Thursday, September 19, 2013 Audio Conference 1:30 – 2:30 PM EASTERN

1. Building the Future of Home-Based Palliative Care Thursday, September 19, 2013 Audio Conference 1:30 – 2:30 PM EASTERN David Casarett, MD, MA Associate Professor of Medicine Chief Medical Officer Penn-Wissahickon Hospice University of Pennsylvania Philadelphia, PA ‎ casarett@mail.med.upenn.edu

2. JR: • A 54 year old man admitted to the hospital via the ED for management of pain due to metastatic colon cancer. • He has severe pain (8/10) on admission, for which he is taking OTC acetaminophen. • Has been admitted 4 times in 6 months for pain (2x), nausea/volume depletion, and altered mental status. • His wife is overwhelmed with caregiving and is particularly interested in learning about resources for caregiving support. Slide 2

3. Building Better Home-based Palliative Care:Outline • The role of palliative care for health systems that care for patients like JR • Designing home-based palliative care • Which patients? • Which services? • CLAIM program • Preliminary experience • Early mistakes and lessons learned • The future of palliative home care Slide 3

4. Challenges of Chronic, Serious Illness For patients/families For health systems? High-cost care Frequent (re)hospitalizations Dissatisfaction with care (HCAHPS scores) Financial penalties/adverse effect on public reporting Leverage • Discoordinated care • Lack of psychosocial support • Inadequate attention to goals/preferences • Poor symptom management Slide 4

5. Where Do We Start? “I rob banks because that’s where the money is.” -Attributed to Willie Sutton by reporter Mitch Ohnstad The truth: “Why did I rob banks? Because I enjoyed it.” -Willie Sutton Slide 5

6. CLAIM Conceptual Model Slide 6

7. CLAIM Conceptual Model: JR • Advance care planning • Had clear but unrecognized preferences to avoid hospitalization. (>10% of patients; Casarett, JCO 2010; Casarett, JAGS 2009, Lynn JAGS 1997) • Case management • JR’s wife couldn’t reach his oncologist; called 911 • Symptom control • Admitted to the hospital for pain that could have been managed at home Slide 7

8. Preliminary Evidence: Impact on 30-day Readmissions • 2 years’ UPHS home care and palliative care patients (n=27,429 total) • Palliative care (n=1,103): • Hospice nurse • 24/7 triage • 30-day readmissions (p<0.001)*: • Home care: 12.4% • Palliative care: 6.3% *Propensity score matched on : Age, gender, living situation, cognitive impairment, pain, dyspnea, ADLs, overall health, rating of risk of rehospitalization, DNR (In press; Journal of Palliative Medicine) Slide 8

9. CLAIM Design • Patients with cancer • Additional services layered on to home nursing • Goal: Demonstrate that additional services result in reduced costs (acute care utilization) • But: • Which patients? • Which services? Slide 9

10. Which Patients? • What eligibility criteria should we use? Slide 10

11. Could We Use Hospice EligibilityCriteria? • 2 studies of patients with cancer: • Cross-sectional (300 patients, 174 family members) • Longitudinal (128 patients) • Setting: • 6 oncology clinics within the University of Pennsylvania Cancer Network • Eligibility: • Patients who would have a prognosis of 6 months or less if they discontinued disease-modifying treatment (in the judgment of the patient’s oncologist) Slide 11

12. Services Presented In Interviews • Visiting nurse • Chaplain • Transportation • Counselor • Respite care • Meal delivery • Peer support group • Care of family member (child/parent) • Home health aide/voucher • Telephone case management Slide 12

13. Sample Interview Question If these two home care service plans were exactly the same in every other way, which would you prefer? Please select the number that best describes how you feel Slide 13

14. Do Hospice Eligibility Criteria Identify Patients with the Greatest Needs? • Prognosis: Significantly higher needs for all services among patients in the last 6 months of life • Focus on comfort care: Patients who are willing to forgo aggressive life-sustaining treatment don’t have greater needs for services Casarett D, Fishman J, O’Dwyer PJ, Barg FK, Naylor M, Asch DA. How should we design supportive cancer care? Journal of Clinical Oncology. 2008. 26 (8): 1296-1301. Casarett D, Fishman JM, Lu HL, O’Dwyer PJ, Barg FK, Naylor MD, Asch DA. The terrible choice: re-evaluating hospice eligibility criteria for cancer. Journal of Clinical Oncology. 2009. 27(6): 953 -9. Slide 14

15. Would JR Have Met Hospice Eligibility Criteria? • A 54 year old man with pain due to metastatic colon cancer. But: • Uncertain prognosis • Wants to continue receiving treatment for cancer (chemotherapy, erythropoetin, transfusions) • Hospice eligibility criteria won’t work • Then what eligibility criteria should we use for home-based palliative care? Slide 15

