PALLIATIVE CARE Why?

1. PALLIATIVE CAREWhy? Australian College of Nursing Victorian Chapter 7 February 2013 Helen Walker Cabrini Palliative Care

2. Current Scene Clinical Outcomes Economic Advantages Role of Health Funds Future Trends

3. PALLIATIVE CARE • Aims to optimise quality of life of patients and their families facing a life limiting illness. • It can be offered at anytime after a diagnosis and integrated into the overall treatment plan. • The palliative approach needs to be practiced by all health care practitioners with assistance from specialist services as required.

4. CHANGING DEMOGRAPHICS • Australia has an ageing population • Increased life expectancy • Decreasing fertility rates • % over 65s increasing • Over 85 aged group growing • – increased health care needs • International trend • ‘Sea change’ phenomena • Cultural diversity • Older age of carers

5. AGING POPULATION • Both the number of deaths and proportion of people aged 65 or over will dramatically increase in upcoming decades. They project: • 1:4 of the population will be aged 65 or older as opposed to 1:8 in 2009. • Pattern of disease changing - to include complex chronic illness in a higher proportion of the population. • An increasing focus on palliative care service provision. • (AIHW 2011)

6. PROJECTED DEATHS

7. Insured persons by age cohort

8. Current service issues Australia is faced with an ageing population and therefore an increasing prevalence of age-related chronic conditions, such as cancer, organ failure, and dementia, which may require palliative care. (Australian Bureau of Statistics, 2009).

9. Current Service Levels Each year in Australia, approximately 134,000 die and approximately half of these deaths are classified as expected, suggesting a large demand for palliative care services. (CareSearch-Palliative Care Knowledge Network, 2012; Gordon, Eager, Currow, & Green, 2009)

10. DEATH TRAJECTORIES Understanding what happens at end of life, helps us to plan, involve patients and families, support and provide best care.

11. Sudden death vs Cancer vs Chronic Illness vs Frail Aged Sudden death Time course to death

12. Sudden death vs Cancer vs Chronic Illness vs Frail Aged Sudden death Cancer Time course to death

13. Sudden death vs Cancer vs Chronic Illness vs Frail Aged Sudden death Chronic illness Time course to death

14. Sudden death vs Cancer vs Chronic Illness vs Frail Aged Sudden death Time course to death

15. Models of Palliative Care in Australia • Palliative care is provided by public, non-government and private organisations, through a combination of delivery models, including: • Designated hospice services • Designated palliative care units in acute and sub acute hospitals • Non-designated inpatient palliative care services in acute or sub acute hospitals • Ambulatory palliative care hospital services • Specialist palliative care community services • Primary care community-based services • (Gordon, et al., 2009)

16. Models of Palliative Care in Australia By international standards, Australia has been described as having impressive palliative care coverage of 85% of the population, delivered through flexible models of care across inpatient, outpatient and home settings. (Gomes, Harding, Foley, & Higginson, 2009)

17. Palliative Care Services in the Australian Private Sector • Privately insured patients: • Have an expectation their insurance will cover them through all aspects of their illness journey and not cease when curative treatment is no longer appropriate. • Are unable to access palliative care - therefore receiving more expensive, and at times, aggressive treatment in the final stages of life in a private acute hospital, which may not be the best place of care on many fronts.

18. Preferred place of death – need to invest • Most people want to die at home • Many don't get this opportunity • Many reasons – many with a solution • Deaths in acute facilities are often problematic • We need to invest in community support to address this problem – cheaper than ICU

19. Models of Palliative Care in Australia However, more progress is required, with regard to the establishment of flexible funding and financing models to improve integration of care and encourage service substitution across settings. (Gordon, et al., 2009)

20. Strategic Frameworks Australian Government and States and Territories have developed over arching strategic frameworks to guide the formation of palliative care policies, including funding arrangements and structures for service delivery (e.g. Strengthening palliative care: Policy and Strategic Directions 2011-2015, Victorian Department of Health, 2011).

21. Website Brochure New Patient Information Media Building the Narrative 1 Informing and involving clients and carers Mentorship of Professional Bodies Proposal for funds to support increased care packages for carers 2 Caring for carers NSAP 4 Providing specialist care when and where it is needed 3 Working together to ensure people die in their place of choice Client and carers Advance Care Planning CABRINI HEALTH APPROACH Education 5 Coordinating care across settings Research Green Sleeve Protocol Quality Boosting Community Services 7 Ensuring support from communities 6 Providing quality care supported by evidence Press Ganey • Integrated Model • Consult • - Case Management Cabrini Hiealth Integrated Services Model

22. Providing specialist services to ensure all patients/residents in a Cabrini Health Facility will receive end of life care – the right setting in the right way INTEGRATED PALLIATIVE CARE CABRINI HEALTH MODEL

23. Clinical Outcomes Clinical Outcomes

24. Building Rigour in Palliative Care The Australian Government has, as part of its palliative care strategy, a goal to build clinical evidence, quality and measurement in the sector. To this end, it has funded the Palliative Care Outcomes Collaboration (PCOC), Care Search and the National Standards Assessment Program.

