Measuring the Impact of Palliative Care Programs

1. Measuring the Impact of Palliative Care Programs February 2, 2010 Department of Veterans Affairs Audio Conference 1:30 – 2:30 PM EST Carol A. Luhrs, MD Chief of Hematology/Oncology Brooklyn Campus of VA New York Harbor Healthcare System Director, Palliative Care, VISN 3 Director, CELC Implementation Center Associate Professor of Clinical Medicine SUNY-Downstate Medical Center, Brooklyn, NY E-mail:carol.luhrs@va.gov R. Sean Morrison, MD Director, National Palliative Care Research Center Hermann Merkin Professor of Palliative Care Professor of Geriatrics and Medicine Vice-Chair of Research Brookdale Department of Geriatrics and Palliative Medicine Mount Sinai School of Medicine Staff Physician James J. Peters VAMC, Bronx, NY E-mail: sean.morrison@mssm.edu Web: http://www.npcrc.org/

2. Learning Objectives • In this audio conference, you will: • Use national quality standards and benchmarks • of palliative care quality • Discuss data collection tools for measuring • the impact of your program • Examine tips and techniques for measuring the • impact of palliative care

3. Our current health care industry Medical errors Risks that often outweigh benefits Preventable suffering Wasted resources Inequitable access to care Variability in care

4. The Quality Chasm The American health care delivery system is in need of fundamental change….Health care today harms too frequently and routinely fails to deliver its potential benefits…Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge. Yet there is strong evidence that this frequently is not the case. Quality problems are everywhere, affecting many patients. Between the health care we have and the care we could have lies not just a gap, but a chasm. IOM: Crossing the Quality Chasm: A New Health System for the 21st Century

5. What is Quality? Quality is the degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

6. Quality Healthcare Source: Institute of Medicine Patient centered Timely Beneficial Safe Equitable Efficient

7. Palliative Care and Quality Mr. M., an 89 year old retired machinist: Admitted to the hospital for scleroderma and progressive kidney failure. Declined hemodialysis. Palliative care consult called to assess patient’s capacity to refuse dialysis and to assure that he was not suicidal. Discharged home with hospice after 5 days. Did well at home for 4 months. Said good bye to his grandchildren, his son, and his friends, then died quietly at home 3 days later.

8. How did palliative care deliver quality? • He received good hospital palliative care. • Goals of care assessment, development of a care plan consistent with goals, symptom management, discharge planning • Transitioned effectively to, and received good care from, hospice at home. • Meticulous symptom management, psychosocial support from hospice RN, SW, MD to patient and his distressed family and friends. Assured a peaceful dignified death at home How would you measure and report this?

9. The Purpose of Measurement External Quality Assessment Internal Quality Assessment Research/Exploratory Quality Improvement Initiatives

10. External Quality Measures Undertaken at the behest of purchasers, government, regulatory bodies Required, designed for broad audiences, undertaken across multiple organizations simple, consistent, inexpensive High standard of reliability/validity desirable with respect to the relationship between processes and outcomes consequences for provider choice, certification, reimbursement

11. Internal Quality Measures Undertaken by institutions providing care Voluntary, limited audiences, usually undertaken within a single organization As detailed, intense, and comprehensive as desired by their initiates

12. Research/Exploratory Quality Improvement Initiatives Undertaken within organizations, provider groups, research initiatives Voluntary, exploratory, small scale feasibility studies exploratory with respect to links between processes and outcomes As detailed, intense, and comprehensive as desired by their initiates

13. Measuring Quality Structure characteristics of the physician or health care institution (e.g., credentialing of palliative medicine professionals, presence of a palliative care program) Process encounters between the patient and health care institution/provider (e.g., appropriate referral for palliative care, concurrent laxative treatment with opioid therapy) Outcome the persons subsequent health status (e.g., reduction in symptom distress, improved quality of life)

14. The link between structure, process, and outcome Structure and process indices are most useful as quality indicators if changes in the attributes that they measure have been shown to improve patient outcomes. Outcome indices are most useful as quality indicators if they can be linked to specific process or structural measures that if altered, change the outcome.

