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Sharp HealthCare Hospice and Palliative Careavoidablecare.org/wp-content/uploads/2011/12/Hoefer-The-Continuum... · CMO, Outpatient ... Sharp HealthCare Hospice and Palliative Care

Jun 15, 2018

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  • Sharp HealthCare Hospice and Palliative Care

    Daniel R. Hoefer, MD CMO, Outpatient Palliative Care and Hospice

    Suzi K. Johnson, MPH, RN Vice President Sharp HealthCare Hospice and Palliative Care

    The Continuum for Advanced Illness and End Stage Disease Management

    (AAC)

  • Principles of Transitions

    1. Proactive Disease Management

    2. Proactive Psychosocial Management

    3. Accurate description of what the health care industry can provide

  • 27% of patients with incurable terminal disease believed they could have been cured

    Unresectionable non-small-cell lung cancer 54%

    AIDS 32% CHF 22% ALS 16% COPD 12%

    Daniel P Sulamsy, OFM, MD, PhD, et al, The Accuracy of Substituted Judgment in Patients with Terminal Diagnoses, April 1998, Annals of Internal Medicine, Vol 128(8), PP 621-29

  • Medicare Cost in Matched Hospice and Non-Hospice Cohorts

    Bruce Pyeson FSA, MAAA et al, Journal of Pain and Symptom Management, May 2004, Vol 28(3) pp 200-210

  • Comparing Hospice and Non-Hospice Patient Survival Among Patients Who Die Within a Three Year Window

    Steven Connor PhD, et al, Journal of Pain and Symptom Management, March 2007, Vol (3) pp 238-246

  • Increased by 29 days for patients who chose hospice over non-hospice care:

    CHF = + 81 days Lung Cancer = + 39 days Pancreatic Cancer = + 21 days Colon Cancer = + 33 days Breast Cancer = + 12 days Prostate Cancer = + 4 days

    Mean Survival

  • Birth of the Concept for the Transitions Program

    1. Medicare is based on an archaic model of health management

    2. Professional Experience and Evidenced Based Hospice Care

  • 4 Pillars of Transitions

    1. Comprehensive in-home patient and family education about their disease process; proactive medical management

    2. Evidence-based Prognostication 3. Professional Proactive Management of the Caregiver 4. Advance Health Care Planning

    Transitions - Extending the evidenced based benefits of Hospice Care to patients at an earlier point in their healthcare.

  • 1. In Home Proactive Disease Management

    a. Do not need to be home bound b. Do not need a Medicare Part A skilled

    requirement

  • 2. Evidenced-Based Medical Prognostication

    British Medical Journal; Extent and Determinants of Error in Doctors Prognoses in Terminally Ill patients; Prospective Cohort Study; Vol 320(7233), 19 Feb 2000 pp.469-473

    1. 343 doctors 2. Estimates on 468 terminally ill patients 3. Mean patient survival 24 days 4. Considered accurate if estimate within 33% for any

    give patient 5. 20% of the time accurate

    1. 80% of the time inaccurate 2. 63% over-optimistic

    6. The average over-optimistic estimate was off by 530%

  • The Clinical Consequences of Institutionalized Over-optimism

    a. Increases the risk that treatment decisions by patients, families and healthcare providers are NOT consistent with reality

    b. Leaves patients and families emotionally unready for inevitable outcomes

    c. Increase risk that providers will lose credibility

  • 3. Professional Evidence-Based Care for the Caregiver

    Evidenced-based medicine - Hospice care is associated with an absolute reduction in death rates in the caregiver at 18 months post death of the patient of 0.5% (1 in 200)

    Nicholas Christakis, et al, The Health Impact of Health care on families: a Matched Cohort Study of Hospice Use by Decedents and Mortality Outcomes in Surviving, Widowed Spouses, Social Science and Medicine 2003, vol57 pp.465-475

  • 4. Advance Health Care Planning

    Evidenced-based medicine shows that AHCDs (which would include POLST) do not consistently match the health care desired by the patient with the care received by the patient

  • Problems with Advance Health Care Directives

    1. They are not disease specific 2. They are too vague or contradictory to be interpreted in the context of the care which is being provided

    Resolve Moral Conflict Proactively

  • What Transitions does not do

    1. We do not prevent or discourage the patient from seeing their cardiologists or PCPs

    2. We do not prevent or discourage state-of-the-art cardiology therapies or interventions

    3. We do not discourage hospitalizations 4. We do not "take over" the medical management of

    the patient

  • Results from June 2007 to December 2008

    229 Referrals

    109 Admissions

    26 Referrals to Hospice

    94 Not Admitted

  • Transitions Program

    SRS

  • 94% reduction in ER visits and Hospitalizations

  • CHF Can you see it?

