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Community-based Palliative Care: Trends, Challenges, Examples and Collaboration with Payers - Eric Wall
- 1. Community Based Palliative Care: Trends, Challenges, Examples, and Collaboration with Payers/Insurers Eric Wall, MD, MPH NW Medical Director United Healthcare
- 2. Disclosures United Healthcare University of Washington School of Medicine
- 3. Agenda Goals of Palliative Care The Cast of “Players” Trends Challenges Examples of Community-based initiatives Working with Payers/Insurers
- 4. Oh Death Oh death, oh death Won't you spare me over till another year Well what is this that I can't see, With ice cold hands taking hold of me Well I am death none can excel, I'll open the door to heaven or hell Whoa death someone would pray, Could you wait to call me till another day I'll fix your feet till you can't walk, I'll lock your jaw till you can't talk
- 5. Palliative Care Care, not cure Relief- from symptoms, pain, stress Focus= quality of life- patient and family Control over choices and care: patient and family
- 6. Lean On Me Sometimes in our lives, we all have pain we all have sorrow. But if we are wise, we know that there’s always tomorrow. Lean on me, when you’re not strong and I’ll be your friend, I’ll help you carry on. For it won’t be long, ‘til I’m gonna need somebody to lean on. Please swallow your pride, if I have faith you need to borrow. For no one can fill those of your needs that you won’t let show. You just call on me brother, when you need a hand. We all need somebody to lean on. I just might have a problem, that you’ll understand We all need somebody to lean on.
- 7. Who Really Provides Palliative Care? Individual (Patient) Family Community Everyone Else?
- 8. The “Players” in Palliative Care Palliative Care Hospice Family Community Medical Care Payers
- 9. The “Medical” Care Team PCP Nurses Palliative Care Specialists Case Managers Social Worker Complementary Care
- 11. You’ll Never Walk Alone When you walk though a storm hold your head up high and don’t be afraid of the dawn. At the end of the storm is a golden sky and the sweet silver song of the lark. Walk on through the wind, walk on through the rain, though your dreams be tossed and blown. Walk on, walk on, with hope in your heart and you’ll never walk alone. You’ll never walk alone.
- 12. Trends/Statistics 90 million Americans with serious chronic illness (expected to double in 25 yrs) 1/1000 in commercially insured populations 5-10/1000 estimated in Mcare population 46% of family caregivers perform medical/nursing tasks for care recipients with multiple chronic physical and cognitive conditions (AARP, 2012) 20% of Mcare recipients with 5 or more chronic conditions= 2/3 of Mcare spending Approximately half of all dying patients will receive some form of pain management care >35% of patients referred to hospice had length of service < 7 days
- 13. Bridge over Troubled Water When you’re weary, feeling small When tears are in your eyes, I will dry them all. I’m on your side, when times get rough And friends just can’t be found Like a bridge over troubled water I will lay me down When you’re down and out When you’re on the street When evening falls so hard I will comfort you When pain is all around Like a bridge over troubled water I will lay me down
- 14. Challenges
- 15. Challenges Glass half empty: FINANCIAL: need for bundled payment/creative financing models that are sustainable Resistant hospital/medical community Unfamiliar public and provider Uncoordinated care “Piece of the action”/Turf wars Quality of care issues
- 16. Challenges Glass half full: Patients/families have high satisfaction with care Providers have high satisfaction in care delivery NO one is closer to the patient than the caregivers and care providers Payers know palliative care saves money
- 17. Making it Personal: Studs Terkel 2001
- 18. Elements of Quality Palliative Care Structure/process of care Physical care Psychological support Social support
- 19. Elements of Quality Palliative Care (cont.) Spiritual care Culturally appropriate Care of the imminently dying patient Ethical/Legal aspects
- 21. Questions for Community-based Palliative Care Start-ups Local needs assessed? Well-articulated goals? What will it provide? Who will it serve? How will it be financed? Who will orchestrate, coordinate, define services provided (e.g. Governance)?
