On January 29 and 30, 2013 the Coalition to Transform Advanced Care (C-TAC) convened over 400 leaders -- from clinicians and policy makers to faith leaders and large employers -- to tackle one of America’s greatest challenges, breaking though the cultural, health system and policy barriers so that seriously ill people receive the right care at the right time and place.
5. Care Journey: Personal Reflections
on Advanced Care Moderators
Richard Address, Congregation M’Kor Shalom
Tyrone Pitts, Progressive National Baptist Convention
Panelists
Amanda Bennett, Bloomberg News
Nancy Brown, American Heart Association
Suzanne Mintz, Caregiver Action Network
Susan Reinhard, AARP
Don Schumacher, National Hospice and Palliative Care Organization (NHPCO)
Closing Remarks
Brad Stuart, M.D., Sutter Care at Home
9. Care Journey: Personal Reflections
on Advanced Care Moderators
Richard Address, Congregation M’Kor Shalom
Tyrone Pitts, Progressive National Baptist Convention
Panelists
Amanda Bennett, Bloomberg News
Nancy Brown, American Heart Association
Suzanne Mintz, Caregiver Action Network
Susan Reinhard, AARP
Don Schumacher, National Hospice and Palliative Care Organization (NHPCO)
Closing Remarks
Brad Stuart, M.D., Sutter Care at Home
10. 65 Million Family Caregivers
Typical Family Caregiver 1/3 are Higher Burden
• 49 year old woman • Approx 40 hours of
• Cares for a parent who care per week or more
doesn’t live with her • Lives with Loved One
• Provides approx 20 • Provides significant
hours of care per week help both medical and
• For about 5 years non medical
• Can provide care for 10
years or more
11. Caregivers Vs. Non-Caregivers
• Spend $5,531 more on medical expenses, supplies,
etc.
• More likely to
• go part-time
• turn down promotions
• give up employment
• Over $300,000 in lost income, pensions, SSI
• Higher incidence of depression and chronic disease
12. Poverty, Race, Ethnicity Impact on Health
• Lack of Access and Poorer Outcomes
Compared to Whites
· Those in poverty 80%
· Latinos 60%
· Blacks and AI/ANs 40%
14. Assessing the Benefits and Costs of
Transforming Care
Moderator
Mark McClellan, Brookings Institution
Panelists
Jeff Burnich, M.D., Sutter Medical Network
Gail Hunt, National Alliance for Caregiving
Randall S. Krakauer, M.D., Aetna
Diane E. Meier, M.D., Center to Advance Palliative Care
Dan Mendelson, Avalere Health
15. Aetna Compassionate Care
Trained, experienced case
Impact
managers provide:
Case Management Education, support and
resources for the member and their Favorable impact aligning
family/caregivers
Pain and symptom management – ensure patient goals with outcomes
member has access to effective pain
management and ongoing evaluation 82% of engaged decedents
Facilitation of informed care decision choose hospice1
making – allowing the member/family to
actively plan with the case manager and 82% reduction in acute
their medical team what their wishes are inpatient days2
for continued care
Review what they understand their 77% reduction in ER visits2
prognosis to be – Concerns about the path 86% reduction in ICU days2
ahead;
making decisions when/if they are unable Improved quality of life
Planning how to spend their time as options
become limited for Aetna members and
Review potential trade-offs that may arise over
time
their families
Address spiritual and cultural needs as
appropriate
15
16. Member Engagement:
the Roots of Impact
•Wife stated member passed away with Hospice. Much emotional support given to
spouse. She talked about what a wonderful life they had together, their children, all
of the people's lives that he touched - they were married 49 years last Thursday and
each year he would give her a piece of jewelry. On Tuesday when she walked into
his room he had a gift and card laying on his chest, a beautiful ring that he had their
daughter purchase. She was happy he gave it to her on Tuesday - on Thursday he
was not alert. She stated through his business he touched many peoples lives, and
they all somehow knew he was sick, and he has received many flowers, meals, fruit,
cakes - she stated her lawn had become overgrown and the landscaper came and
cleaned up the entire property, planted over 50 mums, placed cornstalks and
pumpkins all around. She said she is so grateful for the outpouring of love. Also
stated that Hospice was wonderful, as well as everyone at the doctors office, and
everyone here at Aetna. {She tells all of her friends that "when you are part of
Aetna, you have a lifeline.”} Encouraged her to call CM with any issues or
concerns. Closed to Case Management.
Compassionate Care
16
17. Barriers and Solutions
• Inability to Identify cases • ID Algorithm, work with
physicians to ID cases
• Members with Advanced • Case manager initiates
Illness are not engaged in outreach after verifying
support in a timely manner case with physician
• Insufficient communication
between case managers • Case managers embedded
and physicians and staff in medical offices
• Hospice eligibility criteria • Liberalize Hospice entry
represent unnecessary criteria – concurrent care
barrier and 12 month course
18. Using Patient Flow Data to
Manage Risk, Enhance Patient
Outcomes, and Improve
Financial Performance /
Dan Mendelson
February 2013
Avalere Health LLC | The intersection of business strategy and public policy
27. Having Your Own Say
Jeff Thompson, MD
Chief Executive
Officer
28. About
us... Delivery System
•Integrated
– Approximately 6,300 Total Employees
– 768 providers employed / 484 medical staff – 51
clinic locations
– 325-bed Tertiary Medical Center
•Western Campus of the University of Wisconsin
Medical & Nursing School
•Gundersen Lutheran Medical Foundation
•Residency and Medical Education Programs
•Research
Program
•Many affiliate organizations including EMS air and ground
ambulance service, rural hospitals, nursing homes, hospice, etc.
•$866.2 million Operating Budget
•Physician-led organization
•Strong Administrative/Medical partnership
29. cialgaT Strategic Plan 2012-
2016
Mission: We will distinguish ourselves
Our Purpose is to bring health and
well-being to our patients
through excellence in patient care, education,
and communities.
research and improved health in the communities we serve.
Vision: We will be a Health System of excellence, nationally recognized for improving the health and well-being of our patients,
families, and their communities.
Commitment: We will deliver high quality care because lives depend on it, service as though the patient were a loved one, and
relentless improvement because our future depends on it.
Values: integrity — Perform with honesty, responsibility and transparency.