    Nov 2006

    Feb 2007

    May 2007

    June 2008

    Dec 2008

    May 2009

    Dec 2009

    Mar 2010

    Dec 2010

    Jan 2011

    BUN 16 30 11 23 23 26 17 48 44 44

    Creatinine 1.2 1.2 1.0 1.1 1.1 1.2 1.1 1.9 2.0 1.5

    HGB 14.4 13.4 13.1 12.6 12.0 12.5

    BNP 148 170 111 173 103 386 631 1270

    ADL defecit

    2 2 2 2 2 3 3

  • Fried, Linda P., et al, Frailty In Older Adults: Evidence of a Phenotype, 2001 Journal of Gerontology, Vol 56A(3), M146-M156

  • Issues Important in the Management of a Pre-terminal Aging Population:

    1. Mobility Deficit 2. Transportation Deficit 3. Financial Restraint 4. Social Support/Family Deficit 5. Cognitive Deficit 6. Compliance Deficit 7. Change in Goals of Care

  • Title Pt # Patient Charges Pre-Transitions

    Pre-Transitions Hospital/ER

    Visits

    Patient Charges During

    Transitions

    Hospital/ER Visits

    During Transitions

    Cost Differential

    1 $59,444.81 1 $631.57 0 $58,813.24

    2 $5,791.69 1 $2,564.47 2 $3,227.22

    3 $8,428.68 1 $7,874.01 1 $554.67

    4 $0.00 1 $2,549.50 0 -$2,549.50

    5 $6,388.42 1 $2,792.40 0 $3,596.02

    6 $1,897.07 1 $1,917.93 0 -$20.86

    7 $578.27 2 $0.00 0 $578.27

    8 $6,104.97 1 $857.01 0 $5,247.96

    9 $0.00 0 $992.95 0 -$992.95

    10 $719.54 1 $293.41 0 $426.13

    11 $0.00 2 $0.00 0 $0.00

    12 $4,412.67 1 $1,420.61 0 $2,992.06

    13 $21,926.08 5 $2,390.11 0 $19,535.97

    14 $0.00 2 $5,166.58 2 -$5,166.58

    15 $0.00 0 $1,375.86 0 -$1,375.86

    16 $0.00 0 $1,760.46 0 -$1,760.46

    17 $0.00 0 $880.23 0 -$880.23

    18 $1,203.86 1 $3,783.05 2 -$2,579.19

    19 $5,650.07 1 $1,941.15 0 $3,708.92

    20 $0.00 0 $699.54 0 -$699.54

    Totals $330,755.54 61 $168,776.39 16 $161,979.15

    ** Grayed cell charges include Hospital/Lab/ MD claims while on Transitions

    Calculations based on:

    1. Data for 60 patients provided by SRS Managed Care

    2. MCA charges for all Diagnoses pre & during Transitions

    Transitions Program

    SRS

  • Comparative Data 76% reduction in ER visits and

    hospitalizations

  • Discharge Data

    80% go to Hospice 20% die on service

  • Paradigm Shift #1

    Historically 63% of CHF patients died in the hospital (2005)

    Three Hospital Deaths on Transitions Cardiac Cath COPD Cardiac Arrest

  • Paradigm Shift #2

    Historical average hospitalizations for CHF during the last year of life 3.5

    Average number of CHF admissions for Transitions patients is < 1 during the last year of life

