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Home , Palliative care

Palliative Care

Impact on

Quality and Cost

By Jessica D. Squazzo alliative care is an emerging piece of P the healthcare system that many predict will have a profound ability to improve quality of care, communication and coordination for seriously ill patients and their families and, through this process, reduce reliance on emergency departments and . Different in name and function than and end-of-life care, palliative care is a unique, team-oriented approach to caring for the sickest of patients who are also, without doubt, the costliest.

Though not a new concept, it is perhaps one of the least improve access to palliative care across all settings,” Meier understood service lines. It is, however, showing signs of told the audience at the ACHE program “Palliative Care: growth, with the number of U.S. hospitals offering pallia- Impact on Quality and Cost.” The program, funded in tive care rising rapidly, according to the Center to part by the Foundation of ACHE’s Fund for Innovation Advance Palliative Care. Data from the Center and the in Healthcare Leadership, was held Sept. 11, 2012, in American Association reveal that the number of conjunction with ACHE’s Atlanta Cluster Program. programs in U.S. hospitals with 50 or more beds increased from 658 (24.5 percent) to 1,635 (66 percent) During her keynote address, Meier, who is also vice chair from 2000 to 2010—a 145.8 percent increase. of public policy and professor of and palliative and Catherine Gaisman Professor of Medical One person on the front lines of the emergence of pallia- Ethics at Mount Sinai School of Medicine in New York tive care programs in the U.S. healthcare system is Diane City, made the case for why palliative care is so important E. Meier, MD, FACP, director of the New York-based to healthcare today and how organizations can begin to Center to Advance Palliative Care. “My mission is to develop such programs.

Reprinted from 27 Healthcare Executive Jan/Feb 2013 ache.org Palliative Care Impact on Quality and Cost

According to Meier, it isn’t difficult Palliative care differs from hospice of doctors, nurses and other special- to make the business case for estab- or end-of-life care because the ists who work with a patient’s other lishing palliative care programs, espe- patients benefiting from palliative doctors to provide an extra layer of cially at a time when, she said, the care programs aren’t necessarily support. Palliative care is appropriate largest cause of bankruptcy in the dying. Often they are patients who at any age and at any stage in a seri- U.S. is healthcare bills, and a very are very sick but have a good prog- ous illness, and can be provided large portion of our population is nosis and are expected to live. Most together with curative treatment.” underinsured. people with serious and complex chronic illness in the United States As described in the above definition, “It is the costliest, very small propor- are not dying, but living with signif- palliative care is delivered by a care tion of patients that drive the vast icant burden of illness for many “team.” The team consists of key majority of spending,” she said. years. Meier said the fact that there players such as , nurses and “Healthcare spending is highly con- are pediatric palliative care programs advance practice nurses, - centrated on the sickest and most operating at some organizations ers, chaplains or spiritual advisors, vulnerable 5 percent of patients. highlights the importance of not management specialists and oth- Palliative care models have been linking palliative care to end-of-life ers. The emphasis is on treating the shown to improve for care. In Meier’s program at Mount patient’s medical condition but also these patients and families, to pro- Sinai, they are very accustomed to helping him or her through the diffi- long life in a number of studies and, taking care of patients who are likely cult practical challenges and emo- as a result, to enable patients to avoid to be cured, such as marrow tional and spiritual distress that the preventable crises and emergen- transplant patients, she said. accompany a serious illness. cies that land them in the hospital. The costliest patients are palliative Meier shared the Center to Advance Patients’ family members and other care patients. That’s why palliative Palliative Care’s definition of palliative loved ones also play a key part in pal- care is so critical to improving quality care with the audience. The definition liative care. In a successful palliative and reducing costs.” was crafted using language that was care program, they are part of the most highly rated among the public, conversation at the moment treat- Defining Palliative according to a public opinion survey ment begins. Palliative care programs Care conducted by the Center, so as to use also provide the proper counseling Meier said one key way to help orga- language that is meaningful and and support, including bereavement nizations think about palliative care important to patients and families: programs, if necessary, to patients’ and distinguish it from other service loved ones. lines is to remember that, “Palliative “Palliative care is specialized medical care is not what we do when there’s care for people with serious illnesses. Meier said the impact of serious ill- nothing else to do.” Palliative care is This type of care is focused on pro- ness on patients’ family members— delivered at the same time as appropri- viding patients with relief from the including increased mortality and ate disease-related , she said. symptoms, pain and stress of a seri- morbidity and post-traumatic stress “You don’t move to hospice until dis- ous illness—whatever the diagnosis. disorder—cannot be ignored. “The ease-directed therapies are no longer The goal is to improve quality of life cost to society from this is incalcula- working or their burdens begin to for both the patient and the family. ble … [resulting in] people who outweigh their benefits.” Palliative care is provided by a team can’t function as mothers, who can’t

