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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 ‎

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Thursday september 19 2013 audio conference 1 30 2 30 pm eastern

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 ‎

Thursday september 19 2013 audio conference 1 30 2 30 pm eastern

  • 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

Building better home based palliative care outline
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

Challenges of chronic serious illness
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


  • Discoordinated care

  • Lack of psychosocial support

  • Inadequate attention to goals/preferences

  • Poor symptom management

Slide 4

Where do we start
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

Claim conceptual model jr
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

Preliminary evidence impact on 30 day readmissions
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

Claim design
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

Which patients
Which Patients?

  • What eligibility criteria should we use?

Slide 10

Could we use hospice eligibility criteria
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

Services presented in interviews
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

Sample interview question
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

Do hospice eligibility criteria identify patients with the greatest needs
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

Would jr have met hospice eligibility criteria
Would JR Have Met Hospice Eligibility Criteria? Greatest Needs?

  • 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

Designing ideal palliative home care use the tools you have
Designing Ideal Palliative Home Care: Greatest Needs?Use the Tools You Have

Slide 16

Claim eligibility skilled home care eligibility
CLAIM Eligibility: Skilled Home Care Eligibility Greatest Needs?

  • Eligibility: Cancer plus…

    • Skilled nursing need

    • Homebound

  • Advantages:

    • Simple

    • Already codified and understood

    • Existing revenue stream

    • Scalable

Slide 17

Which services
Which Services? Greatest Needs?

  • Which services should we offer as part of a palliative home care program?

Slide 18

Utilities of palliative home services patients with cancer families n 474
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

Claim services
CLAIM Services Cancer/Families (n=474)

  • Visiting nurse plus:

    • Nurse case management

    • 24-hour triage

    • Emergency scripts

    • Medication management

    • Chaplain

    • Social worker

    • Home health aide

    • Consulting physician oversight

Slide 20

Claim project design
CLAIM Project Design Cancer/Families (n=474)

  • 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

Claim experience
CLAIM Experience Cancer/Families (n=474)

  • 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

Staffing model
Staffing Model Cancer/Families (n=474)

  • RN caseload 12-15 (acceptable)

  • SW caseload 25-35 (too high)

  • Chaplain caseload 40-50 (underutilized?)

  • One NP for entire program (inadequate)

Slide 23

Staffing model mistake 1
Staffing Model (Mistake #1) Cancer/Families (n=474)

  • One NP inadequate

  • Goals/responsibilities:

    • Triage/safe landing

    • Staff education

    • Curbside consults

    • Home visits

      • Symptoms

      • Goals discussions

      • Liaison to oncologists

Slide 24

Staffing model mistake 2
Staffing Model (Mistake #2) Cancer/Families (n=474)

  • 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

Staffing model mistake 3
Staffing Model (Mistake #3) Cancer/Families (n=474)

  • 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

Lessons surprises
Lessons/Surprises Cancer/Families (n=474)

  • 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

Thursday september 19 2013 audio conference 1 30 2 30 pm eastern
JR Cancer/Families (n=474)

  • 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

The future of palliative home care
The Future of Palliative Home Care Cancer/Families (n=474)

  • Home-based

  • Population-centered

  • Increasingly integrated with inpatient and outpatient care

  • Quality-driven

  • Funded by cost-avoidance/gain-sharing

Slide 29

Present and future
Present and Future Cancer/Families (n=474)

“The future is here now. It’s just not very evenly distributed.”

-William Gibson

Slide 30

Collaborators Cancer/Families (n=474)


  • 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

Question answer period
Question & Answer Period Cancer/Families (n=474)

Thank you for joining us today!


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

Thursday september 19 2013 audio conference 1 30 2 30 pm eastern

Continue the Discussion on Cancer/Families (n=474)

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:

to post your message and comments within the

“Palliative Care Outpatient Services”

discussion topic!

Slide 33