25. Why are Health Funds concerned about Palliative Care? Senate Enquiry into Palliative Care, October 2012 Committee commented as follows: “The committee acknowledges that in the future, demand for palliative care services will increase as the population ages. As more Australians invest in private health insurance, the committee calls on the private health sector to contemplate the role they might play in helping meet the growing demand for comprehensive palliative care. The committee considers that further research into the potential role of the private health sector, including private health insurers, in providing palliative care services is required and suggests that the federal government initiate such a review.”

26. PCOC A 15% improvement in clinical outcomes has been demonstrated nationally since 2009 - with all but 5 specialist units in Australia participating in this robust program.

32. PCOC • By standardising palliative care assessments, PCOC has: • Led to the development of a common language in palliative care • Allowed for clinical outcomes to be measured and compared • Facilitated the development of benchmarking in the palliative care sector.

33. Mean Survival for Lung Cancer Patients Mean Survival for Pancreatic Cancer Patients Days p=0.0102 n=493 n=386 Days p=0.0001 n=700. n=586 Average hospice length of stay was 38 days Average hospice length of stay was 47 days 279 210 189 240 PALLIATIVE CARE EXTENDS LIFE Usual Patients Hospice Patients • Study in Brief: Comparing Hospice and Non-hospice Patient Survival • Retrospective review of 4,493 patients using Medicare claims data • Included patients with six terminal diagnoses: congestive heart failure, breast cancer, colon cancer, lung cancer, pancreatic cancer, prostate cancer. • Patients were assigned to hospice group if they had at least one hospice claim within three years of their diagnosis • Average hospice length of stay was 43 days • Survival difference was not statistically significant for breast and prostate cancer patients

34. TOI3 Symptom Management Scores FACT-L1 Symptom Management Scores LCS2 Symptom Management Scores p=0.009 n=74. n=77 p=0.03 n=74. n=77 p=0.04 n=74. n=77 Higher scores indicate fewer symptoms, better quality of life 98 92 59 53 21 19 Usual Care Palliative Care Usual Care Palliative Care Usual Care Palliative Care

35. A service complementing curative therapies Curative Treatment Palliative Care Spec PC Bereavement VALUE OF PALLIATIVE CARE

36. Economic Benefits

37. Private Health Insurance and Palliative Care • In 2008/2009: • 77% of palliative care was provided for public patients • 16% of this cohort were funded by private health funds, and • 7% by the Department of Veterans Affairs • (AIHW, 2011)

38. Why are Health Funds concerned about Palliative Care? • Palliative care is seen as a “bottomless pit” and not a “prudent investment”, by some health insurers. • Concern that there is no legislative barrier to funds placing palliative care in their schedules.

39. Private Health Insurance and Palliative Care Home based palliative care services are premised on the fact the needs of most palliative care patients can be met through the primary health care system including the GP. Benefits are generally structured based around an initial visit, usually by a nurse and paid on a daily basis, irrespective of the number of visits per day. Allied Health is not funded in the payment, nor is medical support, personal care or equipment and medical supplies. Bereavement services are provided in most cases.

40. Private Health Insurance and Palliative Care • Potential benefits of health insurance funds covering out of hospital home based palliative care services include: • Decreased re-admission rates. • Increased savings from lower readmission rates to hospital and shorter duration of hospital stay. • Decreased waiting periods for accessing publicly funded home based palliative care services (which can result in adverse patient episodes and prolonged hospital admission). • Immediate access to these services in the home upon discharge -significantly improving outcomes.

41. Future Trends

42. Influences? • Equity of Access – from Rolls Royce for some to Mercedes Benz for all • Role of the Private sector • Population aging • National Standards • Euthanasia debate • Person centred care movement • Education/Research

43. In the future: • Have built capacity and capability across the health system to manage terminal illness and death • The quality of the way we die won’t be determined by lottery • Will be patient and family choice • Will be quality community services • %futile treatment would have decreased • Symptom burden at end of life decreased • Bereavement programs in place • More even service distribution in 3rd world • More people comfortable to discuss death and dying in the community

44. Health Promotion • http://www.compassionatecommunities.ie/about#bills-story-video

45. HALLMARKS OF SUCCESS