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Palliative Care Benchmarking: Timing is Everything. Mary Ann Gill, RNMA Executive Director, Palliative Care Services Project Manager, Palliative Care Leadership Center . Presented at Recovering Our Traditions II— Journey to Excellence A Catholic Health Care Perspective

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palliative care benchmarking timing is everything

Palliative Care Benchmarking: Timing is Everything

Mary Ann Gill, RNMA

Executive Director, Palliative Care Services

Project Manager, Palliative Care Leadership Center


Presented at

Recovering Our Traditions II—

Journey to


A Catholic Health Care Perspective

On End-of-Life Care

January 26-28, 2006

San Antonio, Texas


Sponsored by

Supportive Care Coalition

Pursuing Excellence in Palliative Care

Catholic Health Association

of the United States

The George Washington

Institute for Spirituality and Health

  • Palliative Care: Mount Carmel’s history and evolution
  • Infrastructure, Models
  • Strategies to achieve Quality
  • Establishing Benchmarks
mount carmel multi hospital system with vertical integration
Mount Carmel: Multi-Hospital System with Vertical Integration
  • Serving Columbus, Ohio, for >125 years
  • Three hospitals -- 53,000+ inpatient admissions
  • Care Continuum-- Hospice, Homehealth, +
  • College of Nursing, Medical Education
  • ASC’s and UCC’s
  • Owned Physician Practices
  • Medicare +Choice Product
  • Member, Trinity Health System
the mount carmel hospice
The Mount Carmel Hospice

Operating since 1985

Established presence in health system

Initiated collaboration re: system-wide pain management program in 1994

Historic presence in hospital ethics committees

Focus of Hospice – care at home

mount carmel palliative care services
Mount Carmel Palliative Care Services

Palliative Care

HospiceAcute Palliative Care

Consult ServiceAPC Units

mount carmel acute palliative care initial vision
Mount Carmel Acute Palliative Care : Initial Vision

Optimal pain and symptom management (physical, emotional, spiritual) for hospitalized patients with chronic advanced diseases

Competent response to patient directives, choices

Timely transfers from ICU, ED, SNF

Concurrent disease focused treatment + palliative care

Effective Continuum to Hospice

strategy understand chronic disease
Strategy: Understand Chronic Disease
  • Chronic disease is continuous with episodic acuity
  • Chronic disease consumes 78% of healthcare expenditures
  • Characterized by shifting severity, pace, setting, and treatment
  • So multifaceted must involve IDT, care coordination
  • Must be able to weave the care of specialists into the overall plan
background hospitals current challenges
Background:Hospitals’ Current Challenges
  • More chronically ill patients often spending 10 or more days in ICU
  • Many DRGs cover 50% cost of ICU, yet market presses for more ICUs
  • Boutique hospitals attracting patients
  • Hospitalists replacing Primary Care physicians
  • Increasing numbers of uninsured or Medicaid
background hospital survival strategies
Background: Hospital Survival Strategies
  • Reduce variable costs
  • Reduce LOS (especially ICU)
  • Increase Physician Satisfaction
  • Increase Patient Satisfaction
  • Meet Healthcare report card benchmarks and become “best hospital”
background hospice and homehealth realities and survival strategies
Background: Hospice and Homehealth Realities and Survival Strategies
  • Earlier referral
  • Appropriate Hospital Discharge Plan
  • Access to patients in hospital to plan admission
  • Increase LOS to provide care and spread costs
  • Advance Care Planning process in place
  • Adherence to formulary
background sources of evidence
Background: Sources of Evidence
  • SUPPORT Study
  • Dartmouth Studies
  • National Concensus Project,
background support recommendations
Background: SUPPORT Recommendations

Create palliative care in hospitals

  • interdisciplinary team process
  • patient and family focus
  • pain and symptom management focus
  • ready access to Palliative Professionals
background why palliative care is needed in hospitals
Background: Why Palliative Care Is Needed in Hospitals

Chronically ill patient volume projections

Hospitals struggling with how to manage this population re: LOS, resource utilization

>50% patients die in hospitals = hospitals should be greatest source of Hospice referrals

Hospitals need to import Hospice paradigm to create effective management of chronic disease and in-hospital mortality.

strategy articulate a vision
Strategy: Articulate a Vision

Optimal pain and symptom management (physical, emotional, spiritual) for hospitalizedpatients with chronic advanced diseases

Competent response to patient directives and choices

Timely transfers from ICU, ED, SNF

Concurrent oncology treatment and palliative care

Seamless continuum to community

strategy clearly define terms
Strategy: Clearly Define Terms

Hospice Care: Interdisciplinary care for dying patient with predictable prognosis; also for family– spiritual, emotional support--primarily in home setting including bereavement support

