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Palliative Care ECHO Clinic We are Nevada's Leading Forum for Interdisciplinary

Palliative CareWe aim to:Collaborate with an interdisciplinary team of palliative care providers

in NevadaAssemble a forum of health care practitioners throughout the state of

Nevada whom Project ECHO supports and prepares to deliver basic palliative care

Raise the quality of life for Nevadans living with serious illness Establish a resource of expertise and education for a diverse health

care audience on practices, resources and policy in palliative care

Palliative Care – Home Based Jessica Cate, PharmD, BCPS, BCGP

Clinical Pharmacy Specialist – Geriatrics and Home Based Primary Care

VA Sierra Nevada Health Care System

Helena Russell, MD

Family Medicine, Geriatric Medicine

Core Faculty Geriatric Medicine, HPM

UNR, School of Medicine

Medical Director – Home Based Primary Care

VA Sierra Nevada Health Care System

Shineka Foy, M.ED, MSW

Managing Partner

Remy Premier Healthcare

Las Vegas, NV

Conflicts of Interest

Presenters have nothing to disclose

1. Define palliative care in the home2. Discuss current models of practice3. Review when to consider home based palliative care 4. Review reimbursement for home based care5. Case presentation

Learning Objectives

Palliative Care

• Care for patients living with serious illness

• Assessment and management of symptoms• Caregiver support• Coordinate care

• Interdisciplinary team• Historically provided in hospitals and

outpatient clinics• Palliative care in the home

Palliative Care in the home

• Palliative care in the home is associated with decreased symptom burden and increased patient and caregiver satisfaction

• Decreased healthcare utilization and costs

• More likely to have advanced directive and discussions about goals of care

cure hospice

Usual Care

cure

comfort

cure hospice

Usual Care

WHO Model

cure

comfort

cure hospice

cure

comfort

Usual Care

WHO Model

HBPC

Goldberg, JN – Creative approaches to complex patients. AAHCM, May 2014

Case presentation

• 89 year old male widowed veteran• Loves fishing, woodworking and his dog• Lives alone in rural Northern California• Complex medical conditions and wants to die at home

Where do Americans Die?

• 80 % of Americans would prefer to die at home but only 20% die at home

• Increased risk of readmission within 30 days after hospital stay and increased risk of death

• May be appropriate for home based care

There is a need for more home based care

• Changing medical practice >>shorter inpatient stays>> cost reduction for hospitals and patients

• 80% of adults requiring long term care live at home

• Unpaid caregiving provides 90% of their care

With an aging population this is expected to increase….

Source Collins and Swartz, AAFP

When to consider

Multiple factors:• Immobility• Requested by patient, caregiver or provider• Direct observation in the home environment• Collaborate- involve additional providers, caregivers in shared

decision making• Assess care coordination/ transitions

Home Bound Status

Homebound is considered to be the inability to leave home because of the following situations:

1. Require the assistance of another individual.2. Require the aid of a supportive device.3. Leaving the home is medically contraindicated.4. Cannot leave home without extreme & taxing effort.

Models for Palliative Care in the Home

•Primary and palliative care•Home health-based model• Hospice based/affiliated models• Home-based palliative care managed care • Consultative management• Co-management

Home-based primary and palliative care model

• Interdisciplinary team• Patients have multiple co-morbid chronic conditions with functional

impairment, high symptom burden and/or complex care coordination needs

• Integrates palliative care into comprehensive and longitudinal primary care

• Extensions of primary care practices (private or medical group)

Home health-based model

• Relies on infrastructure of home health • Traditional home health versus palliative home health• Can combine rehab with palliative care to alleviate symptoms,

facilitate discussion about goals of care and advanced care planning

National Model of Practice

Sutter Health’s Advanced Illness Management (AIM) program• Bridges the gaps between the hospital setting, the community physician’s

office, and the home• At risk of dying in the next 12-18 months • Ensure patients receive the right care and support at the right time, in the

right place

National Model of Practice, cont

AIM program, continued• Relies on frequent and ongoing contact• Continues as the patient’s illness progresses over time• The focus of care for advanced illness moves out of the hospital and

emergency departments and into the patient’s preferred location, their home

Transitional Care Management (TCM)

TCM – Multidisciplinary team focus• Services during the patient’s transition to the community setting • Accepting Primary Care of the patient’s post-discharge from the facility

setting without a gap (within 48 hrs)• Taking responsibility and accountability for patient’s care.• Moderate or high complexity medical decision making • Full wraparound of Social Services • Communicate with agencies and community services

Transitional Care Management (TCM), cont.