Excellence — Measure and achieve excellence in all aspects of delivering healthcare.
Respect — Treat patients, families, and coworkers with dignity.
Innovation — Embrace change and contribute new ideas.
Compassion — Provide compassionate care to patients and families.
Superior Outstanding Great Place Affordability Growth
Quality Patient Create a Culture Make our care more Achieve Growth
that embraces a Affordable to our that supports our
and Safety Experience
passion for caring patients, employers, mission and other
Demonstrate Create an
and a spirit of and
superior outstanding i-nrrtrniirsifti key strategies ou
Liu LAU! Ly uusi.up
Quality & Safety Experience
improvemen
through the eyes for patients t
of the patients & and families
caregivers
30. “We all die. A fundamental question is do we
want to have a say in how we live?”
Jeff Thompson, MD
Having Your Own Say
Getting the Right Care When It Matters Most
Gundersen Health System
4
31. “In most respects, the patient were like those
found in any ICU...yet these patients were
completely different. ”
“None had terminal disease, none battled
metastatic cancer, or had untreatable heart
failure or dementia. ”
Atul Gawande, The New Yorker, August 2,
2010
5
32. “But in La Crosse, the system means that people
are far more likely to have talked about what
they want and what they don ’t want before they
and their relatives find themselves in the throes
of crisis and fear. When wishes aren ’t clear,
families have also become much more receptive
to having the discussion. ”
By Atul Gawande, The New Yorker, August
2, 2010
6
33. “Discussion had brought La Crosse’s end-of-life
costs down to just over half the national
average. It was that simple – and that
complicated.”
Atul Gawande, The New Yorker, August 2,
2010
7
34. Patient and Family
Evaluation
Hospital Satisfaction 90th percentile
th
Clinic Satisfaction 90 percentile
Gundersen Medicare 5 Star
75% Market Share
Advantage Program
35. Our Plan...
•Advanced planning
•Integrated delivery system
•Available health record
•Community collaboration
•Not for profit mission
9
36. Four Key Elements in Designing
an Effective ACP Program
#1 Systems Design
#2 ACP Facilitation Skills Training
#3Community Education and Engagement
#4 Continuous Quality Improvement
37. La Crosse Compared to
National Averages
100
90
80
70
60
50
40
La
30
Crosse
20
Nationall
10
y
0
% of severely or % of physicians Consistency
terminally ill patient who between
are aware of the known care plan
with an advance advance care plan and
care treatment provided
J Am Geriatr Soc 2010;58:1249–
plan 11
1255.
38. Australian Study Cont ’
Outcomes when Subjects Died
Intervention Control P value
n (%) 29 (19) 27 (17) 0.75
Age median, (IQR) 85 (84-89) 84(81-87) 0.06
Sex, male n (%) 17 (59) 13 (48) 0.43
Patients completed ACP 25 (86) 0 (0) <0.001
Wishes known and followed 25 (86) 8 (30) <0.001
Wishes unknown 3 (10) 17 (63) <0.001
Effect on family 5 (2-5.5) 15 (5-21) <0.001
Impact of Event Score: median
Effect on family 0 (0-1.5) 5 (0-9) <0.001
Hospital Depression Scale
BMJ 2010;340:c1345
39. Value of Advanced
Care Planning
•Value of respecting or honoring a patient’s values and
goals
•Avoiding treatments the patient considers
burdensome, thus avoiding unnecessary suffering and
indignity
•Being better able to provide care where the person
would want it
•Diminishing or eliminating the moral distress and its
lasting effects experienced by family or medical staff
members who must make healthcare decisions when
they do not know what the patient would want
13
40. How do we make integrated
healthcare really work?
Preserving your health
Heavy investment in primary care, disease management and
rehabilitation
Multiple layers of connectivity
Electronic Health Record, Best Practice Protocols, Shared Education
Program
Electronic fetal monitoring sites, ER Telemedicine real-time
hookup
Focus on saving lives and preserving function
•Extended TEC/Continuum of care
•The critical care hospital of the future
42. Our Care
Coordination Plan
•Nurses and Social Workers collaborating with
multiple providers, and between patients and
families to coordinate services and resources
across continuum of health care to assist
patients in reaching their optimal health.
•The Care Coordination Program works with
patients of all ages and is a service provided at
no cost to patients.
16
43. Care Coordination Program
Out- We take care of
Patient
Managemen FFS
patients the same
t as
those for whom we
are at financial
risk
Average caseload is
1,200 patients
44. lee
"To heal the patient, heal the system."
Brad Stuart, MD, CMO
Sutter Care at Home
GUNDERSEN
HEALTH SYSIFEM
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46. Having
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47. i
"We all die. A fundamental question is do we
want to have a say in how we live?"
Jeff Thompson, MD
GUNDERS
HEALTH
EN
SYSTEM
50. National Recognition
System-Wide Recognition
•Top 100 Hospitals Five Year Performance Improvement Leader –
Thomson Reuters
•HealthGrades Distinguished Hospital Award for Clinical
Excellence
– Places Gundersen Lutheran in the top 5% of hospitals in the
nation 6 times
•Top 100 Hospital – Thomson Reuters
•Top 100 Integrated Healthcare Network – Verispan
•2009 Dartmouth/IHI/Brookings – Best value of 309 Medicare
regions
•2009 Commonwealth Fund Top Integrated Systems in U.S.
•2010 Delta Group – Ranked # 1 of 118 academic centers
•2011 Top 1% in HealthGrades outcomes
51. Cost of Care in the Last
Two Years of Life
Hospital Days/Patient Total Cost of Care/Patient
Hospital in Last 2 Years of Life During Last 2 Years of Life
Gundersen Lutheran 13.5 $18,359
Marshfield/St. Josephs 20.6 $23,249
University of Wisconsin 19.7 $28,827
Cleveland Clinic 23.9 $31,252
Mayo Clinic 21.3 $31,816
UCLA 31.3 $58,557
University of Miami Hospital & Clinics 39.3 $63,821
New York University Medical Center 54.3 $65,660
* Based on 2007 Dartmouth Atlas Study Methodology. The Dartmouth Atlas methodology examines hospital inpatient care for the last
two years of a Medicare patient ’s life.