- 22. There’s a Bright Side There’s a bright side somewhere I ain’t gonna rest until I find it There’s a bright side somewhere There’s more joy somewhere I ain’t gonna rest until I find it There’s more joy somewhere There’s more love somewhere I ain’t gonna rest until I find it There’s more love somewhere There’s more peace somewhere I ain’t gonna rest until I find it There’s more peace somewhere
- 23. Examples Community-based Hospice care Hospice “hub” with palliative care community outreach/clinic: Lexington, KY; Falls Church, VA; Flat Rock, NC MD led Financially challenged Promotes earlier hospice referrals Outpatient clinic-based palliative care Most often affiliated with an oncology practice Typically subsidized by hospital/health system Health system integrated palliative care (Kaiser, VA, Sutter Health, etc.) Other models (IPA, medical group, home health, etc.)
- 24. Community Example: Midwest CareCenter Community based nonprofit started 1978 Hospice and Palliative care based in Chicago area providing care in 150 Illinois communities Home based or inpatient hospice “Your goals=our goals” Palliative care, hospice care Organization: Executive staff, medical staff Volunteer Board Advisory Council: Medical/Community Leaders Service Board: generates funding/community awareness Cost/Coverage: Insurance, Medicare, charity care, financial assistance
- 25. Payer Example: Blue Shield of CA HMO- Patient-Centered Management (PCM) of Complex Patients Complex care team: Goal-oriented care plans for seriously ill patients Care manager (RN): onsite assessment/education/ongoing contact, home visits Team manager (RN): coordinated team reviews/liaison to health plan MD: provided clinical information, anticipated medical problems, liaison with patient;s treating MD Not provided: medical treatment, home care, authorization of medical services No added expense to patients/families
- 26. Blue Shield of CA HMO- Patient-centered Management of Complex Patients- Intervention In-Home evaluation: domain weakness, knowledge, treatment plan, terminal care plan, benefit plan management, family/living environment, provider support Weekly team meetings: link to providers, health plan High frequency outbound patient calls (2-3x wk) Intervention ended when goals set out at beginning (understanding, hospice plan) were achieved
- 27. Blue Shield of CA HMO- Patient-centered Management of Complex Patients: Results Different treatment choices made Increase adherence with care plans/understanding of medications Decreased use of hospital/ER Increased use of home care/hospice Reduced expenses (+ ROI) Huge patient/caregiver satisfaction
- 28. You’ve Got a Friend When you’re down, and troubled And you need a helping hand And nothing, no nothing is going right. Close your eyes and think of me And soon I will be there To brighten up, even your darkest nights When you call out my name You know wherever I am, I’ll come running to see you again. Wintertime, summer or fall, All you’ve got to call. And I’ll be there. You’ve got a friend.
- 30. Working with Payers/Insurers Find an influential champion (case manager, medical director) Identify benefits (eg. medical, hospice, etc.) Collaborate on creative solutions Bundle/package services to work around non-traditional service delivery
- 32. Thank You!
Editor's Notes
- I have many musician friends in the Bellingham community who influenced my approach to this subject. It may at times seems like a musical journey down palliative care lane so for that, I must apologize.
- Ralph Stanley This is how I approached the subject of palliative care in preparing for this talk I learned a great deal to change my musical impression and I hope you will too.
- In reality, this is the care we should be delivering to all people- I discovered this while researching this topic. -Any age, any stage, any diagnosis -Team-based -Can be provided with treatment At least 3 types of palliative patients: those with curable diseases, such as a 23-year-old with leukemia who receives a bone marrow transplant with a 70-percent success rate; those with serious or complex medical illnesses such as emphysema, MS, diabetes or even Alzheimer's disease that may last for decades; those with progressive incurable diseases such as metastatic cancer.