  • 71.5% reduction in cost

    CHF ICD-9 as primary reason for admission

  • Pt #

    Patient Charges

    Pre-Transitions

    Pre-Transitions Hospital/ER

    Visits

    Patient Charges During

    Transitions

    Hospital/ER Visits During Transitions

    Cost Differential

    1 $59,444.81 1 $631.57 0 $58,813.24

    2 $5,791.69 1 $2,564.47 2 $3,227.22

    3 $8,428.68 1 $7,874.01 1 $554.67

    4 $0.00 1 $2,549.50 0 -$2,549.50

    5 $6,388.42 1 $2,792.40 0 $3,596.02

    6 $1,897.07 1 $1,917.93 0 -$20.86

    7 $578.27 2 $0.00 0 $578.27

    8 $6,104.97 1 $857.01 0 $5,247.96

    9 $0.00 0 $992.95 0 -$992.95

    10 $719.54 1 $293.41 0 $426.13

    11 $0.00 2 $0.00 0 $0.00

    12 $4,412.67 1 $1,420.61 0 $2,992.06

    13 $21,926.08 5 $2,390.11 0 $19,535.97

    14 $0.00 2 $5,166.58 2 -$5,166.58

    15 $0.00 0 $1,375.86 0 -$1,375.86

    16 $0.00 0 $1,760.46 0 -$1,760.46

    17 $0.00 0 $880.23 0 -$880.23

    18 $1,203.86 1 $3,783.05 2 -$2,579.19

    19 $5,650.07 1 $1,941.15 0 $3,708.92

    20 $0.00 0 $699.54 0 -$699.54

    Totals $330,755.54 61 $168,776.39 16 $161,979.15

    ** Grayed cell charges include Hospital/Lab/ MD claims while on Transitions

    Calculations based on:

    1. Data for 60 patients provided by SRS Managed Care

    2. MCA charges for all Diagnoses pre & during Transitions

    Transitions Program

    SRS

  • 50% Cost Reduction

    CHF ICD-9 as primary or secondary reason for admission

  • The patients live longer and better The caregivers live better and survive The families are happier with the care provided Cardiologists and PCPs still provide state-of-the-art

    Cardiology care Care provided is increasingly consistent with the goals of

    care of the patient Cost effective

    Outcomes

  • Transitions Admissions 2007 - 2011

    Admissions to Transitions

    13

    73

    109

    204

    142

    0

    50

    100

    150

    200

    250

    FY '07 FY '08 FY '09 FY '10 FY'11

  • Emergency Room and Hospital Visits

    Hospitalizations/ED Visits

  • Hospice Transitions Transfers to Hospice

    2

    31

    54

    99 101

    0

    20

    40

    60

    80

    100

    120

    FY '07 FY '08 FY '09 FY'10 FY'11

  • Hospice Total Admissions - Heart Failure

    118 111

    147158

    178169

    507090

    110130150170190210230250

    FY '06 FY '07 FY '08 FY '09 FY '10 FY'11

  • Hospice Length of Stay Heart Failure

    78.4

    25

    88.6

    24

    94

    22

    92

    23

    120

    33

    0

    20

    40

    60

    80

    100

    120

    FY '07 FY '08 FY '09 FY'10 FY'11

    ALOS

    MLOS

  • Patient Family Satisfaction Transitions FY2011

    Percent VERY satisfied CHF COPD Dementia

    Overall

    1. The extent to which you were taught to manage your medications and symptoms related to your diagnosis

    76% 75% 88% 79%

    2. The education you received regarding contacting the Transitions team at any time for assistance in managing your symptoms

    75% 88% 90% 82%

    3. The assistance you received with long term care planning and advanced directives

    81% 86% 88% 84%

    4. Improvement in your quality of life 69% 57% 89% 72% 5. Assistance received from the nurse or medical social worker when problems occurred

    69% 75% 82% 74%

    6. Likelihood of recommending the Sharp Transitions Program to others for managing advanced chronic illness

    78% 100% 91% 86%

  • Transitions - Dementia

    Launched July 1, 2009

  • 4 Pillars of Transitions

    In home proactive disease management Evidenced based medical prognostication Care for the caregiver Advanced healthcare planning

  • Standard of Care versus Evidenced-Based Medicine

    Perceived benefit of feeding tubes by physicians 195 returned surveys from 500 physicians in the AMA master file

    Decreased aspiration pneumonia (76.4%) Improves pressure ulcer healing (74.%) Increases survival (61.4%) Improves nutritional status (93.7%) Improves functional status (27.1%) Most physicians felt that feeding tubes were standard of care in advanced

    dementia and 62% underestimated the 1 month mortality rate (actual rate is 20% to 40%.

    Is there any medical evidence that mortality decreases by hospitalizing demented patients with pneumonia?

