Primary Palliative Care

1. Palliative Care in Primary Care
Christian Sinclair, M.D., F.A.A.H.P.M.
Assistant Professor
Division of Palliative Medicine
University of Kansas Medical Center
Email: csinclair@kumc.edu
Office Phone: 913-588-3807
Twitter: @ctsinclair
19th Annual Primary Care Update

2. 19th Annual Primary Care Update
Relevant Disclosure
Under Accreditation Council for Continuing Medical Education
guidelines disclosure must be made regarding relevant financial
relationships with commercial interests within the last 12 months.
Christian Sinclair, M.D., F.A.A.H.P.M.
Commercial Interest
Nature of Relevant Financial Relationship
What was received? For what role?
Hospice Compassus Honorarium External Advisory
Board
The conflict was resolved by Dr. Sinclair agreeing to refrain from making clinical
recommendations on topics in which the conflict exists.

3. Learning Objectives
Upon completion of this session, participants will
improve their competence and performance by being
able to:
1. Increase patient completion of advance care plans in
a busy primary care clinic.
2. Apply new advance care planning billing codes to help
value time dedicated to goals of care.
3. Collaborate with palliative and hospice resources in
your community.

4. Palliative Care
• Not just for end-of-life
• Not just for crisis management
• Variable access and models
• “Extra layer of support”
• “A bridge across gaps in the road”
• Similar but different

5. …But Different
Palliative Care Hospice
Symptom management Symptom management
Whole-person care
(bio-psycho-social-spiritual)
Whole-person care
(bio-psycho-social-spiritual)
Emphasis on good communication Emphasis on good communication
Any age Any age
Palliative Care Hospice
Any stage End-of-life only
Prognosis: Life-threatening Prognosis: Terminal
Variable models Clear defined benefit
Not always widely available Widely available
Similar…

7. CAPC 2015

8. CAPC 2015

9. Hospice and Palliative Medicine
as a Specialty
• ABMS formally recognized HPM in 2008
• Nearly 7,000 HPM board certified doctors
• HPM Fellowships in 2015
– 123 programs for 280 positions
– University of Oklahoma College of Medicine
• AAHPM is the physician organization

10. HPM for PAs and NPs
• Advanced Certified Hospice and Palliative
Nurse (ACHPN)
– Through HPCC and HPNA
– Only 4 in Oklahoma
• Physician Assistants in Hospice and Palliative
Medicine (PAHPM)
– No formal certification (yet)

11. Primary vs Secondary
Palliative Care

13. Primary Palliative Care
• Provided by all health care professionals
• Management of chronic illness
• Basic symptom management
• Communication
• Advance care planning
• Care coordination

14. Lunney et al. JAMA 2003

15. Lunney et al. JAMA 2003

16. Gill et al. NEJM 2010

17. Gill et al. NEJM 2010

18. A Duty to Prognosticate?
• Patients accept built-in uncertainty
• Ask what your patients want to know
• “What I expect” & “What would surprise me”
• Make use of ranges
• Explain how you got there
• The role of advance care planning

19. Advance Care Planning (ACP)
• All starts with the goals of care
• Reframing ACP
– Adult responsibility not just for sick people
– Dynamic, ongoing process not just one and done
• Types of ACP
– Orders
– Proxy Identification
– Advance Directives

20. Advance Care Planning
Orders Proxy Identification Advance Directive
Examples DNAR; OkPOLST DPOA, State Law Living Will
For who? Seriously ill Any adult Any adult
Details Specific orders Primary, alternate General wishes
Ease of Access Stays with patient Variable Variable
When does it apply? When signed When incapacitated When incapacitated
Can EMS follow? Yes Yes No
HCP completes? Physician SW, RN can assist SW, RN can assist

22. New ACP Billing Codes
• Started Jan 1, 2016
• 99497 (approx $86)
– First 30 minutes of ACP planning
• 99498 (approx $75)
– Each additional 30 minutes of ACP planning
• Can be billed in addition to E/M codes*
• Inpatient and outpatient
• Documentation requirements

23. How to Document ACP
• Work with your colleagues to standardize
• Document time dedicated to ACP discussion
• Surpass at least half the time of the code
– 5 mins should not be enough to bill
• Scan or copy any documents completed
• Use quotes from discussion

24. Importance of Communication
• Communicating prognosis
• Breaking bad news
• Discussing disease transitions
• Coordinating care
• Providing support

25. Phrases to Avoid
• “There's nothing we can do for you.”
• “It's time to think about withdrawal of care.”
• “Do you want us to do everything that we can
to keep you alive?”
• “You've failed the treatment.”
• “I think you should consider hospice”

26. Diversity in Palliative Care
• Physician frankness
• Involvement of family members
• Preference for autonomy
• Decision making
• Advance care planning
• Religion and spirituality
• Social, education and family factors

27. Collaboration with Community
• What PC resources are in your community?
• What hospice resources are in your
community?
• Do you know a Hospice Medical Director?
• Are you a Hospice Medical Director?
• Meet

28. Resources
• OU Palliative Care Resource Center
• AAHPM
– American Academy of Hospice & Palliative Med
• EPERC
– End-of-Life/Palliative Education Resource Center
• CAPC
– Center to Advance Palliative Care
• Pallimed
• AAFP
– American Academy of Family Physicians

29. Conclusion and Clinical Pearls
• Palliative care is more than crisis management
• PC and Hospice - similar but different
• Understand trajectories & share expectation
• Engage your staff with ACP
• Document and code for ACP
• Improve your communication skills
• Collaborate with the H&PC community

30. Bibliography
• McCormick E, Chai E, Meier DE. Integrating palliative
care into primary care. Mt Sinai J Med. 2012 Sep-
Oct;79(5):579-85.
• Ngo-Metzger Q et al. End-of-Life Care: Guidelines for
Patient-Centered Communication Am Fam Physician.
2008 Jan 15;77(2):167-174.
• IOM (Institute of Medicine). 2015. Dying in America:
Improving quality and honoring individual
preferences near the end of life. Washington, DC: The
National Academies Press.