Main Points Definition of Palliative Care The Model of Concurrent - PDF document

5/28/2013  Concurrent Care: the New Paradigm of Palliative & Oncologic Care Michael W. Rabow, MD Director, Symptom Management Service Helen Diller Family Comprehensive Cancer Center Professor of Clinical Medicine, UCSF May 23, 2013 Tom Reid, MD Associate Director, Palliative Care Fellowship Assistant Professor of Medicine Division of Hospital Medicine, UCSF June 27, 2013 Main Points  Definition of Palliative Care  The Model of Concurrent Care  Role of the PCP in concurrent care  Pearls & Specific Interventions 1

5/28/2013 Main Points  Definition of Palliative Care  The Model of Concurrent Care  Role of the PCP in concurrent care  Pearls & Specific Interventions 2

5/28/2013 How knowledgeable are you about Palliative Care? 1. Very knowledgeable 2. Knowledgeable 3. Somewhat knowledgeable 4. Not at all knowledgeable 5. Don’t know 3

5/28/2013 Once They Know About Palliative Care…  Extremely positive about it and want access  >92% say:  It is important  Patients with serious illness and their families should be educated  Likely to consider palliative care for a loved one if they had a serious illness  It is important that palliative care services be made available at all hospitals for patients with serious illness and their families Once They Know About Palliative Care…  Universal  Democrats and Republicans  Although don’t know about race and ethnic differences in this definition 4

5/28/2013 What Palliative Care is Not necessarily  about end-of-life & dying  hospice 9 Conceptual Shift for Palliative Care 5

5/28/2013 The Consumer Definition • Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness whatever the diagnosis . • The goal is to improve quality of life for both the patient and the family . Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support . Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment . Main Points  Definition of Palliative Care  The Model of Concurrent Care  Role of the PCP in concurrent care  Pearls & Specific Interventions 6

5/28/2013 Mounting Evidence Improved outcomes pre/post for cancer pts • Pain, Fatigue, Nausea, Depression, Anxiety, Drowsiness, Appetite, • Dyspnea, Insomnia, Constipation, and Satisfaction Yennurajalingam, JPSM, 2011; Follwell, J Clin Onc, 2008 ; Kim, JPM, 2012 Positive impact of embedded PC in Oncology office • Improved ESAS by 21% • • Referrer satisfaction of 9/10 9720 minutes; 162 hours = time saved? • Muir, JPSM, 2010 Improved outcomes in a controlled trial • The CCT Trial at UCSF: outpatient palliative care team working with • primary care physicians • Dyspnea, Anxiety, Sleep, Spiritual Well ‐ being improved compared to routine primary care Rabow, Arch Intern Med, 2004 Prolonged Survival  151 patients with NSCLC at Mass General  Immediate vs. delayed palliative care along with usual oncologic care  Early pc patients with…  Improved QOL  Less depression  Less chemo in last 2 weeks  Fewer hospitalizations in last month  Nearly 3 months longer survival (11.6 mos. vs. 8.9 mos., p<0.02) Temel, NEJM, 2010 7

5/28/2013 Temel Study: The Finances Align Mean cost savings of $2,282 • Accounted for by… • Longer lengths of hospice stays • • Higher hospice costs (mean of $1,125/patient) Reduced costs • Inpatient visits (mean of $3,110/patient) • Chemotherapy (mean of $640/patient) • Greer J, McMahon P, Tramontano A, et al. J Clin Oncol. 2012;30 (suppl; abstr 6004) Concurrent Palliative & Oncologic Care The Post-Temel Universe  Not either/or  Right from the start  Co-management  Coordinated, integrated 8

5/28/2013 The American Society of Clinical Oncology now recommends concurrent palliative care for seriously ill cancer patients “ …combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden. ” Sharing the Load: Co-Management PC and Oncologists Focused on Different but Complimentary Tasks Palliative Care: • Initial visits focused on sx mgmt, coping, rapport ‐ building, prognostic awareness • Later on resuscitation preferences and hospice • • Oncologists: • Cancer treatment and management of medical complications Co ‐ management allows each to focus on their area of expertise • Yoong, JAMA Intern Med, 2013 9