52. Stages of Advance Care Planning Over the Life Time of Adults
First Steps Next Steps Last Steps
ACP: Create POAHC and consider ACP: Determine what ACP: Establish
specifi a
when a serious neurological injury goals of treatment should plan of care
c
would change goals of treatment. be followed if expressed in medical
complications result in orders using the POLST
“bad” outcomes. paradigm.
Healthy adults between ages 55 and 65. Adults with progressive, Adults whom it would not
life-limiting illness, suffering be a surprise if they died in
frequent complications the next 12 months.
54. Lessons for
Healthcare Systems
•Almost all patients and families are willing to consider
and talk about future medical decisions IF they see
how this effort will improve their own treatment....we
must be able to explain the benefits of the effort of
having the conversation to the patient/family.
•A standardized, patient-center, staged approach to
these advance care planning conversations is crucial
(rather than a legalistic approach).
•An organized system of work flows, processes, and
EMR is needed in all health care settings. The effort of
ACP must be built into the routine of care and shown
that it improves patient outcomes.
28
55. Lessons for
Healthcare Systems
•To be successful with ACP requires the
understanding, support, and involvement of the
whole community and the other institutions that
hold the community together: religious;
business; government; schools; service groups.
•In order to actually honor the preferences and
goals of patients/families at the end of life, we
need a delivery system that is more versatile that
can be individualized to the patient ’s goals and
health condition.
29
56. Lessons for
Healthcare Systems
•The health organizations need to develop the
“capacity” to assist patients with ACP and to honor
plans before any public engagement.
•Health organization should involve leaders from
other organizations/institutions relatively early in
this work and get these leaders on board.
•Perhaps two years into the effort, the public at large
need to be engaged about the value of this work for
them knowing that all major institutions/leaders are
supportive.
30
57. Lessons for
Healthcare Systems
•This approach not only insulates health organizations
from negative attacks, but can create a more positive
image of health care.
•The evidence shows that families who face complex,
moral/medical decisions are better prepared with
effective advance care planning and deal with grief in
a healthier way (fewer complications). One might
assume that this leads to not only positive feelings
toward the health organization who provide end of
life care, but also to fewer missed days at work.
31
58. Definition: Advance
Directive (AD)
•A plan, made by a capable person or their
surrogate, for future medical care regarding
treatments or goals of care for a possible or
probable event.
•This plan could be expressed:
•Orally or in writing
•If written, it could be in strict accord with specific
state statutes or simply a documentation of the
plan, e.g., a physician’s note.
59. Definition: Advance
Care Planning (ACP)
A process of planning for future medical
decisions. This process, to be effective, needs
to meet similar standards as the process of
informed consent, i.e., the person planning
needs
to...
– Understand selected possible future situations and
choices;
– Reason and reflect about what is best; and
– Discuss these choices and plans with those who might
need to carry out the plan
60. Relationship of
ACP to ADs
ADs are only as good as the process of planning:
•If the person planning does not understand,
reflect on, or discuss their choices/options
adequately, the plan has a high probability of
failure.
•ADs success is directly tied to the quality of
the planning process or ACP.
61. Family Member...
“I just want to thank you again for helping my
Dad. The meeting was just what we needed. It
would have been difficult to broach those
subjects without you there to facilitate. I think
his mind was put to ease by getting everything
out in the open and it led to some very
productive and loving conversations later in the
day.
”
35
62. Participating
Organizations
•AARP
•Aetna
•Amedisy
s •Center to Advance Palliative Care
•Coalition to Transform Advanced Care (C-TAC)
•Dartmouth Institute for Health Policy and Clinical Practice
•Gundersen Health System
•Honoring Choices Minnesota
•National Palliative Care Research Center
•Respecting Patient Choices, Australia
•Sutter Health/Sutter Care at Home
36
63. C TAC’s Four Key
Areas of Focus
•Do what works: promote best practice care delivery (the models that
work in clinical and community settings) to ensure high-quality,
coordinated advanced illness care, across all settings;
•Empower the public: help people to understand and make informed
choices for themselves and their families and to call for change in
care
delivery and in
policies;
•Educate health professionals: to better serve patients
andfamilies/caregivers so people know their options, make
informed
choices, get the care they need, and avoid procedures they
want
don’t
; Create policy change: develop and advocate for federal and
•
state
legislative, regulatory, judicial, and administrative initiatives, and
for
also private policies, to improve care for those with advanced
illness.
37
64. “La Crosse is Unique”
Not
so...
Minneapolis-St. Paul, Medical Society, Allina,
Health East, Park Nicollet
Honoring Choices Minnesota
38
65. HCM Engagement In
the Community
•To Demystify...taboo issues related to the
death dying processes in the 21 st Century;
and
•To Inspire...Minnesotans to imagine
becoming
more involved in the end-of-life care decision-
making process;
•To Model...ways in which families can discuss
embrace end-of-life care
and
planning;
•To Support...families with an online “toolkit” of
video and text tools; and
•To Prepare...caregivers and families alike to
certain that family choices are always
make
honored.