    Joseph Shega, MD, et al, Barriers to limiting the Practice of Feeding tube Placement in Advanced Dementia, Journal of Palliative Medicine, vol.1, Nov. 6, 2003, pp.885-893

  • Standard of Care versus Evidenced-Based Medicine Contd

    Robert Thompson, DO, et al, Hospitalization and Mortality Rates for Nursing Home acquired Pneumonia, The Journal of Family Practice, April 1999vol.48(4) (Acute mortality rates the same) Terri Fried, MD, et al, Whether to Transfer? Factors Associated with Hospitalization and Outcome of Elderly Long-Term Care Patients with Pneumonia, J. Gen Intern Med, 1995, vol. 10, pp.246-50 (Acute mortality rates the same) Terri Fried, MD, et al, Short-Term Functional Outcomes of Long-term Care Residents with Pneumonia Treated With and Without Hospitalization, JAGS, March 1997, vol.45(3), pp.302-07 (Acute mortality rates the same) However, at two months, the patients transferred to the hospital had increased mortality rates than those not transferred and markedly decreased functional decline compared to those not transferred.. The worst functional loss was seen for those who were independent or mildly demented at baseline. Robert R Muder, MD, et al, Pneumonia in a Long-term Care Facility: A Prospective Study of Outcome, 1996, Arch Intern Med, vol.156, pp.2365-70 (Acute mortality rates the same) David R Mehr, MD, MS, Risk Factors for Mortality in Lower Respiratory Infections in Nursing Home Patients, 1992, J Fam Pract vol.34, pp585-91 (Acute mortality was slightly higher for hospitalized patients)

  • Iatrogenic Consequences of Hospitalization

    1. Infections 2. Falls and Trauma 3. Delirium 4. Treatment errors

  • Predictive Model For Delirium Criteria: (1 point for each)

    1. Hearing or visual deficit 2. Severe Illness 3. Cognitive Impairment (MMSE < 24) 4. BUN/Cr ratio > 18

    0 points 9% risk 1-2 points 23% risk 3-4 points 83% risk

    Inouye, Sharon K, MD, et al, A Predictive Model for Delirium in Hospitalized Elderly Patients Based on Admission Characteristics, 1999, Ann Intern Med, vol.119, pp474-81

  • Standard of Care versus Evidenced-Based Medicine

    Delirium is always reversibleFALSE Delirium is associated with permanent:

    Mental Decline Physical decline Markedly increased mortality Increased Institutionalization Prolonged Hospitalization

  • Delirium accounts for 49% of all hospital days in hospitalized older patients

    Inouye, Sharon K, MD, Delirium in Older Persons, NEJM, 2006, vol.354(11), PP.1157-68

    Demented Patients are at 500% the risk of developing Delirium

    Cole, Martin G, MD, FRCP, Delirium in Elderly Patients, 2004, J Ger Psychiatry, vol.12(1), pp.7-21

    Standard of Care versus Evidenced Based-Medicine Contd

  • My Mother was Never the Same

    Understanding that delirium is not necessarily reversible mandates a revised medical and ethical standard when recommending treatments to the at risk population

  • The minimum we should know ...

    Delirium is NOT always reversible Delirium is induced by the treatments we provide Dementia increases the risk of developing delirium by

    500% 60-70% of hospital cases of delirium are NOT

    preventable

    Sharp HealthCareHospice and Palliative CarePrinciples of TransitionsSlide Number 3Slide Number 4Slide Number 5Slide Number 6Slide Number 74 Pillars of TransitionsSlide Number 9Slide Number 10Slide Number 11Slide Number 12Advance Health Care PlanningSlide Number 14Slide Number 15Results from June 2007 to December 2008Slide Number 17Slide Number 18CHFCan you see it?Slide Number 20Slide Number 21TitleSlide Number 23Slide Number 24Slide Number 25Slide Number 26Slide Number 27Slide Number 28Slide Number 29Slide Number 30Slide Number 31Slide Number 32Slide Number 33Slide Number 34Slide Number 35Slide Number 36Slide Number 37Slide Number 38Transitions - DementiaSlide Number 40Slide Number 41Slide Number 42Slide Number 43Slide Number 44Slide Number 45Slide Number 46Slide Number 47Slide Number 48

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