MC Acute Palliative Care: Interdisciplinary care for seriously ill patient with unpredictable prognosis during acute hospitalization ; spiritual/emotional support for patient/family; concurrently preparing for improvement or decline/death

strategy use hospital data to determine need
Strategy: Use Hospital data to determine Need
  • 5% Hospital Admissions annually
  • Top 20 DRGs resulting in death
  • Readmission rates within 6 months
  • Number of SNF patients entering ED
  • ICU deaths post 5 day LOS
strategy define program
Strategy: Define Program
  • In-Patient or Out-pt Consult Service? Units? Upstream or End of Life?
  • Administrative Responsibility
  • Location
  • Staffing
  • Routine, Standard Processes
  • Continuum Partners
strategy describe tools needed
Strategy:Describe Tools Needed

Standard admission orders and criteria

Rounds Worksheet

Procedures: e.g. Palliative Extubation

Educational materials

  • Staff/Students/physicians
  • Patient/family

Data Base

strategy define routine processes
Strategy: Define Routine Processes
  • Interdisciplinary Team Functionality (team rounds, IDT conferences)
  • Palliative Consultation- physician, nurse clinician roles in coordination, mentoring
  • Intensive pain/symptom management /protocols
  • IDT education, competency development
  • Data collection, analysis, feedback
  • Continuum interface
strategy employ processes for palliative chronic disease management
Strategy: Employ processes for Palliative Chronic Disease Management

Care Coordination across settings

Education of patient to interpret symptoms to team and to provide self management

Adaptation by all to changing role of physician (cardiologist to palliative physician and team)

Emphasis on behavioral techniques to understand impact of chronic disease

Problem: None of this is norm in chronic disease management

Holman,H. JAMA September 1, 2004, vol 292, no. 9

strategy differentiate patienttypes
Strategy: Differentiate PatientTypes

Patients with exacerbation of chronic illness who choose palliative life-extending treatment

Patients receiving disease-directed treatment who may benefit from palliation of sx arising from disease or treatment

Patients with serious, life-limiting illnesses for whom hospitalization often segue into Hospice

Patients with acute event such as CVA

strategy determine referral source criteria process and management
Strategy: Determine Referral Source, Criteria, Process, and Management
  • ICU Physicians and Staff
  • ED Physicians and Staff
  • Oncology Physicians and Staff
  • Nephrology Physicians and Staff
  • Case Management Staff
  • Hospitalists Physicians
strategy create a palliative care continuum
Strategy: Create a Palliative Care Continuum

Presence / collaboration-- hospital Ethics committees and consultations

Develop tools which support continuum--

Develop processes to identify continuum patients who enter hospital through Emergency Department

Explain/ Understand Reimbursement ramifications fo all partners

strategy build rapid cycle organic quality processes importance of timing
Strategy: Build Rapid Cycle, “Organic Quality Processes & Importance of Timing
  • Patient, family, physician, PC Team determine care plan concurrently
  • Plan checked daily for validity by the palliative care team
  • Benefits/burdens of treatment weighed daily
  • Plan Changed rapidly if indicated
  • Family support ongoing and into bereavement
  • Discharge planning initiated on entry
strategy define relevant data
Strategy: Define Relevant Data
  • Patient demographics
  • Clinical Characteristics

Functional status


Advance directive status at time of consult

Presence and timing of DNR orders

  • Pain and other symptoms
  • Evidence-based Interventions
  • In-hospital and ICU death rate and length of stay
  • Discharge destinations, -- hospice, homehealth, SNF, home referrals
  • Readmission Rates
  • New patients, all patients served
  • Total Admissions to APCUs
  • Most Frequent Symptoms
  • % Cancer/Non Cancer
  • ALOS on APCU or Consultation
  • % from ICU, IMCU
  • ALOS in prior unit
  • P/F Satisfaction (HCAHPS) “Would you recommend?”
data cont d
Data Cont’d
  • PPS
  • CMI
  • Variable Cost Savings
  • Contribution to Overhead
  • % transferred to hospices
  • Hospice ALOS
delineate clinical benchmarks
Delineate Clinical Benchmarks

Accessible, expert Advance Care Planning begins at initial consult

Assessment of patients’ needs for effective pain/symptom management at each encounter

Provision of Interdisciplinary palliation for patients and families within explicit time frames -

Timely transfer of patients from ICU and ED into APCS; from APCUs to Hospice & to other providers

sample diagnosis types
Sample: Diagnosis Types

Primary Diagnosis %

Cancer 38.6%

Non Cancer 61.4%

Cardiac 17.0%

Pulmonary 15.3%

CVA 9.6%

sample discharge destinations
Sample: Discharge Destinations

Continuum (48% Discharged)