39
67. British Medical
Journal, March 2010
“Systematized model of advance care planning,
following the principles established by Respecting
Choices; could significantly improve ”
•Patient and family satisfaction regarding care
•Improve the knowledge of and respect for
patients’ end-of-life wishes
•Contribute to the quality of the end-of-life care
•Reduce the incidence of clinically significant
anxiety, depression and post-traumatic stress
disorder in the surviving relatives of deceased
patients
41
69. The Washington Context: Policy
Opportunities to Improve Advanced
Illness Care
Moderator
Bruce Chernof, The SCAN Foundation
Panelists
Hanns Kuttner, The Hudson Institute
Chris Jennings, Jennings Policy Strategies
Senator Blanche Lincoln (D-AR), Alston & Bird
Len Nichols, George Mason University
70. Perspectives From the U.S. Senate:
Achieving High Quality Advanced
Illness Care for Our Seniors
Moderator
Susan Dentzer, Health Affairs
Panelists
U.S. Senator Johnny Isakson (R-GA)
U.S. Senator Ron Johnson (R-WI)
U.S. Senator Mark Warner (D-VA)
U.S. Senator Sheldon Whitehouse (D-RI)
73. Keynote Address
Speaker
Kathy Greenlee, Assistant Secretary for
Aging, and Administrator, Administration
for Community Living, U.S. Department of
Health and Human Services
74. Empowering the Public to Make
Informed Decisions and Plans Moderator
Alexandra Drane, Eliza Corporation
Opening Speaker
Kent Wilson, M.D., Honoring Choices Minnesota
Panelists
Amy Berman, The John A. Hartford Foundation
Lindsay Hunt, Institute for Healthcare Improvement/The Conversation Project
Peg Chemberlin, National Council of Churches
Terry Clark, UnitedHealth
Bill Hanley, Twin Cities Public Television (TPT)
76. “Honoring Choices MN”
What We Set Out to Do …
•Change Societal Attitudes
- Needed to be simple
•Family Conversations
–No Documents Required
77. “Honoring Choices MN”
What We Needed…
•Broad Public Awareness:
- 6 Full Docs, PSA’s, Web, Social Media, Newspapers
•Human Story-Telling: Authenticity, Humor
•Diversity: Faith, Culture, Identity
•Direct Engagement: Listening Sessions, Ambassadors
•Long-Term Commitment: Seven (7) Full Years
78. “Honoring Choices MN”
How We Approached It …
•TCMS Laid Groundwork: with Medical Colleagues
•Public TV: Asked to Design, Plan, Budget
•Partnership: Shared Costs, Control, Copyright, Fund-raising
•Plan, Revise, Go Again
•Corporate “Lead”: CEO, Health Partners
•Enlist other Media: TV, Radio, Newspapers, Social Media
79. “Honoring Choices MN”
Progress to Date …
•Broadcasts (Docs & Spots): 700+
•Web Usage: 22,000 Videos
•Comm. Engagement: 38 Ambassadors, 100 Trainings
•2011-12: Viewed as “Broadly Effective”
•2013-17: Public TV will Continue to Broadcast
87. Impact
1. 26 hospitals/health care systems
2. 600 community based partners
3. 45 volunteer Ambassadors trained; hundreds of
presentations given
4. Nearly 1,000 Facilitators trained to have discussions
with individuals and families; 50 Instructors
5. Documentaries air 90+ times; PSAs over 900 times
6. 15,700 health care directives downloaded in the last
18 months.
88. Lessons learned
Collaboration is essential
Local oversight and governance is necessary
Community wants to be engaged in this work
Broad based public engagement tactics are needed
89. Contact Information
Kent Wilson, MD Sue Schettle
Medical Director Chief Executive Officer
Honoring Choices MN Twin Cities Medical Society
tcms@metrodoctors.com sschettle@metrodoctors.com
612-362-3704 612 -362-3799
90. Working Together: Innovations in
Inter-Professional Training
Moderators
David E. Longnecker, M.D., Association of American Medical Colleges Washington
DC
Cynda Rushton, PhD, RN, FAAN, Johns Hopkins University
Panelists
Patricia A. Grady, PhD, RN, FAAN, National Institute of Nursing Research
Bud Hammes, Gundersen Health System
Richard Payne, Duke Institute for Care at the End of Life
Bob Wolf, Healthcare Chaplaincy
91. Care Planning
and
Advanced Illness Management
Bernard “Bud” Hammes, PhD
Director of Medical Humanities
Gundersen Health System
La Crosse, WI
www.respectingchoices.org
92. Fragmentation of Care
People with advanced illness suffer greatly because
our current system is fragmented:
1.In space…from one setting to another we don’t
share a common plan/approach;
2.Over time…we don’t keep in tune with individuals
changing goals of care;
3.By protocol…we provide treatment approaches
that are inflexible and at time either/or.
Credit to Brad Stuart, MD.
93. Correcting Fragmentation Requires:
1. A care model that puts the ill person at the
center of the care model; and
2. A care team that can deliver this model
through time and a cross settings of care in a
way that meets the individual goals of each
person.
94. A new care model for those with
advanced illness requires:
• Care planning build into the routine of care
• Care planning is achieved by well organized,
effective conversations with individuals (and
those close to them) and are updated over time
• Care planning leads to clear plans
• Care plans are always available to providers
• Care plans are used thoughtfully when needed
• The individual care plans can be met by a flexible
care system where treatments provided are
consistent with treatments desired
95. Designing this new model requires
1. We change our approach to the process of
care planning…we need a staged approach;
2. We need some fundamental redesign of the
care system.
96. Stages of Advance Care Planning Over the Life Time of Adults
First Steps Next Steps Last Steps
ACP: Create POAHC and consider when a ACP: Determine what goals ACP: Establish a specific
serious, permanent neurological injury would of treatment should be plan of care expressed in
change goals of treatment. followed if complications medical orders using the
result in “bad” outcomes. POLST paradigm.
Healthy adults between ages 55 and 65 or Adults with progressive, Adults whom it would not be a
anyone younger with a serious illness life-limiting illness, suffering surprise if they died in the next
frequent complications 12 months.
97. We also need to…
• Redesign specific workflows, roles, and tools
in the health system;
• Train health professionals to conduct the care
planning conversations at each stage and to
work as a team;
• Provide community engagement;
• Improve these new systems through
continuous performance improvement.
100. Definition - Spiritual Care
Interventions, individual or communal, that facilitate
the ability to express the integration of the body,
mind, and spirit to achieve wholeness, health, and a
sense of connection to self, others, and[/or] a higher
power.
American Nurses Association, & Health Ministries Association. (2005). Faith and community nursing:
Scope and standards of practice. Silver Spring, MD: American Nurses Association.
103. The NCP Guidelines
Address Eight Domains of
Care:
Structure and processes
Physical aspects
Psychological and psychiatric
aspects
Social aspects
Spiritual, religious, and existential
aspects
Cultural aspects
Imminent death
Ethical and legal aspects
105. Spiritual Support &
Cancer
In a large study of advanced cancer patients:
88% said religion was at least somewhat important
72% said their spiritual needs were minimally or not at all
supported by the medical system
42% said their spiritual needs were minimally or not at all
supported by their faith community.
Spiritual support was highly associated with QOL.
(P=.0003)
Balboni, et al. (2007). Religiousness and Spiritual Support Among Advanced Cancer Patients and
Associations with End-of-Life Treatment Preferences and Quality of Life. Journal of Clinical
Oncology, 25(5), 555-560.
107. Spiritual Screening
Is religion/spirituality important to you as you cope
with your illness?