5/28/2013 Survey of Medical Oncologists  Question texted to CA medical oncologists 8/2012: “If a patient with solid tumor has mets after chemo x3, would you refer to palliative care?” Yes 22 23% No 13 13.5% It depends 61 63.5% Total responders: 96 100% It depends on … (most common) Type of tumor 21 Patient performance scale 30 Goals of care 7 Main Points  Definition of Palliative Care  The Model of Concurrent Care  Role of the PCP in concurrent care  Pearls & Specific Interventions 10

5/28/2013 # of U.S. Hospital Palliative Care Programs 2000 ‐ 2009* (*AHA Annual Survey – 2010 data pending) 1600 1500 1400 1300 1200 1100 1000 900 800 700 600 11

5/28/2013 Where is Palliative Care Available?  Increasing:  24.5% (658) in 2000 to 63.0% (1568) in 2009  138.3% increase from 2000-2009 (CAPC 2011)  Large hospitals (300 or more beds) 85%  Mid-size hospitals (50-299 beds) 54%  Small hospitals (fewer than 50 beds) 22%  The Northeast 73%  The South 51%  Implications for socio-demographic, ethnic inequities Outpatient PC in Cancer Centers  142 cancer centers (Hui et al. JAMA. 2010) NCI site NCI site Non Non-NCI site I site Palliative care 98% 78% program Inpatient palliative 92% 56% care consult team Outpatient 59% 22% palliative care 12

5/28/2013 Availability of Expertise: Certification in Palliative Care  Physicians  ABMS approved PC as a sub-specialty (2006)  Grandfathering ended 2012  10 participating boards  5,000 physicians certified in HPM  Nurses  National Board for Certification of Hospice & Palliative Care RNs  17,000 nurses, advanced, pediatric, nursing asst.  Social Workers  Certified Hospice & Palliative Social Worker and Advanced Certified Hospice & Palliative Social Worker  Chaplains  Palliative Care Chaplaincy Specialty Certificate (HealthCare Chaplaincy & The CSU Institute for Palliative Care) But…  1 cardiologist for every 71 heart attacks  1 oncologist for every 145 new patients with cancer  1 PC doc for every 300 deaths  1 PC doc for every 1300 patients with serious illness = 6,000-18,000 projected gap in pc physicians  Just for hospitals and hospices! Lupu, J Pain Sx Mgmt, 2010 13

5/28/2013 How much Palliative Care to you provide in your daily practice? 1. For all of my patient encounters 2. For most of my patient encounters 3. For about one ‐ half of my patient encounters 4. For some of my patient encounters 5. Rarely or never Primary Palliative Care All physicians must be competent in the basic skills of primary PC Generalist Palliative Care  • Basic management of pain and symptoms  • Basic management of depression and anxiety  • Basic discussions about  Prognosis  Goals of treatment  Suffering  Code status Quill & Abernethy, NEJM, 2013 14

5/28/2013 Secondary/Tertiary Palliative Care Specialist Palliative Care  • Management of refractory pain or other symptoms  • Management of more complex depression, anxiety, grief, and existential distress  • Assistance with conflict resolution regarding goals or methods of treatment  Within families  Between staff and families  Among treatment teams  • Assistance in addressing cases of near futility Quill & Abernethy, NEJM, 2013 Workforce  Need to think creatively…Who will do the work of PC?  UC San Marcos Palliative Care Institute  ELNEC  Mid ‐ career training  Special certification 15

5/28/2013 The Future: Improving Access The window of opportunity for pall care is wide ‐ open: Accountable Care Organizations Patient ‐ Centered Medical Homes Bundled payments Adding palliative care (targeted to the highest cost, highest risk populations) to these new delivery and payment models and coordinating with primary care is key to success at improving quality and reducing cost. Main Points  Definition of Palliative Care  The Model of Concurrent Care  Role of the PCP in concurrent care  Pearls & Specific Interventions 16

5/28/2013 Clinical Pearls and Interventions: Primary Palliative Care in Oncology  Pain: neuropathic pain  Fatigue  Depression Neuropathic Pain – Diagnosis  No clear way to prevent chemo ‐ induced neuropathy  Diagnosis  Shooting, electrical, burning, tingling  Hypersensitivity  Allodynia: Pain with non ‐ painful stimulus  Hyperalgesia: Over ‐ response to painful stimulus  Caveats  Recommendations largely extrapolated from studies of Diabetic Neuropathy and Post ‐ Herpetic Neuralgia  Most trials no longer than a few months  Treat the cause when possible 17