- Bill Withers showed what we have to offer in delivering quality palliative care
- Hospice= palliative care for patients with < 6 month prognosis Notice the absence of the hospital
- There are many care players in palliative care and as you may imagine, this sometimes can be quite challenging. I will return to this later
- Rodgers and Hammerstein- amazing this was for the musical Carousel Inspirational in nature and the theme, “you’ll never walk alone” is the back drop behind the care support for patient and family
- So if you truly understand what palliative care is all about, these statistics demonstrate that there are clearly not enough palliative care specialists available to meet the needs of all Americans with complex chronic and serious illnesses In a 2012 AARP survey, : -78% of family caregivers who provided medical/nursing tasks were managing medications, including administering intravenous fluids and injections -38% of those caregivers providing wound care wanted more training -Most family caregivers who provided help with medical/nursing tasks believed they were helping their family member avoid institutionalization More than 1/3 of patients had hospice referrals so late in the course of their illness that they and their families had little time to benefit from the services
- Abbreviated Paul Simon So what are the challenges for palliative care today given these trends and statistics?
- Other challenges: -Evidence-based showing positive outcomes is lacking including cost-reductions -No benchmarks/normative data for staffing or best practices -Who benefits from the care besides the patient/family enough to pay for the services? -Lack of qualified/credential personnel -Unclear relationship between primary and specialist-level palliative care
- Studs Terkel October 2001 Issue On December 23, 1999, as I was beginning to interview people for a new book on death and dying, my wife, Ida, died. She had been my companion for sixty years. She was eighty-seven. A few months later a friend of mine, disturbed by my occasional despondency, burst out, "For chrissake, you've had sixty great years with her!" Ida had lived seventeen years beyond her traditionally allotted three score and ten, though on occasion I'd heard her murmur in surprise, "Why do I still feel like a girl?" They were roller-coaster years we shared, after I first spotted her, in a maroon smock, in 1937. She was a social worker during most of those tumultuous years: the Great Depression, World War II, the Cold War, Joe McCarthy, the sixties, the civil-rights and peace movements. She was, as they say, "involved." Garry Wills remembers her greeting him, years after the Vietnam War had ended, with "Oh, we were arrested together in Washington." A year or so before Ida's death Laura Watson, a neighbor, "looked out the window and saw this slim young girl in jeans, with a flower in her hair, plucking out weeds in her garden." The girl looked up. "It was Ida, of course." Yes, she did live to the ripe old age of eighty-seven, but it doesn't cut the mustard, Charlie. I still see that girl in the maroon smock who liked yellow daisies. Each week there is a fresh bunch of yellow daisies near the windowsill. On the sill is the urn containing her ashes. On occasion, either indignant or somewhat enthusiastic about something, I mumble toward it (her), "Whaddya think of that, kid?" Naturally, when I pick up a newspaper these days, the first place I turn to isn't sports, or arts, or the business of business, or the op-eds. I immediately turn to the obituaries. The old doggerel with which many mature readers may be acquainted has become my mantra. I wake up each morning and gather my wits, I pick up the paper and read the obits. If my name is not in it, I know I'm not dead, So I eat a good breakfast and go back to bed.
- Consensus Guidelines from National Quality Forum (2006)
- Community-based palliative care: outside the hospital, outside of regulatory and reimbursement structures of hospice care under Medicare Medicare’s reimbursement does not support registered nurses, social workers, bereavement counselors, other kinds of therapists, and the administrative staff needed for an effective advanced illness management program. Given the unreliability of philanthropic or grant funding, many community-based programs struggle for survival.
- More joy, more love, more peace- indeed these are the goals of palliative care
- Community-based palliative care programs are often not part of integrated health care systems or medical centers which can subsidize its affiliated programs. Supporting a multi-disciplinary team, thesine qua non of quality palliative care, cannot be achieved with traditional Medicare fee-for-service reimbursement alone
- James Taylor, Carole King: The anthem of palliative care? This reflects my changed attitude towards palliative care. I hope you agree
- Monthly case rates, that is, fixed amounts paid each month for all services provided, could potentially fund community-based, non-hospice palliative care. This approach is a viable alternative to fee-for-service. . A monthly rate that averages $800-$900 can support the entire team and meet the needs of a patient and his or her family to achieve an optimum level of independence in the community. High case rates for adult and pediatric palliative care are justifiable if there are substantial savings from reduced hospital admissions, ICU use, readmissions, and emergency department visits; and quality indicators indicate high patient and family satisfaction as