How much strength/comfort do you get from your
religion/spirituality right now?
Has there ever been a time when religion/spirituality
was important to you?
Fitchett, G and Risk, J. L. (2009). Screening for spiritual struggle. Journal of Pastoral Care
and Counseling, 62 (1, 2), 1-11
109. Cicely Saunder’s implied
postulate?
The spiritual life provides an integrative
function, working through attribution of
meaning to connect our existence to the
grand narrative of existence.
physical spiritual
social psychological
DAME CICELY SAUNDERS, OM, DBE, FRCP, FRCN
FOUNDER AND PRESIDENT
ST CHRISTOPHER’S HOSPICE
22 June 1918 - 14 July 2005
113. Identifying and Replicating Best
Practices in Clinical and Community
Models Moderator
Tom Smith, Johns Hopkins University
Panelists
Eric Anderson, Allina Health System
Bill Borne, Amedisys
Malene Davis, Hospice Innovations Group
Dan Johnson, Kaiser Permanente
114. LifeCourse
“As I live well with serious illness, I am in charge. You listen to me,
help me, guide me, honor me, and support me as a person.”
1. Ongoing, personal relationship
with a non-clinical Care Guide
2. Interdisciplinary Team to address
all domains of palliative care
and coordinate across care
settings and care partners
3. A complement to existing
services and to the existing
strengths and assets of the
individual and caregivers
Center for Healthcare
114
Research & Innovation
115. Health Care @ Home
Inflection Disruption Early Adoption
Facilities
The community-based
delivery model is
standardized.
The interface differs
Advanced Care
according to the anchor
Management
in the community.
116. Kaiser
Permanente
• Integrated health system, 8 regions + D.O.C.
• Advanced illness care grounded in 3 RCTs
• Strategies: INVEST, EDUCATE, and INTEGRATE
• Access to specialty-trained palliative support across inpatient,
home, clinic and NH settings
• Systematic approaches to care planning (e.g., Respecting Choices)
• Moving away from “referral-only” models; imbedding specialty
support in high risk settings
• Developing complex medical homes for most seriously ill
117. The Innovations Group
• What is the Innovations Group?
• Additional examples of care
coordination.
• Hospice as a foundational model of
community-based interdisciplinary
care.
• Advanced Illness---The Next
Generation!
118. The Innovations Group
• Hope HealthCare Services • Capital Caring
• Valley Hospice • The Elizabeth Hospice
• Hospice of the Bluegrass • Covenant Hospice
• Four Seasons • Hosparus
• Hospice of Michigan • Suncoast Hospice
• Chapters Health System • Midwest Palliative &
• Hospice of Palm Beach Hospice CareCenter
County • HopeHealth
• Nathan Adelson Hospice • The Denver Hospice
• Home & Hospice Care of • Hospice of Chattanooga
Rhode Island • Hospice & Palliative Care of
• Sutter Care at Home Western Colorado
* The NHWG CEO participates as an invited member and an advisor
120. COMPREHENSIVE COORDINATED ADVANCED ILLNESS CARE
H o s p i c e
Interventions with Curative
Capacity*
Disease Modifying Interventions* Bereavement
Palliative Interventions
Consumer Education, “Coaching”, Empowerment
Prognosis of
Diagnosis of a Death
foreseeable limited
serious or chronic life expectancy or
condition end-stage disease
LTC = Long Term Care * until no longer meeting medically specified outcomes o
Adapted from: Fine PG, Davis M. Fine PG, Davis M: 2006. Hospice: comprehensive
care at the end of life. Anesthesiol Clin;24(1):181-204.
123. The benefits are straightforward…better care,
and people who use hospice for even one day
live longer.
Connor SR, et al. J Pain Symptom Manage. 2007 Mar;33(3):238-46.
124. We miss opportunities to recognize hospice
eligible patients, they are readmitted, and
cost more.
U of Iowa Hospitals.
•688 in-hospital deaths
•209 decedents had preceding admission
•60% of decedents were eligible for hospice on the
penultimate admission, based on NHPCO, National Hospice
and Palliative Care Organization worksheets.
-Only 14% had any discussion of hospice, despite being
eligible; 14 of 17 enrolled, all from ONE service
Freund K, et al. J Hosp Med. 2012 Mar;7(3):218-23. doi: 10.1002/jhm.975. Epub 2011 Nov 15.
125. We miss opportunities to recognize hospice-eligible
patients, they are readmitted, and cost more.
Table: Comparison of Cost and Length of Stay Between Patients
Enrolled and Not Enrolled in Hospice During a Terminal Hospital
Admission
Enrolled in hospice before last Not enrolled in hospice, all
admission n = 7/14 diagnoses, n = 202/209
Cost
Mean $4963 $52 219
Median $3690 $23 322
Standard $3250 $85 101
deviation
Standard 4.47 25.05
deviation
Palliative Care Consultation YES, $41,859 NO, $58,386
P<0.04
Freund K, et al. J Hosp Med. 2012 Mar;7(3):218-23. doi: 10.1002/jhm.975. Epub 2011 Nov 15.
Weckmann MT, et al. Am J Hosp Palliat Care. 2012 Sep 5.
126. People who use hospice are re-admitted less
often, use less medical resources, and get
better care.
Table 2. Readmission Rate by Post-discharge Medical Service Use
Post-discharge medical services Ratio of readmissions Percent
Hospice 11/240 4.6
Home-based palliative care 5/60 8.3
Home health 2/15 13.3
Nursing facility 14/58 24.1
Home no care 9/35 25.7
Enguidanos S, Vesper E, Lorenz K. 30-Day Readmissions among Seriously Ill Older Adults. J Palliat
Med. 2012 Dec;15(12):1356-61. doi: 10.1089/jpm.2012.0259. Epub 2012 Oct 9.
Hospice saves Medicare $2309 per decedent, and the longer the hospice
Length of stay, the bigger the savings.
Taylor DH Jr, Ostermann J, Van Houtven CH, Tulsky JA, Steinhauser K. What length of hospice
use maximizes reduction in medical expenditures near death in the US Medicare program?
Soc Sci Med. 2007 Oct;65(7):1466-78. Epub 2007 Jun 27.
Better care, consistent with what people would choose.
