triggered by service delivery so volume is not linked to payment  Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (e.g., ≥1 year)  Limited in Medicare fee- for-service  Majority of Medicare payments now are linked to quality  Hospital value- based purchasing  Physician Value Modifier  Readmissions / Hospital Acquired Condition Reduction Program  Accountable Care Organizations  Medical homes  Bundled payments  Comprehensive Primary Care initiative  Comprehensive ESRD  Medicare-Medicaid Financial Alignment Initiative Fee-For- Service Model  Eligible Pioneer Accountable Care Organizations in years 3-5  Maryland hospitals Source: Rajkumar R, Conway PH, Tavenner M. CMS ─ engaging multiple payers in payment reform. JAMA 2014; 311: 1967-8.
  • 282. During January 2015, HHS Announced Goals for Value-Based Payments Within the Medicare FFS System  30% of Medicare payments are tied to quality or value through alternative payment models (categories 3-4) by the end of 2016, and 50% by the end of 2018  85% of all Medicare fee-for-service payments are tied to quality or value (categories 2-4) by the end of 2016, and 90% by the end of 2018 Goals Purpose  Set internal goals for HHS  Invite private sector payers and Medicaid to match or exceed HHS goals Stakeholders  Consumers  Businesses/Purchasers  Payers  Providers  State partners (including Medicaid programs) Next steps  Testing of new models and expansion of existing models is critical to reaching incentive goals  Creation of the Health Care Payment Learning and Action Network to align incentives and identify best practices
  • 283. 50% Target Percentage of Payments in ‘FFS Linked to Quality’ and ‘Alternative Payment Models’ by 2016 and 2018 ~20 0%
  • 284. CMS Increasingly Linking FFS Payments to Quality or Value 1 2 2 1 2 2 1 2 1.75 2 3 2 3 2 2
  • 285. CMS is Aligning with Private Sector and States to Drive Delivery System Reform Convening Stakeholders  Convened payers in 7 markets in Comprehensive Primary Care  Convening payers, providers, employers, consumers, and public partners through the Health Care Payment Learning and Action Network CMS Strategies for Aligning with Private Sector and States Incentivizing Providers  Pioneer ACOs agreements required 50% of the ACO’s business to be in value- based contracts by the end of the second program year Partnering with States  The State Innovation Models Initiative funds testing awards and model design awards for states implementing comprehensive delivery system reform  The Maryland All-Payer Model tests the effectiveness of an all- payer rate system for hospital payments
  • 286. Early Results CMS Innovation Center Delivery System Reform and Our Goals
  • 287. Source: CMS Office of the Actuary 9.24% 5.99% 4.63% 7.64% 7.16% *27.59% 1.98% 4.91% 4.15% 1.36% 2.25% 1.13% 0.35% 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Medicare Per Capita Growth Medical CPI Growth *Medicare Part D prescription drug benefit implementation, Jan 2006 28% 27% Results: Per Capita Spending Growth at Historic Lows
  • 288. Pioneer ACOS were designed for organizations with experience in coordinated care and ACO-like contracts Pioneer ACOs showed improved quality outcomes Quality outperformed published benchmarks in 15/15 clinical quality measures and 4/4 patient experience measures in year 1 and improved in year 2 Mean quality score of 85.2% in 2013 compared to 71.8% in 2012 Average performance score improved in 28 of 33 (85%) quality measures Pioneer ACOs generated savings for 2nd year in a row  $384M in program savings combined for two years†  Average savings per ACO increased from $2.7 million in PY1 to $4.2 million in PY2‡ Pioneer ACOs Provided Higher Quality and Lower Cost Care to Medicare Beneficiaries in Their First Two Performance Years  19 ACOs operating in 12 states (AZ, CA, IA, IL, MA, ME, MI, MN, NH, NY, VT, WI) reaching over 600,000 Medicare fee-for-service beneficiaries  Duration of model test: January 2012 – December 2014; 19 ACOs extended for 2 additional years † Results from regression based analysis ‡ Results from actuarial analysis
  • 289.  CMS convenes Medicaid and commercial payers to support primary care practice transformation through enhanced, non-visit-based payments, data feedback, and learning systems  Across all 7 regions, CPC reduced Medicare Part A and B expenditures per beneficiary by $14 or 2%*  Reductions appear to be driven by initiative-wide impacts on hospitalizations, ED visits, and unplanned 30-day readmissions Comprehensive Primary Care (CPC) is Showing Early Positive Results  7 regions (AR, OR, NJ, CO, OK, OH/KY, NY) encompassing 31 payers, nearly 500 practices, and approximately 2.5 million multi-payer patients  Duration of model test: Oct 2012 – Dec 2016 * Reductions relative to a matched comparison group and do not include the care management fees (~$20