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go to work, who can’t return to their Evidence showcasing these and other rates (11.6 months versus 8.9 role in society,” she said. “That is a benefits of palliative care programs is months). Other studies have pointed fault in the system we don’t think mounting, with hundreds of studies to cost savings including reductions about much.” showing how palliative care can in use of costly imaging and pharma- improve care quality, Meier said. ceuticals and reductions in ED visits Palliative care addresses three A Harvard / and time spent in the ICU. domains, said Meier. By addressing Massachusetts General Hospital these domains, quality of care is study published by the New England Making Palliative improved and because patients feel Journal of Medicine in 2010 found Care Work better and remain in control, costs that in a randomized trial of patients Meier provided attendees with an are reduced: receiving standard care with overview of what it takes in a health- palliative care co-management from care organization to make palliative Physical, emotional and spiritual the time of diagnosis versus a control care succeed. At the top of the list is distress group receiving standard cancer care medical staff engagement. “If you Patient-family-professional com- only, the group receiving palliative don’t have respectful and strong rela- munication about achievable goals care co-management experienced tionships with front-line medical staff for care and the decision making improved quality of life, reduced working with the patients and fami- that follows major , reduced “aggres- lies, it won’t work,” Meier said. “A Coordinated, communicated con- siveness” in treatment (e.g., less che- social worker alone can’t do it. tinuity of care and support for motherapy before death, less likely to Palliative care teams without a doctor practical needs of both patients be hospitalized during the last month are not going to work well.” Meier says and families across settings of care, etc.), and improved survival having medical staff on the palliative

The Fund for Innovation in Healthcare Leadership

The program “Palliative Care: Impact on Quality and Cost” was funded in part by the Fund for Innovation in Healthcare Leadership, a philanthropic initiative of the Foundation of the American College of Healthcare Executives (ACHE). An article on the first of two Fund programs for 2012, “The Ethics of Mission and Margin,” appeared in the September/October 2012 issue of Healthcare Executive.

The Fund was established in 2006 to bring innovation to the forefront of healthcare leadership by developing and enhancing its focus on future healthcare leaders, ethics in healthcare management and healthcare management innovations. In its commitment to developing future leaders, the Fund also has provided scholarships for the Foundation of ACHE’s Senior Executive and Executive Programs.

Since the Fund’s inception, more than 1,300 generous donors have made contributions. This support has enabled the Fund to strengthen the field of healthcare leadership by providing educational opportunities on important trends and issues.

For more information on the Fund, including ways to contribute, please visit ache.org/Innovation or contact Laura J. Wilkinson, CAE, vice president, Development, ACHE, at (312) 424-9305 or [email protected].

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care team provides added credibility to Commission, which in September process—the process of knowing and the information presented to patients 2011 released its Palliative Care honoring a patient’s informed plans. and their families. Advanced Certification Program; MedPAC; and the Institute for Hammes outlined the three key desired Other strategies for convincing physi- Healthcare Improvement. outcomes of advance care planning: cians and others in the organization to get on board with palliative care “Palliative care is key to survival Creating an effective plan, includ- include identifying opinion leaders in under a capitated, global budget,” ing selecting a well-prepared healthcare agent or proxy when possible and creating specific Palliative care differs from hospice or end-of-life care instructions that reflect informed decisions geared toward a person’s because the patients benefiting from palliative state of programs aren’t necessarily dying. Having advance care plans avail- able to the treating Incorporating the plans into the organization and getting their said Meier. “When fee-for-service medical decisions when and wher- interest and investment to help you goes away and you’re not managing ever needed sell the idea to others; interviewing the sickest 5 percent in the best others in the organization about what way possible, they will bankrupt “Planning isn’t enough,” said problems/issues they perceive and your budget.” Hammes. “We have to make sure how they feel they should be these plans are available to the treat- addressed (this aids in relationship After her keynote address, Meier ing physicians, and they incorporate building); gathering quality data; introduced the program’s three them correctly into decisions.” focusing on quality; and, finally, panelists, who each discussed their seeking senior leadership’s support for organization’s experiences with pallia- Hammes discussed the relationship a universal, systemwide palliative care tive care. of ACP to advance directives. screening checklist. “Palliative care According to Hammes, the successful should be part of the admission pro- Advance Care implementation of an advance direc- cess,” said Meier. “They should be Planning tive is directly tied to the quality of screening for unmanaged illness just Bernard “Bud” Hammes, PhD, the planning process or advance care as they screen for or director, medical humanities, and planning. “If the process of planning fall risk.” director, Respecting Choices, at has a poor quality to it, the plan will Gunderson Lutheran not work,” said Hammes. “Quality of Palliative care is sure to gain more in La Crosse, Wis., discussed advance communication with the patient and ground in the future, as it is already care planning (ACP) as a comple- the family predicts the quality of on the radar of several national ment to palliative care. He said the the outcome.” healthcare groups such as the health system, which serves approxi- National Quality Forum, which has mately 560,000 people in 19 counties There are four key elements in listed it as one of six of its National in western Wisconsin, has invested designing an effective ACP program, Priorities for action; The Joint heavily in the quality of the planning according to Hammes. They are:

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1. Systems design—build an infra- curriculum are paramount. This ensures a successful system because we were structure that assists in hardwiring delivery of a consistent, reliable ACP persistent,” said Hammes. “We excellence, including effective, stan- service, according to Hammes. redesigned it and redesigned it until dardized documentation, reliable it worked.” medical records storage and retrieval, 3. Community education and and an ACP team and referral mech- engagement—reach out to commu- Making the Case anism. According to Hammes, nities with consistent messages for Palliative Care advance care planning must be made about advance care planning. Stacie T. Pinderhughes, MD, director routine among staff members and a Because care in the La Crosse region of palliative medicine at Banner part of the care process. “It has to be involves two integrated health sys- Good Samaritan Medical Center in hardwired into how we relate to our tems, all ACP-related materials dis- Phoenix, told the audience about her patients,” he said. “No matter where tributed throughout the community experience with setting up a palliative patients are being treated, the written have the names of both systems on care program at the system, which care plan must be available to the them so patients know they can comprises 23 acute-care hospitals, treating physicians.” contact both systems related to their when she began her job at the organi- advance care plans, according to zation in 2010. She shared several 2. Advance care plan facilitation Hammes. This makes it possible to important lessons learned. skills training—build confidence work effectively with all community among staff and create an effective groups and institutions. One key lesson was to know your ACP team. Hammes said Gunderson organization’s culture before you Lutheran Health has experienced suc- 4. Continuous quality improve- jump in. For Pinderhughes, she was cess with teams featuring “facilitators” ment—measure and improve. fortunate to be at a hospital where who on behalf of doctors talk with Hammes noted the importance of “the doctors were very receptive and patients about their values and goals in continuously measuring your open to the whole concept of pallia- order to develop their care plans. organization’s ACP program—and tive care,” she said. Facilitators help take some of the bur- constantly looking for ways to den off already-busy physicians. improve it. That buy-in from physicians is criti- cal to the success of a palliative care Once the team is in place, staff “We didn’t create a successful system program, according to Pinderhughes. training and use of a standardized because we were smart—we created But there was some education of physicians that had to be done, espe- Related Resources cially among the specialty groups such as hospitalists, American College of Healthcare Executives “Strategic Integration of Palliative and Hospice Care: Implications for doctors and the hospital’s two large Health Systems, Physicians and Payors.” 2013 Congress on Healthcare intensivist groups. Leadership session. Visit ache.org/Congress She recalled how it was helpful at Center to Advance Palliative Care Good Samaritan to have physicians For tools and technical assistance for palliative care teams, visit round with the palliative care team to www.capc.org. Information for patients, families and the general gain a better understanding of how a public may be found at www.getpalliativecare.org palliative care program works and see