Smith TJ, Schnipper LJ. The American Society of Clinical Oncology program to improve end-of-
life care. J Palliat Med. 1998 Fall;1(3):221-30.
127. Hospice eligibility is straightforward –
take out your smart phones and Ap this!
• The SURPRISE QUESTION: “Would you
be surprised if this person were to die in
the next 6 months?”
• Failure to thrive: BMI < 22, involuntary
weight loss
• CHF NYHA Class IV, EF < 20%
• COPD: hypoxemia at rest, FEV1 < 30%
• Dementia < 6 words
• Liver disease: INR > 1.5, albumin < 2.5
• Cancer – much easier. Salpeter et al.
J Palliat Med. 2012 Feb;15(2):175-85.
Prognoses < 6 months.
129. How do we better integrate hospice
into our care?
• Have a “hospice information visit” when we think the
person has 3-12 months to live.
• Can’t hurt. OK to predict wrongly.
• Can dramatically help
• Makes us address difficult issues like “code status”
• Informs family that the situation is serious and their
loved one is dying (moves the angst upstream)
• MOLST
• Will, Living Will, DPMA, Life Review, Dignity therapy
Smith TJ, Longo DL. Talking with patients about dying. N Engl J Med. 2012 Oct
25;367(17):1651-2. doi: 10.1056/NEJMe1211160.
130. Barriers Opportunities
•Provider Competition •Payer-Provider Collaboration
•Challenges to System •Private Sector Leadership
Integration •National Scale Pilots
•Lack of Incentives •Common Metrics
•New Training Needs •Comparative Data Analysis
•Startup Costs •Payment Reform Advocacy
•Reimbursement •Model Flexibility
•Unique Local Issues
131. Key Barriers and Solutions to
Innovations in Advanced Illness Care
& Management
133. Breakout Session
Moderators
Randall S. Krakauer, M.D., Aetna
Brad Stuart, M.D., Sutter Care at Home
NAS 125
134. Empowering Employers as Part
of the Solution
Moderator
Brent Pawlecki, The Goodyear Tire and Rubber Company
Panelists
Ann Richardson Berkey, McKesson Corp.
Neil Trautwein, National Retail Federation
Jack Watters, Pfizer
Pam Kalen, National Business Group on Health
Kathy Brandt, National Hospice Palliative Care Organization
135. Advanced Illness and Caregiving:
A workforce challenge
Brent Pawlecki, MD, MMM
Chief Health Officer
The Goodyear Tire & Rubber Company
National Summit on Advanced Illness Care
January 30, 2013
136. The Goodyear Tire & Rubber Company
• Goodyear is one of the world's leading tire companies.
○ Goodyear is the No. 1 tire maker in North America and Latin America.
○ Goodyear is Europe's second largest tire maker.
○ The world’s largest operator of commercial truck service and tire retreading
centers.
○ Operates approximately 1,500 tire and auto service center outlets.
• Founded in 1898 in Akron, Ohio.
• 2011 annual sales of $22.8 billion.
Consumer
• Employs approximately 73,000 people around the world.
• Operates 54 plants in 22 countries.
• Blimps—our aerial ambassadors since 1925.
○ Goodyear operates three blimps in North America.
136
137. Global Health Services
• Building the Culture of Health
– Health Benefits
– Wellness Programs
– Environment, Health and Safety
– Emergency Preparedness
Healthy,
Engaged,
Productive
Employees
137
138. Global Health Services
Goal:
Maximize the health and wellbeing of our associates, control
benefits costs and improve productivity by:
Preventing illness.
When prevention is not possible, securing the right care at the right
place at the right time.
When treatment is no longer possible, assuring that people have the
tools available to support a dignified and respectful end of life.
好生活, 生活好选择
138
139. Workforce Challenge—advanced illness
Advanced Illness / End of Life
• Americans living with advanced illness and their caregivers
– Are not asked what care they want
– Are not given the help to make good decisions about coordinated high
quality care
– Creates physical, emotional and financial hardships
Coalition to Transform Advanced Care (C-TAC)
140. Workforce Challenge—advanced illness
Why it is an employer issue
1. Employees are caregivers
– Demographic shifts
• One in five will be 65 and older by 2030
• percentage of working age 18 - 64 declining
– Caregiver duties
• 7 to 10 million adults care for parents from distance
• 25% of adults provide care to another adult
• 64% of caregivers work full or part-time
• 1 in 8 aged 40 – 60 care for both parent and child
• roughly half were men
141. Workforce Challenge—advanced illness
Why it is an employer issue
1. Employees are caregivers
– Productivity & financial impact (2006 MetLife)
• $17.1 to 33.6 billion per year
• Workday interruption at least one hour per week
• 60% needed to attend to some crisis
• 2.4 percent leave workforce entirely
• Cost for full-time employed caregiver $2,110
• Uncaptured presenteeism costs
142. Workforce Challenge—advanced illness
Why it is an employer issue
1. Employees are caregivers
– Unprepared
• fewer than half of baby boomers have discussed their parents’ treatment
wishes in the event of terminal illness
• only 40% have discussed their parents’ will
– Adverse health effects (2010 MetLife)
• 8% increased health care expenses—13.4 billion/yr
– Leaving workforce
• Leave of absence (survey showed roughly 25% of caregivers considering
and/or planning for it)
143. Workforce Challenge—advanced illness
Why it is an employer issue
2. Unexpected health crisis for employee or partner
– 627,000 working age adults die each year
– 2007, unintentional injuries caused 120,000 deaths and 26 million
disabling injuries
– Undocumented end of life issues
• Treatment decision confusion
• Emotional burden
• Mounting medical and disability costs
144. Workforce Challenge—advanced illness
Why it is an employer issue
3. Childhood health issues
– Parents / Grandparents as caregivers
• Balance needs of other family members, household, jobs
• Travel to specialty centers
– Prematurity
• One in eight in U.S., often with serious health conditions
• First year medical costs 10 x greater for preterm vs. full-term
– Currently, 2% deaths are in children
• Heavy emotional toll
146. Workforce Challenge—advanced illness
How to address
• Recognize the issue on your human capital
• Determine the impact on your workforce
• Provide appropriate services
– Encourage financial planning
– Encourage wills
– Encourage Advance Directives
– EAP and counseling services
• Review and revise policies as needed
– Bereavement policies
– Long-term care policies
147. Workforce Challenge—advanced illness
Resources
• Caring Connections — http://caringinfo.org/employer
• National Business Group on Health — www.businessgrouphealth.org
• Coalition to Transform Advanced Care — http://advancedcarecoalition.org/
• Best-practice care delivery models
• Empowering the public
• Educating health professionals
• Creating policy change
• Publications
• End of Life: A Workplace Issue. Health Affairs, 29, no.1 (2010): 141-146.