TCM – Multidisciplinary team focus, cont• Review discharge information • Follow-up on diagnostic tests and treatments• Interact with other health care professionals who resume care of the

patient• Provide education to support self-management, independent living, and

activities of daily living• Follow-up on referrals and arrange for needed community resources• Assist in scheduling required follow-up

Resources for supporting Home Based Palliative Programs

• Credentialing – ability to service multiple insurance plans• Department of Age and Blind Community Resources and Funding• Essential elements in planning for Palliative Care program include:

• Data/analytics capacity• Ability to bill/code properly• Management of the mix of PC staff disciplines• Sales and marketing plan• Education/training plan

Resources for funding

• Centers for Medicare and Medicaid Services – Chronic Care Management Services

• https://www.cms.gov › MLNProducts › Downloads › ChronicCareManage

• Palliative Care Handbook – document and coding• https://www.chcf.org › wp-content › uploads › 2019/05 › Documentation

• National Association for Home Care & Hospice (NAHC)• Palliative care white paper: https://report.nahc.org › nahc-releases-palliative-

care-white-paper.

• The Home Centered Care Institute - Resource Center

Case presentation- Continued

• 89 year old male with complex medical issues related to metastatic rectal cancer

• Repeatedly refused rehabilitation, left Against Medical Advice (AMA)• Complicated family social dynamics

Past Medical History

• Metastatic rectal cancer with diverting colostomy

• Congestive Heart Failure on supplemental oxygen

• Atrial fibrillation on anticoagulation• Deep vein thrombosis• Symptomatic anemia

• Bladder outlet obstruction with chronic indwelling foley

• Chronic kidney disease• Hyperlipidemia

• Transient Ischemic attack• Recurrent falls with vertebral compression

fracture, humeral fracture

• Neurocognitive impairment• Diabetes Mellitis Type 2• Lymphedema

Home Care Checklists

INHOMES checklist• Impairment/ Immobility• Nutritional status• Home environment• Other people• Medications• Examinations• Safety

Palliative Care Domains• Physical symptoms• Psychological/ psychiatric• Cognitive symptoms• Illness Understanding• Social/ economic factors• Cultural aspects• Spiritual aspects• Care coordination

→

Checklist Continued

Interdisciplinary services- including nurse case manager, social worker, certified nursing assistant for bathing, occupational therapist, dietician, clinical pharmacist, geriatric physician

Physical symptoms- focused on comfort (pain, breathing, constipation, appetite, skin, dry mouth etc.) reduced frequency foleychanges, medications/ treatments tailored to symptoms, ordered additional Durable Medical Equipment (DME) including home oxygen, use of video/ telehealth visit to address acute care.

Checklist ContinuedIllness understanding: • Getting to the core of “What Matters Most”

• Seven end-of life questions Dr Gawande- conversation guide for people living with serious illness

Source, Atul Gawande- Being Mortal. 2014

Checklist Continued- “What Matters Most”

Checklist Continued

Psychological/ psychiatric- assessed for depression, post traumatic stress disorder PTSD, caregiver burden, delirium

Cognitive symptoms- evaluation with SLUMS St Louis University Mental Status Examination (similar to Mini Mental State Exam MMSE) 16/30, FAST score (functional assessment staging) 4

Social/ economic factors- Social work support, nutritional support services, identified caregivers, completed release of information (ROI), Advance Directive, POLST Physician Order for Life Sustaining Treatments, Elder Protective Services

Checklist Continued

Advance care planning • Durable power of attorney• Advance directive• POLST/ MOLST (Physician/

Medical Order for Life Sustaining Treatments)

Checklist Continued

Cultural aspects/ Spiritual aspects• A connection with something greater than oneself, a sense of

meaning and purpose

Checklist Continued

Care coordination- interdisciplinary team conferences, communication with volunteer hospice, ER visits, inpatient and rehabilitation teams

Continuity- ensuring patient/ caregivers had telephone access to medical team, continued home visits with increased frequency.

What makes a good death?

After fishing season ended veteran collapsed at home and was brought by caregiver to local hospital where he passed away 10 days later.

0%

25%

50%

75%

100%

Home Hospital NursingHome

Location of Death

General Population

0%

25%

50%

75%

100%

HomeCare

Hospital PalliativeCare

HomeHospice

Location of Death

Home Care Patients

Measure of Success: Dying with Home Care

American Academy of Home Care Medicine – May 2014

In conclusion..

Benefits of home based palliative care:• Guide patients into right care at right time• Reduce overall health costs• Reduce hospitalization/re-hospitalization rates, ER visits and costs

associated with end of life • Decrease caregiver burden while retaining their involvement• Improve quality of life and satisfaction

Questions?

