High costbut low health Jeff Thompson, MD Chief Executive Officer The - PDF document

The constant complaint… Advanced Disease Coordination High cost…but low health Jeff Thompson, MD Chief Executive Officer The Determinants of a Health Population But the U.S. spends 80% of Physical Environment resources here 10% Health Care 20% And 20% in Healthy all other Behavior Social and areas 30% Economic combined 40% To begin, we must… Admit and recognize that patient/family outcomes are not as good as they might be…that we might do better. Face the Brutal Facts – Jim Collins 1

Lack of Advance Care Planning A few early observations… Results In… • Great moral and emotional distress for families • Simply getting patients to fill out statutory and providers. documents like living wills would not help. • Demands heavy time commitments for health • Simply telling health professionals that they professionals to work through decisions. should talk to patients or they should • Creates conflicts among health professionals. document patient plans would not work. • Uses significant health resources while decisions • Stressing these two processes would not were sorted out. improve the system. • Leaves everyone with moral uncertainty about the choices made. Four Key Components of Good Advanced Disease Coordination Advance Care Planning Systems Attributes NOT focused on limitation of treatment, but is • Community engagement focused on: • Professional education and skills training • Helping patient and family understand chronic illness • A system that honors wishes • Helping guide subsequent care from an • Continuous quality improvement informed vantage point • Accompanying and supporting patient, family and staff through subsequent journey Stages of Advance Care Planning Over the Life Time of Adults Study by Fried, Bradley, Towle and Next Steps (DS ‐ ACP) First Steps Last Steps ACP: Determine what goals ACP: Create POAHC and consider when a ACP: Establish a specific plan of Allore (2002) of treatment should be serious neurological injury would change goals care expressed in medical of treatment. followed if complications orders using the POLST result in “bad” outcomes. paradigm. Three factors that influence treatment decision making 1. treatment burden 2. treatment outcome 3. the likelihood of the outcome Adults with progressive, Adults whom it would not be a Healthy adults between ages 55 and 65. life ‐ limiting illness, suffering surprise if they died in the frequent complications next 12 months. 2

For the Patient “The discussion, not the list [written plan], was what matter most…it was that simple – and that complicated.” A statement made about Gundersen’s advance care planning work by Atul Gawande, MD in “Letting Go” The New Yorker, August 2, 2010. Authors include: AARP “One of the most intractable...politically Aetna Center to Advanced charged…third rail issues…put a screeching half Palliative Care to the much needed public conversation.” Dartmouth National Palliative Care How to Die In America: Welcome to La Crosse, WI Research Center Forbes, 9/23/14 Senator Warner, D ‐ Va Secretary Leavitt, R ‐ Ut Sutter Health Institute of Medicine 2014 Report: Current State “We all die. A fundamental question is do we • Who have made their wishes clear? want to have a say in how we live.” • Do clinicians follow patients’ previously expressed wishes? — Jeffrey Thompson, MD • Does Advance Care Planning Having Your Own Say affect patient or caregiver outcomes? • Does Advance Care Planning affect healthcare costs? Dying In America: Improving Quality and Honoring Individual Preferences Near the End of Life, Institute of Medicine (2014, pgs 3 ‐ 8 to 3 ‐ 18) 3

Gundersen Health System Model Institute of Medicine 2014 Report: for End ‐ of ‐ Life Care Model Advance Care Planning Initiatives • Person/patient ‐ and family ‐ centered care • Electronic Health Record • Advance care planning • POLST • Care coordination • Respecting Choices • Palliative • Hospice • Organ & tissue donation • Bereavement Dying In America: Improving Quality and Honoring Individual Preferences Near the End of Life, Institute of Medicine (2014, pgs 3 ‐ 42 to 3 ‐ 52) La Crosse Compared to National Continuum of Care Averages 100 90 Primary Advanced Disease 80 Care Coordination 70 60 50 Advance Advance Nursing 40 La Crosse Care Palliative Coordination of 30 Specialty Clinics Planning Care Nationally Care 20 Disease Next 10 Management Steps 0 (CHF, Nephrology, Additional Services Additional Services % of severely or % of physicians who Consistency between Pulmonary, Hem ‐ Social Services Onc) terminally ill patient are aware of the known care plan and Spirituality with an advance care advance care plan treatment provided Bereavement plan Organ/Tissue Donation Organ/Tissue Donation Hospice J Am Geriatr Soc 2010;58:1249–1255. 22 GHS 4

