Palliative Care at SNF: Should it be part of your program? Jeffrey N. Stoneberg, D.O. Medical Director Alta Bates Summit Medical Center
Palliative Care at SNF: Should it be part of your program?
Jeffrey N. Stoneberg, D.O.
Medical Director
Alta Bates Summit Medical Center
An inquiry/discussion…
Outpatient Pall Care
• PCQN currently collecting data on outpatient palliative care…
• Does anyone perform palliative care at SNFs? – How often?
– How many SNFs does your program visit?
– Who provides the resources?
– Collaborative between SNF/Hospital?
Why are SNFs important?
• They care for our sickest patients
– Care too complex to provide at home
– Patients with multiple medical conditions
– Often blurred goals of care • Insufficient advance care planning
– Conflicting expectations • Patient
• Family
• Medical team
Why are SNFs important?
• Initial pall care intervention in hospital
– Unable to complete due to pt discharge
– Resume conversations upon readmit instead
of outside of hospital
• Could have avoided the readmit
• Poor physician coverage in SNFs
• Many unmet palliative care issues
Medicare SNF benefit in last 6 months of life
• Entitled to 100 days of SNF care – After 3+ day hospitalization
– Skilled need • Rehab, IV medications, wound care, etc
– Covers 100% for first 20 days, then pt has copay of $144.50/day.
• Many use this for end of life care – Medicare hospice benefit does not pay room/board
Arch Intern Med. 2012 November 12; 172(20):1573-1579.
Medicare SNF benefit in last 6 months of life
• Nearly 1/3 of those 65 and older receive SNF
level care in last 6 mo of life under SNF benefit
– 1 in 11 died while enrolled (most in first 30 d)
• Do care expectations match overall goals?
– Decline as inpatient may better reflect deteriorating
overall health
– Same needs indicating need for SNF are same
indicators for end of life trajectory
Arch Intern Med. 2012 November 12; 172(20):1573-1579.
Medicare SNF benefit in last 6 months of life
• At time of hospital D/C – Goals may not be clear
– Provider may not recognize end of life path
• Families face choice – $ for room and board with hospice VS Medicare
SNF benefit and relying on NH for EOL services
Arch Intern Med. 2012 November 12; 172(20):1573-1579.
Medicare SNF benefit in last 6 months of life
• Need for palliative care:
– End of life symptoms
• Pain, SOB, spiritual distress, CG burnout, grief
– NH residents have little access to PC
– Hospice in NH is variable
• But better with hospice than without
– SNF benefit does not provide depth of EOL
services
• Comfort care is NOT hospice care
Arch Intern Med. 2012 November 12; 172(20):1573-1579.
Interdisciplinary Care
• Need to incorporate all “specialties”
– Physician/NP/PA
– Nursing staff
– PT/OT/ST
– Social Work
– Chaplaincy
– “Hotel Staff” (cleaning staff, admin, meal prep, etc)
• Involve and educate anyone who may be in contact with a
dying patient
International Journal of Palliative Nursing, 2006, Vol 12, No 5.
Advance Care Planning in SNF
• Examined the effect of social worker intervention on
advance care planning
• Controlled clinical trial
– 139 participants
– Intervention group: extensive education in ACP
– Control group: education in NY State law re advance
directives
JAGS. 53:290-294, 2005.
Advance Care Planning in SNF
• Intervention group sig more likely to have preferences
documented for:
– CPR (40% vs 20%)
– ANH (47% vs 9%)
– Antibiotics (44% vs 9%)
– Hospitalization (49% vs 16%)
JAGS. 53:290-294, 2005.
Advance Care Planning in SNF
• Study showed minimal evidence of physician initiated
ACP discussion
– Excluding specific discussion about CPR, physician
initiated discussion documented in only 5% in both
groups
JAGS. 53:290-294, 2005.
Advance Care Planning in SNF
• 44 sentinel events in both groups
– 17% who died had CPR in Control Group
• 0% in Intervention Group
– 27% had 1 or more hospitalizations in CG
• 16% in Intervention Group
– 7% remained in SNF and received abx in CG
• 5% in Intervention Group
JAGS. 53:290-294, 2005.
Advance Care Planning in SNF
• Residents in CG
– Significantly more likely to receive tx discordant with
prior stated wishes
– 18% received tx in conflict with prior stated wishes
• 5% in Intervention Group
JAGS. 53:290-294, 2005.
Comprehensive ACP Program
• Comprehensive program
– Education of SNF staff, resident and family
– Documentation of choices
• Care preferences for life threatening illness,
cardiac arrest, nutrition
– Associated with high family satisfaction and
lower service utilization
– Symptom management not addressed in this
study
JAMA 2000;283:1437-1444.
Early Stages of a QI Project
Collaboration between
UCSF and ABSMC
Background
• ABSMC had our own SNF for rehab in the Summit Campus in Oakland
• Closed about 1.5 years ago
• Now contract with 3 local SNFs
• Initiative for better collaboration between hospital and SNF – Monthly meetings with inpatient staff, admin and SNF
teams
– Identify areas of improvement
– Initiate QI projects
– Continual re-evaluation and improvement
Data Gathering Methods
• Meet with DON and determine who is eligible and meets criteria for Pall Care Needs – Interact 3.0
– About 31% of residents eligible
• 70 patients at initial eval
Criteria for Eligibility
• Diagnoses appropriate for hospice including extent of disease in: – CHF
– COPD
– Dementia
– Cancer
Criteria for Eligibility
• Those at high risk of actively dying who should be considered for comfort care – Freq ED visits/admits in last 6 mo
– Sudden, irreversible major decline
– 1°dx of met cancer with pain, poor fcn, no tx
– Semi-comatose or comatose w/o reversible cause
– Inability/difficulty taking oral meds
– Minimal po intake
– Mottling of extremities due to poor po intake or dehydration
Data Collection
• Use Minimum Data Set primarily – 28 total interviews so far
• 7 patients
• 21 families (family interviewed when pt unable)
• Interview process – Resident Interview Guideline
– Family Interview Guideline
– Interview transcription
• Qual-E tools
– Measures QOL of seriously ill pts
What has been found…
• Preliminary results:
• Very few residents/families know what a POLST is
• Many feel the absence of physician at SNF
• Families mostly feel informed
– Concerns that those who live far away do not know
what’s happening and they generally want more
aggressive care
What has been found…
• Families feel the need to advocate for care
• Families have good insight into challenging care
needed by pt
– Poor insight into extent of disease
• Families find fault in small things
– Food, environment, etc
– influences their overall satisfaction
Still a LOT to learn…
• Next steps – Meet with hospital admin
– Pall Care to visit and tour each SNF • See facilities, begin to establish how to work
together, set expectations
– Follow up pts who received PC consult in hospital
– Provide PC to pts identified in study • ACP
• Symptom control
• Communication/education of pt/family
• Education of SNF staff
Barriers
• VERY limited resources
– Likely will be 1 PC physician for all 3 SNFs who still
has a full inpatient clinical load
• Hesitation of admin to fund outpt program
– Need to demonstrate ROI
• Current lack of Interdisciplinary resources
– No Social Worker
To Be Continued…
• Still in the information gathering phase
• Suspect that this won’t really get off the ground
for a little while
• Open to any and all comments if anyone has
experience in PC at SNF