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the variety of services it offers. total cost avoidance attributed to rounds. “Now he is an effective ally According to Pinderhughes, it also Good Samaritan’s palliative care pro- in the C-suite,” said Pinderhughes. helped clinicians understand that pal- gram is approximately $1.5 million. liative care is different from hospice Pinderhughes said the team created care. “We made a deliberate decision At the end of the program’s first year, tools to ensure palliative care at Good at Banner Health System to debrand a Palliative Care System Developmental Samaritan was standardized. The palliative care from hospice,” she said. Initiative was convened and charged team created an information card, with developing a stable platform for which they distributed to physicians, During year one of the palliative care the delivery of palliative care across residents, nurses, social workers and program, the team consisted of the healthcare continuum. This case managers. The organization’s Pinderhughes, a nurse practitioner group called together stakeholders EHR now includes a Palliative Care and one social worker. Pinderhughes across the system, including provid- Rounding Tool in which palliative said bringing a social worker on ers, risk management staff and care team members document infor- mation. Palliative care information is also captured on the Palliative “This type of care is focused on providing patients Medicine H&P (history and physical) with relief from the symptoms, pain and stress of a Template the team developed. serious illness—whatever the diagnosis.” Banner Health is now looking at —Diane E. Meier, MD, FACP developing palliative care programs in Center to Advance Palliative Care several of its hospitals and plans to work with its ACO to develop pallia- tive care further across other settings. board helped make connections in administrators. The group began the “We’ve laid the infrastructure, now the community, an important aspect process of defining palliative care for we’re moving to the design phase,” of palliative care. the system and developed a business Pinderhughes said. plan, a plan for educating others Another key lesson Pinderhughes and about the program and an IT infra- Buy-In From the her colleagues learned was the impor- structure for documentation. The C-suite tance of getting C-suite buy-in. palliative care team also defined the When John M. Haupert, FACHE, Showing senior leaders the cost bene- program’s mission and vision (and became CEO of Grady Health fit of a palliative care program is key. alignment with Banner Health’s overall System in Atlanta in 2011, one of his mission and vision) and defined its priorities was improving the way the “We found significant cost avoidance patient population. system was managing the significant among these patients, which got the number of patients in need of hospice attention of the C-suite early,” Pinderhughes recalled how crucial it and palliative care. At least one-third recalled Pinderhughes. In the first was to have the CFO’s support with of those patients were being improp- year of its program, Good Samaritan’s developing the business plan. Good erly placed in the ICU. palliative care team had seen approxi- Samaritan’s CFO was involved from mately 500 patients. Since the pro- the beginning, even accompanying As a safety net provider for Atlanta gram’s start, Pinderhughes said, the the palliative care team on walk and one of the nation’s largest public

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hospitals with 625 acute-care beds, Haupert said the vision is inclusive Established operational infra- Grady’s payor mix is 30-30-20-20 and looks at the full continuum of structure—including implementa- (charity, , , com- palliative and hospice services. “We tion of a palliative care service mercial). “To make this work eco- wanted to avoid a model consisting of scorecard and deployment of nomically takes a lot of work,” just life-prolonging care,” Haupert resources to meet demand for Haupert told the audience. said. An ideal model, he said, is a pal- services liative care team working with hos- The development of Grady’s pallia- pice care staff and supportive services Enhanced system integration— tive care program is one major solu- including after-care support. including clinical partnerships tion developed to help more with other service lines such as efficiently and economically manage The palliative care program at and the most vulnerable among Grady’s Grady is constantly evolving and patient population. Haupert and his improving as the organization learns Haupert knows firsthand the impor- staff established a vision statement what works best to serve its patient tance of having C-suite buy-in for a for palliative care at the system, population. The focus is always on palliative care initiative. “With my which “has become our calling card doing what’s best for patients and commitment, we will get there and make this happen,” he said.

Patients’ family members and other loved ones also Attendee Tammie Quest, MD, asso- play a key part in palliative care. In a successful ciate professor of and director, Emory Center for palliative care program, they are part of the Palliative Care, which has a close working relationship with Grady conversation at the moment treatment begins. Health, emphasized Haupert’s senti- ment. It makes a difference in the for everything we do, every action their families in difficult times. “We success of a palliative care program we take and every action we put our have a lot of work to do to treat peo- when you work with senior leaders energy behind,” he said. The vision ple with the dignity they deserve,” who are “incredibly motivated and is: “The program assists patients and Haupert said. enthusiastic,” she said. their families by providing relief from the symptoms, pain, and stress Grady’s palliative care program “When you don’t have that from the of a serious illness with the goal of has been developed in three levels. C-suite, it’s really hard to take these improving their quality of life. The organization is currently work- programs to the next level.” The program affirms life and recog- ing to get from level two to level nizes death as a normal process; three, and Haupert says they have Jessica D. Squazzo is senior writer with helps people live as actively as possi- identified the following factors Healthcare Executive. ble and, in the event of terminal ill- that must be in place to make ness, neither postpones nor hastens that happen: death but helps them experience the end of their life with dignity Enhanced leadership—including and comfort.” identifying clinical leaders

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