How we do it Ask your CFO Higher Quality, Lower Cost for Medicare Patients System Characteristics Do you really want to be balancing your books • Living the Mission of not ‐ for ‐ profit culture by over treating unsuspecting and unwilling • Broad Integrated System seniors? • Physician Leadership/Engagement • Process Change; PDSA/Lean, etc. • Hire people (esp. MD’s) who believe the mission How we do it Continuum of Care Higher Quality, Lower Cost for Medicare Patients Patient Level Characteristics Primary Advanced Disease • Care Management/Coordination of Care Care Coordination • Availability of EHR Advance Advance Nursing • Short LOS Care Palliative Coordination of Specialty Clinics Planning Care Care Disease Next • Use of Generics Management Steps (CHF, Nephrology, Additional Services Additional Services • Advance Planning Pulmonary, Hem ‐ Social Services Onc) Spirituality Bereavement Organ/Tissue Donation Organ/Tissue Donation Hospice Palliative Care What Is Palliative Care Palliative care can be provided in the clinic or hospital, at home, or in a nursing home . The palliative care team works closely with the The goal of palliative care is to ease the patient’s primary physician to provide treatment options for the physical, emotional, and spiritual suffering of following: • Pain people with progressive disease or medical • Fatigue conditions. Palliative care focuses on quality • Shortness of breath • Nausea of life and comfort. • Loss of appetite • The palliative care team also addresses concerns such as depression , loss of control, anxiety, loneliness , and fear of being a burden or dying. • Bereavement “Symptom management and support through transitions in life.” 5

Specialist Palliative Care Elements: • Patient ‐ centered, family orientated Outcome Measures: • Expert symptom management • Excellence in communication and care Primary impact is on the patient planning A. Prevention and relief of pain and other symptoms B. Clarification of prognosis and goals of care C. Changes to kind and setting of care provided Secondary impact is on those around patient D. Family – less confused, more satisfied, better coping E. Nurses, doctors – appreciate specialist help, less distress Tertiary impact is on institutions, systems, payors Patient F. Providers and payors – Fiscal and operational changes • Frequency, intensity, duration, costs, revenues Social • Different settings, entities G. Assist hospital or other provider/setting with overall Institutions quality and performance metrics & Systems Cassel 2013 Conceptual Shift for Palliative Care Four Takeaways from La Crosse 1. Conversations and relationships matter. Medicare Old Life Prolonging Care Hospice 2. Innovation in end ‐ of ‐ life care requires highly Benefit personalized local solutions. 3. While the end ‐ of ‐ life advance directive document is standardized, the process for each Life Prolonging New Hospice Care patient and family will be unique and intimate. Care Palliative Care 4. Accessibility of records. How to Die In America: Welcome to La Crosse, WI Dx Death Forbes, 9/23/14 C opyright 2008 C enter to dvance alliative are A P C . R eproduction by permission only . The Reach of 48 United States Germany Spain Australia Canada The Netherlands Singapore Advance Care Planning Implementation Futurescan 2015 6

Jeff Thompson, MD Chief Executive Officer jethomps@gundersenhealth.org www.gundersenhealth.org Today’s Problem • Most healthcare dollars are spent on a small percentage of beneficiaries who have complex Appendix chronic conditions and/or advanced illness. What Is Needed Is More Complicated Than a Form or Chart • We need to create and implement a whole new set of clinical practices…and advance care planning microsystem. • An ACP microsystem is an organized group of people who have the role and responsibility to elicit, to understand, to document and to honor a patient’s preferences about future medical care. • “It takes a whole health system to honor one patient’s preference.” 7