16. Designing Ideal Palliative Home Care: Use the Tools You Have Slide 16

17. CLAIM Eligibility: Skilled Home Care Eligibility • Eligibility: Cancer plus… • Skilled nursing need • Homebound • Advantages: • Simple • Already codified and understood • Existing revenue stream • Scalable Slide 17

18. Which Services? • Which services should we offer as part of a palliative home care program? Slide 18

19. Utilities of Palliative Home Services (Patients with Cancer/Families (n=474) Casarett D, Fishman J, O’Dwyer PJ, Barg FK, Naylor M, Asch DA. How should we design supportive cancer care? Journal of Clinical Oncology. 2008. 26 (8): 1296-1301. Slide 19

20. CLAIM Services • Visiting nurse plus: • Nurse case management • 24-hour triage • Emergency scripts • Medication management • Chaplain • Social worker • Home health aide • Consulting physician oversight Slide 20

21. CLAIM Project Design • Patients with primary/secondary cancer diagnosis who qualify for skilled home nursing care • CLAIM services vs. routine home care • Propensity score match (e.g. based on previous hospitalizations, DNR status, ADL dependencies, Pain, Dyspnea) • Follow-up: • Process measures • Outcome measures (including cost) Slide 21

22. CLAIM Experience • 380 patients served between November 1, 2012 and June 30, 2013 • Current ADC 90-100 • Approximately 50% of referrals from hospital discharge • Approximately 90% with hospitalization in previous 3 months Slide 22

23. Staffing Model • RN caseload 12-15 (acceptable) • SW caseload 25-35 (too high) • Chaplain caseload 40-50 (underutilized?) • One NP for entire program (inadequate) Slide 23

24. Staffing Model (Mistake #1) • One NP inadequate • Goals/responsibilities: • Triage/safe landing • Staff education • Curbside consults • Home visits • Symptoms • Goals discussions • Liaison to oncologists Slide 24

25. Staffing Model (Mistake #2) • Staffed/reimbursed from grant on a per-visit basis • (Accounting: Total salary for RNs x % of visits for CLAIM=RN salary for CLAIM) • Advantages: • Easy scale up • Clear paper trail and robust compliance readiness • Disadvantages: • Leaves $ unspent during ramp-up • Limited capacity Slide 25

26. Staffing Model (Mistake #3) • Reliance on hospice staff • Rationale: Already have the necessary skills and experience. • But may not have ‘upstream’ skills • Goals discussions • Evaluation and problem-solving when goal is life prolongation (terminal delirium vs. delirium cased by hypercalcemia) • Cancer-specific knowledge/skills Slide 26

27. Lessons/Surprises • Nurse practitioner support: Priceless • Chaplain support: Not so much • The importance of an ‘Other’ budget line • Wound care supplies • Transportation • Catheter supplies • DME • etc. Slide 27

28. JR • Discharged to palliative home care • Next 4 months: Multiple clinic visits, no hospitalizations • Use of home infusion 2x for hypovolemia • Transition to hospice; on hospice for 6 weeks; died at home Slide 28

29. The Future of Palliative Home Care • Home-based • Population-centered • Increasingly integrated with inpatient and outpatient care • Quality-driven • Funded by cost-avoidance/gain-sharing Slide 29

30. Present and Future “The future is here now. It’s just not very evenly distributed.” -William Gibson Slide 30

31. Collaborators Support • Jennifer Kapo MD • Joan Harrold MD • Amy Corcoran MD • Mary Naylor RN PhD • Thomas Ten Have PhD • Knashawn Morales ScD • Karen Hirschman PhD • Jessica Fishman PhD • Sharon Xie PhD • Joan Teno MD MS • David Asch MD MBA • Jason Karlawish MD • Neville Strumpf RN PhD • NCI, NIAID, CMS, AHRQ, Paul Beeson Physician Scholars Award, American Cancer Society, Commonwealth Fund, Greenwall Foundation. • CMMI 1C1CMS331016 (The project described was supported by Funding Opportunity Number CMS-1C1-12-from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. Its contents are solely the responsibility of the authors and have not been approved by the Department of Health and Human Services, Centers for Medicare & Medicaid Services.  Slide 31

32. 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. CAPC is a national organization dedicated to increasing the availability of quality palliative care services for people facing serious illness. Slide 32

33. Continue the Discussion on CAPCconnectTM Forum! At the conclusion of this audio conference, we welcome you to continue the discussion with your peers and faculty on CAPCconnectTM Forum! Go to: http://www.capc.org/forums to post your message and comments within the “Palliative Care Outpatient Services” discussion topic! Slide 33