Advanced Disease Coordination Jeff Thompson, MD Chief Executive Officer The constant complaint… High cost…but low health 1
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% 2
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 3
Lack of Advance Care Planning Results In… • Great moral and emotional distress for families and providers. • Demands heavy time commitments for health professionals to work through decisions. • Creates conflicts among health professionals. • Uses significant health resources while decisions were sorted out. • Leaves everyone with moral uncertainty about the choices made. A few early observations… • Simply getting patients to fill out statutory documents like living wills would not help. • Simply telling health professionals that they should talk to patients or they should document patient plans would not work. • Stressing these two processes would not improve the system. 4
Four Key Components of Good Advance Care Planning Systems • Community engagement • Professional education and skills training • A system that honors wishes • Continuous quality improvement Advanced Disease Coordination Attributes NOT focused on limitation of treatment, but is focused on: • Helping patient and family understand chronic illness • Helping guide subsequent care from an informed vantage point • Accompanying and supporting patient, family and staff through subsequent journey 5
Stages of Advance Care Planning Over the Life Time of Adults Next Steps (DS ‐ ACP) First Steps Last Steps ACP: Create POAHC and consider when a ACP: Determine what goals ACP: Establish a specific plan of 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. 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. Study by Fried, Bradley, Towle and Allore (2002) Three factors that influence treatment decision making 1. treatment burden 2. treatment outcome 3. the likelihood of the outcome 6
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. 7
“One of the most intractable...politically charged…third rail issues…put a screeching half to the much needed public conversation.” How to Die In America: Welcome to La Crosse, WI Forbes, 9/23/14 Authors include: AARP Aetna Center to Advanced Palliative Care Dartmouth National Palliative Care Research Center Senator Warner, D ‐ Va Secretary Leavitt, R ‐ Ut Sutter Health 8
“We all die. A fundamental question is do we want to have a say in how we live.” — Jeffrey Thompson, MD Having Your Own Say Institute of Medicine 2014 Report: Current State • Who have made their wishes clear? • Do clinicians follow patients’ previously expressed wishes? • Does Advance Care Planning 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) 9
Institute of Medicine 2014 Report: Model Advance Care Planning Initiatives • Electronic Health Record • POLST • Respecting Choices Dying In America: Improving Quality and Honoring Individual Preferences Near the End of Life, Institute of Medicine (2014, pgs 3 ‐ 42 to 3 ‐ 52) Gundersen Health System Model for End ‐ of ‐ Life Care • Person/patient ‐ and family ‐ centered care • Advance care planning • Care coordination • Palliative • Hospice • Organ & tissue donation • Bereavement 10
Continuum of Care Advanced Disease Primary Coordination Care Advance Advance Nursing Care Palliative Coordination of Specialty Clinics Planning Care Care Disease Next Management Steps (CHF, Nephrology, Additional Services Additional Services Pulmonary, Hem ‐ Social Services Onc) Spirituality Bereavement Organ/Tissue Donation Organ/Tissue Donation Hospice La Crosse Compared to National Averages 100 90 80 70 60 50 40 La Crosse 30 Nationally 20 10 0 % of severely or % of physicians who Consistency between terminally ill patient are aware of the known care plan and with an advance care advance care plan treatment provided plan J Am Geriatr Soc 2010;58:1249–1255. 22 11
GHS 12
Ask your CFO Do you really want to be balancing your books by over treating unsuspecting and unwilling seniors? How we do it Higher Quality, Lower Cost for Medicare Patients System Characteristics • Living the Mission of not ‐ for ‐ profit culture • Broad Integrated System • Physician Leadership/Engagement • Process Change; PDSA/Lean, etc. • Hire people (esp. MD’s) who believe the mission 13
How we do it Higher Quality, Lower Cost for Medicare Patients Patient Level Characteristics • Care Management/Coordination of Care • Availability of EHR • Short LOS • Use of Generics • Advance Planning Continuum of Care Advanced Disease Primary Coordination Care Advance Advance Nursing Care Palliative Coordination of Specialty Clinics Planning Care Care Disease Next Management Steps (CHF, Nephrology, Additional Services Additional Services Pulmonary, Hem ‐ Social Services Onc) Spirituality Bereavement Organ/Tissue Donation Organ/Tissue Donation Hospice 14
What Is Palliative Care The goal of palliative care is to ease the physical, emotional, and spiritual suffering of people with progressive disease or medical conditions. Palliative care focuses on quality of life and comfort. 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 patient’s primary physician to provide treatment options for the following: • Pain • Fatigue • Shortness of breath • Nausea • 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.” 15
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 16
Conceptual Shift for Palliative Care Medicare Old Life Prolonging Care Hospice Benefit Life Prolonging New Hospice Care Care Palliative Care Dx Death C opyright 2008 C enter to dvance alliative are eproduction by permission only A P C . R . Four Takeaways from La Crosse 1. Conversations and relationships matter. 2. Innovation in end ‐ of ‐ life care requires highly personalized local solutions. 3. While the end ‐ of ‐ life advance directive document is standardized, the process for each patient and family will be unique and intimate. 4. Accessibility of records. How to Die In America: Welcome to La Crosse, WI Forbes, 9/23/14 17
The Reach of 48 United States Germany Spain Australia Canada The Netherlands Singapore Advance Care Planning Implementation Futurescan 2015 18
Jeff Thompson, MD Chief Executive Officer jethomps@gundersenhealth.org www.gundersenhealth.org 19
Appendix Today’s Problem • Most healthcare dollars are spent on a small percentage of beneficiaries who have complex chronic conditions and/or advanced illness. 20
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.” 21
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