  • 290. Spotlight: Comprehensive Primary Care, SAMA Healthcare SAMA Healthcare Services is an independent four-physician family practice located located in El Dorado, a town in rural southeast Arkansas “A lot of the things we’re doing now are things we wanted to do in the past… We needed the front-end investment of start-up money to develop our teams and our processes” -Practice Administrator Services made possible by CPC investment  Care management  Each Care Team consists of a doctor, a nurse practitioner, a care coordinator, and three nurses  Teams drive proactive preventive care for approximately 19,000 patients  Teams use Allscripts’ Clinical Decision Support feature to alert the team to missing screenings and lab work  Risk stratification  The practice implemented the AAFP six- level risk stratification tool  Nurses mark records before the visit and physicians confirm stratification during the patient encounter
  • 291. Partnership for Patients Contributes to Quality Improvements and Cost Savings Ventilator- Associated Pneumonia Early Elective Delivery Central Line- Associated Blood Stream Infections Venous thromboembolic complications Re- admissions 62.4% ↓ 70.4% ↓ 12.3% ↓ 14.2% ↓ 7.3% ↓  Data shows a 17% reduction in hospital acquired conditions across all measures from 2010 – 2013 ‒ 50,000 lives saved ‒ 1.3 million patient harm events avoided ‒ $12 billion in savings  Many areas of harm dropping dramatically – patient safety improving Leading Indicators, change from 2010 to 2013
  • 292. Medicare All-Cause, 30-day Hospital Readmission Rate is Declining Legend: CL: control limit; UCL: upper control limit; LCL: lower control limit ReadmissionRate
  • 293. Beneficiaries Move to MA Plans with High Quality Scores  Sent prompt to beneficiaries enrolled in plans with 2.5 star rating or lower  Letters only sent to beneficiaries in consistently low-rated plans  Switch rate 44% (prompt) v. 21% (no prompt) 9% 9%9% 2012 20% 61% 29% 57% 20142013 9% 5% 45% 45% 1% 5-star 4-star 3-star 2-star Medicare Advantage (MA) Enrollment Rating Distribution 29 % 71 % 37 % 63 % 55 % 45 % % 4 or 5 star % 2 or 3 star
  • 294. Early Results CMS Innovation Center Delivery System Reform and Our Goals
  • 295. The CMS Innovation Center Was Created By the Affordable Care Act to Develop, Test, and Implement New Payment and Delivery Models
  • 296. The Innovation Center Portfolio Aligns With Delivery System Reform Focus Areas
  • 297. CMS Has Engaged the Health Care Delivery System and Invested in Innovation Across the Country Models run at the state levelSites where innovation models are being tested Source: CMS Innovation Center website, January 2015
  • 298. Accountable Care Organizations: Participation in Medicare ACOs Growing Rapidly ACO-Assigned Beneficiaries by County 424 ACOs have been established in the MSSP and Pioneer ACO programs 7.8 million assigned beneficiaries This includes 89 new ACOS covering 1.6 million beneficiaries assigned to the shared saving program in 2015
  • 299.  The bundled payment model targets 48 conditions with a single payment for an episode of care  Incentivizes providers to take accountability for both cost and quality of care  Four Models - Model 1: Retrospective acute care hospital stay only - Model 2: Retrospective acute care hospital stay plus post-acute care - Model 3: Retrospective post-acute care only - Model 4: Acute care hospital stay only  102 Awardees and 167 episode initiators in phase 2 as of January 2015  85 new awardees and 373 new episode initiators will enter phase 2 in April 2015 Bundled Payments for Care Improvement is Also Growing Rapidly  Duration of model is scheduled for 3 years:  Model 1: April 2013 to present  Models 2,3,4: October 2013 to present * Current as of January 2015
  • 300.  CMS is testing the ability of state governments to utilize policy and regulatory levers to accelerate health care transformation  Primary objectives include  Improving the quality of care delivered  Improving population health  Increasing cost efficiency and expand value-based payment State Innovation Model Grants Have Been Awarded in Two Rounds  Six round 1 model test states  Eleven round 2 model test states  Twenty one round 2 model design states
  • 301. Round 1 States Are Testing and Round 2 States Are Designing and Implementing Comprehensive Reform Plans Round 1 States testing APMs Arkansas Maine Massachuset ts Minnesota Oregon Vermont Patient centered medical homes Accounta ble care Episodes  Near term CMMI objectives  Establish project milestones and success metrics  Support development of states’ stakeholder engagement plan  Onboard states to Technical Assistance Solution Center and SIMergy Collaboration site  Launch State HIT Resource Center and CDC support for Population Health Plans Round 2 States designing interventions
  • 302.  Maryland is the nation’s only all-payer hospital rate regulation system  Model will test whether effective accountability for both cost and quality can be achieved within all-payer system based upon per capita total hospital cost growth  Quality of care will be measured through  Readmissions  Hospital Acquired Conditions  Population Health Maryland is Testing an Innovative All-Payer Payment Model  Maryland has ~6 million residents*  Hospitals began moving into All-Payer Global Budgets in July 2014 - 95% of Maryland hospital revenue will be in global budgets - All 46 MD hospitals have signed agreements  Model was initiated in January 2014; Five year test period * US census bureau estimate for 2013