Home Hospice 25.2%

ECF Hospice 8.8%

ECF-Skilled 7.1%

Homehealth 3.7%

Other 3.9%

hospital reimbursement basics
Hospital Reimbursement Basics

Medicare Prospective Payment System

Major Disease Categories

Diagnosis Related Groups

Case Mix Index

Comorbidities and complications

Expected Costs and Expected Payments

Based on Bell Shaped Curve Utilization

hospital reimbursement variables
Hospital Reimbursement Variables

Principal Diagnoses mapping to DRG

Co-morbidities & Complications effect payment

Impact of Palliative Consultant and Attending Physician Documentation on DRG

  • MedPac Report to the Congress: Medicare Payment Policy March, 2002
hospital costs rev vs los
Hospital Costs & Rev vs LOS

ICU @ $750 /day+



Cost per day

LOS (Days in acute care bed)

strategy palliative financial management
Strategy: Palliative Financial Management
  • LOS Reduction=ICU Palliative Consultation at day X
  • Variable Cost Reduction = Earlier Transfer from ICU
  • Direct Admissions = Avoiding ICU, Control LOS
  • Consultation Team Productivity Standards
financial benchmark processes
Financial Benchmark Processes
  • Permeable relationship between Clinical and Financial components
  • Commitment to Financial Data Collection
  • Using Data to demonstrate cost savings
  • Effective Care Coordination impact on variable costs
  • Early Identification Criteria impact on LOS management
  • Effective Payer strategies
strategy manage payers
Strategy: Manage Payers
  • Education of Commercial Payers
  • Coordination with Provider Relations
  • Challenge denials
  • MedPac Report to the Congress: Medicare Payment Policy March, 2002
  • Just getting to the data
  • Understanding it
  • Interpreting it so as to project volumes and revenues
how apcs controls costs
How APCS Controls Costs
  • Coordination of Services
  • Reduce LOS (Early Discharge)
  • Change of setting (Transition from ICU)
  • Change of Payer (Transition to HMB)
strategy financial management
Strategy: Financial Management

Reduce variable costs and LOS by transferring ↑ ICU patients earlier

Create net income contribution ↑direct admissions to APCU’s freeing ICU beds and ending ED diversion

Reduce variable costs through improved coordination of care and discharge planning

Meet payer requirements by documenting need for inpatient care and DRG coding

Maintain efficient, properly documented billing by palliative physicians

minimum standard acute palliative care
Minimum Standard: Acute Palliative Care

Consult service regularly available in hospital to facilitate palliative evaluation and management of symptom burden

Supported by Interdisciplinary Process

stepwise approach toward achieving palliative benchmarks
Stepwise Approach toward achieving Palliative Benchmarks
  • Minimum Standard
  • Increased Presence, Breadth and Depth of Services
  • Routine Identification of Appropriate Patients in ED, ICU
  • Routine Advance Care Planning from hospital admission through inpatient course
  • Coherent System of Palliative Care from primary care through hospitalization, to discharge destination
sharpening the saw example acp
Sharpening the SawExample: ACP

Preliminary Discussion

Formal ACP session by trained professionals

Use of Valid, Reliable, Standardized Tool

System in place to process/ accomodate choices

Repository for storing and updating Directives

L Bierbach. St Vincent Health System, Billings Montana ,

benchmark processes and timing
Benchmark Processes and Timing
  • Timing/frequency of rounding assessment
  • Timing of post assessment intervention
  • Timing of ICU Intervention and Transfer
  • Timing of ED Palliative Triage and Intervention
  • Timing of Initial Advance Care Planning Assessment and follow-up discussions
  • Extent to which Family is involved
  • Valid, Reliable Measurement of Symptoms
Patient/Proxy/Family Satisfaction %

Timing/ frequency of Hospice Transfers

Timing Palliative Care Recommendations Implemented

palliative care benchmarks timing
Palliative Care Benchmarks/Timing

Patient status assessed within x days of admission

Pain and Symptoms measured numerically

Pain and Symptoms reduced within 48 hours

Discharge Planning by day x

Psychosocial Assessment by SW by day x

Family Meeting by day x

University Health Systems Palliative Care Benchmark Field Book 2004 Unpublished

predictors of success
Predictors of Success
  • Strong Advocate for System Change
  • Physician “buy in”
  • Partnership with accessible and flexible Hospice
  • Consistent presence of Palliative Physicians, Nurse experts to mentor, teach
  • Commitment to Data collection/analysis
  • Commitment to Quality Improvement
  • Commitment to Financial Management
  • Openness to learning hospital culture