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Iowa Health System Leadership Symposium. Palliative Care and Hospice The “Final” Frontier. “I am not Dr. James Bell”. Palliative Medicine (IHS Affinity Group ).

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Iowa health system leadership symposium

Iowa Health System Leadership Symposium

Palliative Care and Hospice

The “Final” Frontier

Palliative medicine ihs affinity group
Palliative Medicine(IHS Affinity Group )

Palliative Medicine is a medical specialty that provides comprehensive, interdisciplinary care for patients with serious illnesses (and their families) with emphasis upon the quality of life and relief of suffering.  Palliative Care is provided throughout the trajectory of a disease process without regard to prognosis and can be provided in concert with curative care, as well as near end of life.  The Palliative Care team works with patients in conjunction with their primary care physician to address any physical, psychosocial, emotional or spiritual issues the patient may experience.

Palliative care
Palliative Care

Key domains

  • Goals of care

  • Symptom management

  • Resuscitation status

  • Advance Directives/DPOA

  • Psychosocial/Spiritual issues

    Key components

  • Focus on quality of life

  • Team approach for holistic care

    • Physician, nurse, social services, spiritual

  • Primary “procedure”: FAMILY MEETING

How dinosaurs became extinct the very first senior moment
How Dinosaurs became extinct (The very first “Senior Moment")

Palliative care is not
Palliative Care is Not:

Giving up

Pulling the plug

Losing hope

Stopping aggressive therapies

Shortening life

A very good name for what we do

Palliative care seeks to answer
Palliative Care seeks to answer

  • When does “living longer” become “dying slower”?

  • How can we remedy the deconstruction of humanity?

  • How can we accomplish this in a way that is ethically sound, clinically excellent, and fiscally responsible?

Palliative care vs hospice
Palliative Care vs. Hospice

  • Palliative Care is upstream. Primary determinant is potentially life-limiting disease (this differentiates from well elderly, frail, chronically ill but stable)

    • Often continue to seek aggressive treatments

    • Discussing choices with filter of quality of life

  • “Surprise question”

  • Hospice is that specialized form of Palliative Care with 2 requirements

    • Life expectancy of < 6 months

    • Focus on comfort

National landscape
National Landscape


Total health care costs in 2008 of $2.4 trillion (16% of GNP, rising to 20% in 2015)

Medicare hospital expenditures

2001: $93 billion (39% of total)

2004: $136 billion (44% of total)

2009: $220 billion (44% of total)

27-30% of total Medicare budget consumed in last year of life

Medicare Hospice expenditures 2008-- $11.4 billion (3% of total Medicare budget)


Population over 85 will double to 10 million by 2030

20% of U.S. population will be over 65 by 2035


U.S.– 53% die in hospital (not where they want)

With predicted 6 month survival of 50/50, 38% spend >10 days in ICU and 10% spend 4 weeks in ICU

50% of patients report moderate or severe pain at least half of the time in the last three days of life

Source: SUPPORT investigators, JAMA 1995

USA has poor ratings on quality measures of health care among industrialized countries (40th overall, 27th in life expectancy)

Hospice palliative care landscape
Hospice/Palliative Care Landscape

  • Hospice enrollment 1.5 million/year (2008)

    • 40% of all deaths

    • <50% cancer

  • 4000 Board certified HPM physicians (2010)

    • 1 physician/31,000 eligible patients

  • Specialty status under ABMS (began 2007)

  • Palliative care programs

    • 33% of all hospitals

    • 55% with >50 beds

    • 80% with >250 beds

Iowa health system leadership symposium

  • The case for a strong presence of Palliative Care and Hospice in the US is clear based on

    • Dramatically longer life expectancy

    • Dramatically larger cohort of older Americans

    • Dramatically increased health care costs for the sickest segment of the population

    • Well documented benefit

  • Palliative Care and Hospice has grown and developed significantly over the last decade, and there is a developing framework for best practices

Healthcare quality
Healthcare Quality Hospice in the US is clear based on

  • Quality is

    • Patient-centered

    • Beneficial

    • Timely

    • Safe

    • Equitable

    • Efficient

  • Measuring quality

    • Structure

    • Process

    • Outcome

  • Measurement of quality requires data!

    National Quality Forum

    Institute for Healthcare Improvement

I m a doctor not a starship captain
Hospice in the US is clear based on I’m a doctor, not a starship captain!”

Ihs hospice programs
IHS Hospice Programs Hospice in the US is clear based on

Ihs palliative care programs
IHS Palliative Care Programs Hospice in the US is clear based on

Iowa health system palliative care hospice
Iowa Health System Hospice in the US is clear based on Palliative Care/Hospice

  • IHS Hospice Affinity Group, Palliative Care Affinity Group

    • Des Moines, Cedar Rapids, Quad Cities, Waterloo, Cass County, Fort Dodge

      • Development of statewide data base

      • Development of metrics

        • Inpatient

        • Outpatient

      • Support program development for affiliates with early or no programs

  • Physician Affinity Group

    • Support physician training and certification in HPM

    • Support statewide efforts to develop shared database and metrics

    • Support best practices in the system by demonstrating value, reducing variability (2011 focus on symptom management)

Ihs palliative care metrics
IHS Palliative Care Metrics Hospice in the US is clear based on

  • Inpatient

    • Consultation volume

    • Consultation rate

    • Length of stay

    • Length of stay outliers

    • Cost savings on impact days

    • Billable revenue

    • Pain

    • Dyspnea

  • Outpatient

    • Consultation volume

    • Discharge distribution

    • Readmission to acute inpatient care

Cost avoidance
Cost Avoidance Hospice in the US is clear based on

Average hospital charge day
Average hospital charge/day Hospice in the US is clear based on

Iowa health system palliative care hospice1
Iowa Health System Hospice in the US is clear based on Palliative Care/Hospice

  • How we manage to collect data and demonstrate quality and value will likely dictate success or failure in the approaching health care arena

  • Will be reflected in our ability to negotiate value-based contracting

  • The Iowa Health System is poised for success by virtue of

    • Leadership with vision

    • Willingness to allocate resources

    • Critical mass

    • Clinical expertise