Living at the end of your life. The Impact of Palliative Care

1. Living at the end of your life.The Impact of Palliative Care Thank you to: Robert E. Weissinger, D.O. Chief Medical Officer Hospice and Palliative Care Mercy Medical Center – North Iowa

2. Objectives • Why it is important to keep people in their own living setting at the end • How physicians can help people live

3. Palliative Care • Palliative Care is specialized medical care focused on providing relief from symptoms, pain, and stress of serious illness - whatever the diagnosis. • It is appropriate at any age and at any stage of a serious illness, and can be provided together with curative treatment. The goal is to improve quality of life for both patient and the family.

4. Palliative Care • Palliative Care, unlike Hospice Care, is not defined by a patient life expectancy.

5. Palliative Care • Ninety million Americans are living with serious illness and this number is expected to more than double over the next 25 years.

6. Palliative Care • By 2030 there will be more than 72.1 million Americans over 65 in the U.S. (20% of the total U.S. population). • This is more than twice the number in 2000.

7. Palliative Care • Despite the highest per-capita spending on health care in the world, 50% of caregivers of Americans hospitalized with a serious illness report less than optimal care. • More than 30% of families lost most or all of their savings while caring for a loved one with a serious illness.

8. Palliative Care • 5 million Americans die from chronic illness each year. • 70% are admitted to the hospital in the last 6 months of life.

9. Palliative Care • One in four patients report inadequate treatment of pain and shortness of breath • One in three families report inadequate emotional and spiritual support • One in three patients report that they receive no education on how to treat their pain and other symptoms after a hospital stay • One in three patients are not provided with arrangements for follow-up care after hospital discharge

10. Palliative Care • “Geography is Destiny” holds true when speaking of access to hospitals offering Palliative Care • Large Hospitals >/300 Bed - 85% have Palliative Care • Public Hospitals - 54% have Palliative Care • For-Profit Hospitals - 26% have Palliative Care • Community Provider Hospitals - 37% have Palliative Care

11. Palliative Medicine Service Evolution March 2012 Palliative Outreach Clinic at Concord Care Center Garner, Iowa January 2013 Telemedicine services begin at outreach clinic sites September 2011 CMO position begins Mercy Medical Center – North Iowa August 23, 2013 Mercy Medical System Presentation: Feasibility of Palliative Telemedicine Services Palliative Outreach Clinic at Kossuth Regional Hospital Algona, Iowa November 2011 Palliative Emergency Room Team (P.E.R.T.) created May 2013 Two additional ICF facilities commit to Palliative Telemedicine Services January 2012 First Palliative Outreach Clinic – Hampton Rehab Center Hampton, Iowa June 1 – December 31 Telemedicine Infrastructure Developed/Presented September 2011 Palliative Medicine becomes 24/7 service line July 2013 Palliative Telemedicine framework begins • Palo Alto County Health System, Emmetsburg, Iowa • Hancock County Memorial Hospital, Britt, Iowa February 2012 Palliative Outreach Clinic at Franklin General Hospital Hampton, Iowa

12. Mercy Medical Center – North Iowa Service Area

13. Mercy Palliative Care (PC) Inpatient Consults and Outpatient Visits (Annualized Data)

14. Reason for Mercy Palliative Care Inpatient Consults (Annualized Data)

15. Mercy Palliative Care Inpatient Consult Diagnosis (Annualized Data)

16. Mercy Palliative Care Pain Scores (Inpatient)Lower Score at Discharge Better

17. Mercy Palliative Performance Scale (Inpatient)Higher Score at Discharge Better

18. Mercy Palliative Care HCAHPS – Would Recommend(Percent of Top Box – Always) Data not available Data not yet available

19. Mercy Palliative Care Inpatient Discharge Disposition (Annualized Data)

20. Mercy Palliative Care Revenue Generation (in thousands) .55 Million .25 Million (Actual)

21. Mercy Palliative Care Total Operating Expenses vs Total Cost Savings(in thousands) 3.5 Million FY 10 FY 11 FY 12 .55 Million Total Cost Savings = Palliative Care Net Revenue plus Total Cost Savings plus Crisis Avoidance

22. Cost Savings – Relevant Study • Morrison, R.S. et al (2008). Cost savings associated with US hospital palliative care consultation programs: Archives of Internal Medicine 168(16): 1783-1790. • Over 4900 palliative care patients in 8 hospitals with well established palliative care programs • Two categories of discharge disposition: alive and dead

23. Cost Savings - Findings • Discharged Alive • Net savings in total costs = $2642 per admission ($279 per day) • Net savings in direct costs = $1969 per admission ($174 per day) • Discharged Dead • Net savings in total costs = $6896 per admission ($549 per day) • Net savings in direct costs = $4908 per admission ($374 per day)

24. Cost Savings - Findings • Discharged Alive • Statistically significant reductions in laboratory and ICU costs • Discharged Dead • Statistically significant reductions in pharmacy, laboratory, and ICU costs

25. Mercy Palliative Care Cost Savings (in thousands) – Total Costs 1.9 Million (Annualized Data) Total Cost Savings Discharged Alive = $2642 per admission; total cost savings discharged dead = $6896 per admission

26. Mercy Palliative Care Cost Savings (in thousands) - Direct Costs 1.25 Million (Annualized Data) Direct cost savings discharged alive = $1696 per admission; direct cost savings discharged dead = $4908 per admission

27. Mercy Palliative Care ICU Consults (Annualized Data)

28. Mercy Palliative Care ICU Cost Savings (in thousands) .43 Million (Annualized Data) ICU Cost Savings of $5178 per admission

30. Mercy Health Network – Central IowaTelemedicine - 3 Phase Action Plan • Phase 1 • Coordinate educational programs for providers via teleconference to outline service characteristics of palliative medicine and determine level of interest • Develop a site specific program tailored to the culture of each site via on-site meeting with key personnel (providers, I.T., SLT) • Develop a roll-out time frame • Activate telemedicine service from base program with board certified palliative medicine specialist (Mercy Medical Center – North Iowa)

31. Mercy Health Network – Central Iowa Telemedicine - 3 Phase Action Plan • Phase 2 • Evaluate relative value to providers, administration, and patient base via satisfaction survey • Identify physician leader and initiate EPEC training series – Primary Palliative Care • Identify nurse leader and initiate ELNEC training series • Begin telemedicine mentoring program for primary palliative care team to support inpatient and outpatient palliative care • Facilitate active relationship between local primary palliative care providers and local hospice service • Establish data parameters and metrics • Initiate data collection

32. Mercy Health Network – Central Iowa Telemedicine - 3 Phase Action Plan • Phase 3 • Move individual sites to independent primary palliative care status • Provide ongoing mentoring and support for primary palliative medicine providers via telemedicine conference from base program • Integrate data for Mercy Health Network • Establish standards of practice for primary palliative care providers • Utilize evidence based medical practices to support ongoing education and outcomes • Analyze data points that track patient and provider satisfaction

33. Conclusion • Focused efforts by Hospital Administration, the health care community, and policy makers are required to promote the development of quality Palliative Care programs in all Hospitals. • Special attention is needed in small, rural public and for-profit hospitals. • This will result in a more efficient and effective use of hospital resources and will enhance the quality of care delivered to our nations most seriously ill patients and their families.

34. CBS Sunday Morning • Documenting a good death • http://www.youtube.com/watch?v=0-v53ANYIsU&feature=youtube_gdata • Preparing for final days • http://www.youtube.com/watch?v=UNUx_MrAjr8

35. Mitch Albom • http://www.youtube.com/watch?v=rPN8KuiDh_s