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• Next Palliative ECHO:• October 18, 2019 at noon• TOPIC: Nursing home based palliative care

References• Twaddle ML, Mccormick E. Palliative care delivery in the home. Ritchie C, Silveira MJ, ed. UpToDate. Waltham, MA:

UpToDate Inc. https://www.uptodate.com/contents/palliative-care-delivery-in-the-home?search=home-based%20primary%20and%20palliative%20care%20palliative%20care&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#references. (Accessed August 22, 2019)

• Brumley R, Enguidanos S, Jamison P, et al. Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. J Am Geriatr Soc 2007; 55:993.

• Rabow M, Kvale E, Barbour L, et al. Moving upstream: a review of the evidence of the impact of outpatient palliative care. J Palliat Med 2013; 16:1540.

• Riolfi M, Buja A, Zanardo C, et al. Effectiveness of palliative home-care services in reducing hospital admissions and determinants of hospitalization for terminally ill patients followed up by a palliative home-care team: a retrospective cohort study. Palliat Med 2014; 28:403.

• Chen CY, Thorsteinsdottir B, Cha SS, et al. Health care outcomes and advance care planning in older adults who receive home-based palliative care: a pilot cohort study. J Palliat Med 2015; 18:38.

• Gomes B, Calanzani N, Curiale V, et al. Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. Cochrane Database Syst Rev 2013; :CD007760.

References, cont• Justin M Glasgow, Zugui Zhang, Linsey D O’Donnell, Roshni T Guerry and Vinay Maheshwari. Hospital palliative care

consult improves value- based purchasing outcomes in a propensity score–matched cohort. Palliative Medicine . 2019, Vol. 33(4) 452–456

• Dio Kavalieratos, PhD; Jennifer Corbelli, MD, MS; Di Zhang, BS; J. Nicholas Dionne-Odom, PhD, RN; Natalie C. Ernecoff, MPH; Janel Hanmer, MD, PhD; Zachariah P. Hoydich, BS; Dara Z. Ikejiani; Michele Klein-Fedyshin, MSLS, BSN, RN, BA; Camilla Zimmermann, MD, PhD; Sally C. Morton, PhD; Robert M. Arnold, MD; Lucas Heller, MD; Yael Schenker, MD, MAS. Association Between Palliative Care and Patient and Caregiver Outcomes A Systematic Review and Meta-analysis. JAMA. 2016;316(20):2104-2114.

• Pippa Hawley. Barriers to Access to Palliative Care. Palliative Care: Research and Treatment. DOI 10.1177/1178224216688887

• The Support Principal Investigators. A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients . The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). JAMA. November 22/29, 1995-Vol 274. No. 20.

• Morrison, R Sean. Dietrich, Jessica. Ladwig, Susan. Quill, Timothy. Sacco, Joseph. Tangeman, John. Meier, Diane. Palliative Care Consultation Teams Cut Hospital Costs For Medicaid Beneficiaries. Health Affairs; Mar 2011; 30, 3

• Peter May, PhD; Charles Normand, DPhil; J. Brian Cassel, PhD; Egidio Del Fabbro, MD; Robert L. Fine, MD; Reagan Menz; Corey A. Morrison; Joan D. Penrod, PhD; Chessie Robinson, MA; R. Sean Morrison, MD. Eonomics of Palliative Care for Hospitalized Adults With Serious Illness . JAMA Intern Med. 2018;178(6):820-829.

References, cont• Transitional Care Management, CMS (2019)• DOCUMENTATION & CODING IN PALLIATIVE CARE HANDBOOK ©2019. https://www.cms.gov › MLNProducts › Downloads ›

ChronicCareManage• Jean Acevedo, LHRM, CPC, CHC, CENTC, AAPC Fellow. Acevedo Consulting Incorporated. Hospice Fundamentals, LLC.

https://www.chcf.org › wp-content › uploads › 2019/05 › Documentation.• NAHC Releases Palliative Care White Paper – NAHC Report. https://report.nahc.org › nahc-releases-palliative-care-white-

paper.• The Home Centered Care Institute. Resource Center.• DOCUMENTATION & CODING IN PALLIATIVE CARE HANDBOOK ©2019. https://www.cms.gov › MLNProducts › Downloads ›

ChronicCareManage• Jean Acevedo, LHRM, CPC, CHC, CENTC, AAPC Fellow. Acevedo Consulting Incorporated. Hospice Fundamentals, LLC.

https://www.chcf.org › wp-content › uploads › 2019/05 › Documentation.• NAHC Releases Palliative Care White Paper – NAHC Report. https://report.nahc.org › nahc-releases-palliative-care-white-

paper.• The Home Centered Care Institute. Resource Center.