15. Which really means… • Providers should not measure nor be held accountable for: • Outcomes that have not been shown to be alterable by processes or structures under their control • Processes or structures that have not been shown to improve outcomes

16. The Dilemma Facing Palliative Care • Current research does not yet provide a sufficient evidence base to support links between structure-process-outcomes for key palliative care domains: • Quality of life, family burden, spiritual well being, bereavement, continuity, pain and other symptoms • Quality measures are becoming the foundation for healthcare reform • Required by payors, regulatory bodies, certifying agencies • Palliative care cannot afford to ignore quality

17. Unintended Consequences of Inadequate Quality Measures Burden and expense of measuring outcomes that we may not be able to tell someone how to alter Results of a poor measure may look as authentic as the results of a good measure Risk of diverting resources to problems being assessed to the detriment of equally and more important problems not being assessed (e.g., advance directives)

18. What Should I Do? • Develop a plan for internal quality measurement • Participate in national discussions regarding external quality measures • Be aware of unintended consequences • Be prepared and flexible for implementation of sub-optimal external quality measures

19. External Quality for Palliative Care • National Consensus Project • National Quality Forum • VA

20. National Consensus Project • Coalition of CAPC, NHPCO, AAHPM, HPNA, and Last Acts • Purpose • To define an effective national consensus process for establishment of clinical practice guidelines for quality palliative care in the United States. • To develop such guidelines through an evidence-based review process involving major palliative care organizations in the U.S. and a large number of professionals in diverse disciplines. • Identifies core precepts and structures of palliative care in 8 domains www.nationalconsensusproject.org

21. National Quality Forum Framework for Palliative Care • Public-private partnership organization charged with advancing the quality of health care in the United States • Established 38 preferred practices associated with quality palliative care http://www.qualityforum.org/pdf/reports/palliative/txPHreportPUBLIC01-29-07.pdf

22. Internal Quality Measurement • What makes a good measure? • What are my measures? • How should I measure it?

23. What makes a good measure? • Uniform • Core set for all hospitals • Balance utility with data collection ease • Based on best available evidence • Primarily structure and process measures • Select outcome measures • Allows comparisons across institutions to guide programmatic growth, ensure compliance with best practices, and explore quality • Not measures of quality because not (yet) linked to outcomes!

24. What are my metrics? • Operational • Does my program have the features required to provide high quality palliative care? • What metrics do I need to measure in order to demonstrate my program has these core features? • Clinical • Am I improving the clinical care of patients? • Symptom assessment scores, psychosocial assessment scores • Customer • Am I meeting the needs of patients and families? • Satisfaction survey data: patient, family, referring clinician

25. CAPC Metrics • Specific operational details necessary for sustainable high-quality hospital palliative care programs • Developed by consensus panels of PCLC experts, CAPC staff, and CAPC consultants led by David Weissman, MD • Interdisciplinary representation from academic and community hospitals, single hospitals and large health care systems, and from programs coordinated by hospice agencies and hospitals • Operationalizes the National Quality Forum Framework • 38 preferred palliative care practices • Detailed descriptions available in Journal of Palliative Medicine and at www.capc.org

26. What makes a good measure for VA? • Uniform • Data is easy to collect • Based on best available evidence • Allows comparisons across institutions to • Guide programmatic growth • Ensure compliance with best practices • “Explore” quality

27. Measuring the Quality of VA Palliative Care Programs

28. Measuring Quality: Structure • Palliative Care Leadership in every VISN* • Program Manager and Clinical Champion • Palliative Care Consult Team in every VA facility* • Interdisciplinary Staffing • Expertise/Board Certification • Hospice & Palliative Care Units • Homelike setting; adequate number of beds • Dedicated interdisciplinary staffing • Expertise/Board Certification of unit staff • Policies and Procedures *VHA Directive 2008-066 Palliative Care Consult Teams

29. Measuring Quality: Processes of Care TransformationalMeasure% Inpatient Deaths with an associated palliative care consult

30. Structure and Process Measures Words of Caution • Structure and process indices are most useful as quality indicators if the changes that they measure improve patient outcomes. • Providers should not be held accountable for processes or structures that have not been shown to improve outcomes. It is essential to link structures and processes to outcomes.