• MetLife Mature Markets Institute — http://www.metlife.com/assets/cao/mmi/publications/studies/2010/
mmi-working-caregivers-employers-health-care-costs.pdf
• The Caregiver Quandary — http://www.slideshare.net/pitneybowes/the-caregiverquandry-
pitneyboweswhitepaper
149. Empowering Employers as Part
of the Solution
Moderator
Brent Pawlecki, The Goodyear Tire and Rubber Company
Panelists
Ann Richardson Berkey, McKesson Corp.
Neil Trautwein, National Retail Federation
Jack Watters, Pfizer
Pam Kalen, National Business Group on Health
Kathy Brandt, National Hospice Palliative Care Organization
150. Breakout Sessions
Public Engagement – Board Room
Professional Education – Lecture Room
Clinical Models – NAS 125
Employer Solutions – NAS 120
Interfaith and Diversity – Members Room
151. Impact of Advanced Illness
On the Workplace
What Employers Need to Know
Pam Kalen
National Business Group on Health
This presentation was funded by the members of the National Business Group on Health and is for their exclusive use. To protect the
proprietary and confidential information included in this material, it can only be shared, in either print or electronic formats, within and
among member companies. All other uses require permission from the Business Group. 2010 National Business Group on Health.
151
152. Why Employers Care
• End-of-life issues, such as caregiving, serious illness,
bereavement and advance care planning, can have a
far reaching effect on both employees and the
workplace as a whole.
• Family caregivers provide 80% of U.S. long-term care
services
• The total estimated cost to employers for all full-time,
employed caregivers is $33.6 billion.
152
153. Costs to Employers
•U.S. businesses lose $17.1 to $33.6 billion per year in
productivity for full-time employees with caregiving
responsibilities.
•The annual cost of grief in the workplace
for death of a loved one is estimated to be
$37.5 billion.7
•An 8% differential in increased health care costs exists
between caregiver and non-caregiver employees.
153
154. Beginning the Process
• Identify key stakeholders and obtain buy-in.
• Perform employee needs assessment through
workgroups and employee satisfaction surveys
• Include questions in your work-life questionnaire
about advanced illness and palliative care, as well as
planning for the future.
• As part of your health assessment or work-life
questionnaire, ask employees if they are in a
caregiving role
155. Benefits and Communications
• Review coverage under both medical and prescription
plans to determine if there are any gaps in palliative and
hospice care.
• Assess support programs, gap analysis and resources
for advanced illness planning that might be available
through EAP or other vendors.
• Determine the communications needs for both
managers and employees and develop an appropriate
plan for them and other key audiences.
156. Advance Directives
• Share information with employees on the
importance of having an advance directive.
• Require vendors that are involved in care case
management and resource and referral programs to
ask employees and their dependents if they have an
advance directive.
• Include in key communications the legal resources
available for drafting advance directives and estate
planning documents.
158. End-of-Life Issues
in the Workplace
Kathy Brandt, MS
kbrandt@nhpco.org
www.caringinfo.org
159. End-of-life Issues in the Workplace
• Caregiving
• Serious illness
• Grief
• Advance care planning
160. NHPCO’s Employers Guide
• Assessment
• Work-life Programs
• Benefits and Policies
• Communication Resources
• Learning Modules
• Brochures for managers and employees
161. Assessment Strategies & Tools
• Assess workplace programs & policies
• Culture
• Communication
• Training
• Evaluation
• Programs/resources
• Assess the needs of supervisors
• Employee needs assessment
162. Work-Life Programs
• Employer-sponsored initiatives
• Goals :
• Increase employees access to information
• Enhance ability of supervisors to support
employees
• Increase opportunities for peer support
• Improve morale, retention, productivity
163. Programs
• Information and referral programs
• Caregiver support
• Lunch-and-learns
• Employee health fairs
• Support for employees coping with grief
164. Benefits and Policies
Goals:
• Improve company’s competitive
advantage in recruiting
• Improve employee morale
• Increase retention and productivity
165. Benefits and Policies
Assess, modify and/or add:
• Funeral leave
• Bereavement leave
• Sick leave
• Leave of absence
• Alternative work schedules
166. Benefits and Policies
• Action Steps
• Make sure that employees know about
benefits and policies
• Provide ongoing training for supervisors
• Involve staff in the design of benefits and
policies
• Respect the privacy and confidentiality of
employees
169. Outcomes from Pilot
• The assessment process uncovered a
greater need than previously thought
• Managers more aware of employee needs
• Brochures rated as very useful
• Presentations from local hospice were
extremely informative
• Support after sudden death “invaluable”
170. Tools You Can Use
• Caring Connections - www.caringinfo.org
• Employer’s Guide
• Educational brochures
• Outreach Guide
• National Healthcare Decisions Day –
www.nationalhealthcaredecisionsday.org
173. Summit Goals
A greater understanding of the issues and challenges, their causes and
potential solutions among American society and leadership: health care
consumers; faith-based organizations; clinicians; health insurance plans;
employers; policy makers; and public advocates, including those
representing culturally diverse communities.
A shared sense of mission and action steps needed to reform and improve
advanced illness care in America, including: system innovations; public
engagement; policy changes; and health professional education and
support. The emphasis will be on quality care and patient satisfaction, and
an agenda that addresses COMMUNITIES, individuals, systems, and policy.
174. Cost and Benefits
Build on new and existing data from innovative advanced care
management models that improve patient/family quality of
life, lower costs, and affect other key metrics, to identify ways
to improve data and evidence on supporting greater
benefit/value through health care reform.
175. Public Engagement
Highlight best-practices/innovations in public engagement
including: receptive audiences, effective messages, metrics,
and dissemination strategies.
Create awareness of the need for programmatic coordination
among public engagement initiatives -- specifically, related to
developing and coordinating a common language about the
terms to use and shared messaging.
176. Professional Education
Build consensus around the competencies clinicians need to
deliver high quality advanced illness care.
Raise awareness of existing innovative tools and solutions in
clinician support and training.
Empower champions within health care systems to advocate
for curricula transformation.
177. Clinical Models
Identify clinical best practices in caring for people with advanced illness with
the potential to effectively serve the advanced illness population across the
country.
Achieve consensus on common process and outcomes measures that can be
used to assess the clinical effectiveness and patient and family satisfaction with
treatment of advanced illness.
Agree on the structure of a national pilot that can be used to scale and replicate
effective innovations in advanced illness care and to create an evidence base
that is critical to advocacy for payment reform.
178. Empowering Employers
Think about ways in which your organization can take steps to increase
its support of employee caregivers. This can include items that are top-
down such as flexible leave time and geriatric care managers or
bottom-up such as brown bag info sessions and support groups.
Review the Employer Checklist and share with your colleagues. Take
proactive steps to implement one or more of the recommendations.
179. Faith & Diversity
Improve the quality of spiritual care across settings by reducing variations in the
quality of care, particularly for traditionally under-served and marginalized
populations.
Have clergy and faith communities help their members become more health care
literate and invite discussion and dialogue about how their faith, beliefs, and values
inform their health care choices.
Credential clinicians and other health care professionals caring for persons with
advanced illness based on their demonstrated ability to provide compassionate, high
quality, whole person centered care, and to attend to the physical, psycho-social,
and spiritual domains of care.
180. Policy & Advocacy
Identify policy barriers to fundamental system change leading to
more person-centered, comprehensive, team-based approaches to
caring for Americans with advanced illness and lay out a roadmap to
reform with legislative and regulatory remedies to overcome those
barriers
Design a targeted public engagement and advocacy campaign using
identified networks and working with messaging experts on
communication to create a grassroots and grasstops movement for
change
181. Policy & Advocacy
Action Steps from the Perspectives from the U.S. Senate: Achieving
High-Quality Advanced Illness Care for Our Seniors Panel:
•Developing a Brand/Common Terminology
•Supporting CMMI Innovation Challenge Awards/Pilots
•Partnering with Faith Leaders
182. Stay Engaged With C-TAC
For more information on joining C-TAC and participating in any
of our workgroups please visit: www.thectac.org or email
ctac@advancedcarecoalition.org.
Keep up with C-TAC on Twitter at: @CTACorg
The new affiliation will connect Henry Ford physicians, as on-call medical directors, to the 10 Southeast Michigan locations of MinuteClinic. In addition, MinuteClinic and Henry Ford will collaborate on educating patients and helping them to manage chronic diseases—including screenings and monitoring for diabetes, high blood pressure, and high cholestorol. Henry Ford physicians will accept patients who need a level of care that is not provided at MinuteClinic. Mark Kelley, M.D., executive vice president and chief medical officer of Henry Ford Health System, and CEO of the Henry Ford Medical Group. "We will be expanding our ability to provide appropriate care at the appropriate place. "Henry Ford doctors will consult with the on-site practitioners as needed. If people treated at a MinuteClinic do not have a primary care doctor for follow-up care, they will be given a list of local doctors, including Henry Ford physicians, from which to choose. “ MinuteClinic and Henry Ford will be developing a plan to provide clinical data integration to streamline communication for each person's care. With patient permission, MinuteClinic will share medical histories and visit summaries with other Henry Ford locations in Southeast Michigan. And MinuteClinic will continue its standard practice of sending visit summaries to the patient's primary care doctor, usually within 24 hours.
Eric
How many people work in an org that has work-life benefits or programs? Of those who raised hands – how many include grief, living with illness? How many employers educate staff re: ACP
Four EOL issues we are discussing are…. Three of them may impact some of your employees over time. ACP is something that you can promote to all employees. We ’ll talk about why as we review them. Employees with chronic health conditions put tremendous strain on employees Number of people with a chronic disease continues to increase Presenteeism costs are considered the largest costs of chronic health conditions – greater than direct medical costs (American Journal of Managed Care, 2006)
What work-life programs does your organization currently have related to work-life issues? These may seem like “nice to do, instead of need to do” but they can have a real payoff. Orgs of any size can do these.
I&R Explore local resources - AAA or united way, hospices, coalitions, etc have resources What will you offer? Printed materials, phone counselor, local org to manage the process (Fannie Mae) Publicize internally Evaluate – track inquiries, etc. Caregiver Directory of resources (print or online) Printed brochures Articles in employee newsletter re: caregiving Lunch and learns Support network – peer support, Lotsa Helping Hands, Share the Care Formal or informal caregiver support teams – volunteers providing support. Project Compassion www.project-compassion.org Lunch & Learns Based on assessment results Internal or external experts Advertise Evaluate Health fairs – efficient, table top displays, no cost Recruit diverse orgs Invite some re: advance care planning Grief If an employee dies, employee suffers a loss, employee seriously ill, critical or traumatic event Conduct meetings with the employees affected Provide education – supervisors and staff Offer support Be flexible Call local experts
Funeral/memorial – event We talked about grief (Bereavement) as a process. Grief is something people deal with for months. The grieving person can ’t “get over it” in 3-5 days. Funeral leave is what we call time after death for the “service” – minimum 3 days local, 5 days if travel for immediate family. Time off to attend service for colleague. Bereavement leave is available to employees when needed for up a year after death. Model policy has five days paid for immediate family – defined broadly. Basically it is a “trigger” for unscheduled leave. Employee can say “I need to take bereavement leave” by notifying supervisor . Small companies could adjust. It’s important to use language that differentiates between funeral/service and grief/bereavement. Sick leave – family-care and employee sick leave – need to specify in policies what sick leave can be used for – and communicate it Leave of absence – unpaid – typically 4 weeks or longer, case-by-case. Health insurance is offered but employee pays, accrual of benefits stops until employee returns Alternative work Job sharing Voluntarily reduced time Telecommuting Flextime – work hours change Compressed work week
If you change policies and don ’t tell anyone it doesn’t help. Communicate. Provide training annually on each of the EOL topics to assure supervisors know about policies and programs to support employees. Ask former or current caregivers or others who have experienced EOL issues to help create/modify or review policies Do not convey specific situations that employees face to other staff