31. Quality in VA PC ProgramsLinking structures and processes with outcomes Disseminating Best Practices Bereaved Family Survey PROMISE* Center David Casarett, MD Philadelphia VA Center for Health Equity Research and Promotion QI Pilots Implementation Center Carol Luhrs, MD VA-NY Harbor HCS Resources & Tools QI Resource Center Karl Lorenz, MD Great Los Angeles VA *Performance Reporting and Outcomes Measurement to Improve the Standard of care at End-of-life

32. Defining the Palliative Care ConsultQuality Improvement Resource Center • Identify required elements of palliative care consults • Develop a national palliative care consult template • Why? • Standardizes the processes of care delivered • Promotes interdisciplinary involvement • Allows comparisons across institutions • Captures consultation workload • Collects clinical and operational data for program evaluation

33. National Bereaved Family Survey Overall Goal: To define and disseminate processes of care that contribute to improved outcomes for Veterans near the end of life and their families. • Framework – based on the domains of the National Consensus Project guidelines • Data Collection • Outcomes of care - Bereaved Family Survey • Processes of care - Chart Reviews

34. Bereaved Family SurveyUnderstanding process-outcome relationships • Processes of care identified by chart review • Patient admitted to Hospice & Palliative Care Unit (HPC) • Palliative care consultation note • Chaplain contact with Veteran and family • Goals of care discussion • Do these processes of care affect the outcome, i.e., family perception, of the Veteran’s care?

35. Bereaved Family Survey Linking process with outcomes

36. Bereaved Family Survey Linking process with outcomes (continued) Proportion of families who reported that they received enough bereavement support

37. Quality Improvement PilotsImplementation Center • Quality Improvement (QI) Pilot • Test the intervention with facility Palliaitve Care Teams • Data collection by the PROMISE Center • Feedback to the participating Teams • Modification or spread of the intervention • Current QI Pilots • Bereavement (Emotional Support After Death) • Spiritual Support

38. VA as a Learning Healthcare System

39. References • Weissman DE, Meier DE: Operational features for hospital • palliative care programs: consensus recommendations. J Palliat • Med 11:1189-1194, 2008 • Weissman DE, Meier DE: Center to Advance Palliative Care. • inpatient unit operational metrics: consensus recommendations. • J Palliat Med 12:21-25, 2009 • Weissman DE, Meier DE, Spragens LH: Center to Advance • Palliative Care. Palliative care consultation service metrics: • consensus recommendations. J Palliat Med 11:1294-1298, 2008 • Weissman ED et al. Center to Advance Palliative Care. Palliative Care • Clinical Care and Customer Satisfaction Metrics: consensus • recommendations. J Palliat Med, in press. • VHA Directive 2008-066: Palliative Care Consult Teams

40. Additional VA Website Resources PROMISE Center http://www.cherp.research.va.gov/PROMISE.asp Implementation Center https://vaww.visn3.portal.va.gov/sites/NationalImplementationCenter/default.aspx

41. Question & Answer Period Thank you for joining us today! ABOUT CAPC The Center to Advance Palliative Care (CAPC) provides health care professionals with the tools, training and technical assistance necessary to start and sustain successful palliative care programs in hospitals and other health care settings. Located at Mount Sinai School of Medicine, CAPC is a national organization dedicated to increasing the availability of quality palliative care services for people facing serious, complex illness. CAPC is supported by Archstone Foundation, The Atlantic Philanthropies, Brookdale Foundation, The Donaghue Foundation, The Fan Fox and Leslie R. Samuels Foundation, The John A. Hartford Foundation, New York State Health Foundation, The Olive Branch Fund, Robert Wood Johnson Foundation, The United Hospital Fund and The Y.C. Ho/Helen and Michael Chiang Foundation. Direction and technical assistance are provided by the Mount Sinai School of Medicine, New York City.

42. Continue the Discussion! At the conclusion of this audio conference, we welcome you to continue the discussion in two ways: • Join the AACT conference call scheduled for Thursday, Feb 4, 2010 at 3pm ET • Dial: 1 - 800 - 767-1750 and enter Access Code: 35929# • Post your questions and comments on the VHA National HPC Mail Group • Go to the Global Address Book in Outlook and scroll down to “VHA National Hospice & Palliative Care” to post your message and comments