Community-based Palliative Care: Trends, Challenges, Examples and Collaboration with Payers - Eric Wall, MD, MPH
Presented at the 2015 Palliative Care Summer Institute conference at Bellingham Technical College
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Community-based Palliative Care: Trends, Challenges, Examples and Collaboration with Payers - Eric Wall
1. Community Based Palliative
Care: Trends, Challenges,
Examples, and Collaboration
with Payers/Insurers
Eric Wall, MD, MPH
NW Medical Director
United Healthcare
3. Agenda
Goals of Palliative Care
The Cast of “Players”
Trends
Challenges
Examples of Community-based initiatives
Working with Payers/Insurers
4. Oh Death
Oh death, oh death
Won't you spare me over till another year
Well what is this that I can't see,
With ice cold hands taking hold of me
Well I am death none can excel,
I'll open the door to heaven or hell
Whoa death someone would pray,
Could you wait to call me till another day
I'll fix your feet till you can't walk,
I'll lock your jaw till you can't talk
5. Palliative Care
Care, not cure
Relief- from symptoms, pain,
stress
Focus= quality of life- patient
and family
Control over choices and care:
patient and family
6. Lean On Me
Sometimes in our lives, we all have pain
we all have sorrow.
But if we are wise, we know that
there’s always tomorrow.
Lean on me, when you’re not strong
and I’ll be your friend, I’ll help you carry on.
For it won’t be long, ‘til I’m gonna need
somebody to lean on.
Please swallow your pride, if I have faith
you need to borrow.
For no one can fill those of your needs
that you won’t let show.
You just call on me brother, when you need a hand.
We all need somebody to lean on.
I just might have a problem, that you’ll understand
We all need somebody to lean on.
7. Who Really Provides Palliative
Care?
Individual
(Patient)
Family
Community
Everyone
Else?
8. The “Players” in Palliative
Care
Palliative Care
Hospice
Family
Community
Medical
Care
Payers
9. The “Medical” Care Team
PCP Nurses
Palliative Care
Specialists
Case Managers Social Worker
Complementary
Care
10.
11. You’ll Never Walk Alone
When you walk though a storm
hold your head up high
and don’t be afraid of the dawn.
At the end of the storm is a golden sky
and the sweet silver song of the lark.
Walk on through the wind,
walk on through the rain,
though your dreams be tossed and blown.
Walk on, walk on, with hope in your heart
and you’ll never walk alone.
You’ll never walk alone.
12. Trends/Statistics
90 million Americans with serious chronic illness (expected
to double in 25 yrs)
1/1000 in commercially insured populations
5-10/1000 estimated in Mcare population
46% of family caregivers perform medical/nursing tasks for
care recipients with multiple chronic physical and cognitive
conditions (AARP, 2012)
20% of Mcare recipients with 5 or more chronic conditions=
2/3 of Mcare spending
Approximately half of all dying patients will receive some
form of pain management care
>35% of patients referred to hospice had length of service <
7 days
13. Bridge over Troubled Water
When you’re weary, feeling small
When tears are in your eyes, I will dry them all.
I’m on your side, when times get rough
And friends just can’t be found
Like a bridge over troubled water
I will lay me down
When you’re down and out
When you’re on the street
When evening falls so hard
I will comfort you
When pain is all around
Like a bridge over troubled water
I will lay me down
15. Challenges
Glass half empty:
FINANCIAL: need for bundled
payment/creative financing models
that are sustainable
Resistant hospital/medical community
Unfamiliar public and provider
Uncoordinated care
“Piece of the action”/Turf wars
Quality of care issues
16. Challenges
Glass half full:
Patients/families have high satisfaction
with care
Providers have high satisfaction in care
delivery
NO one is closer to the patient than
the caregivers and care providers
Payers know palliative care saves
money
21. Questions for Community-based
Palliative Care Start-ups
Local needs assessed?
Well-articulated goals?
What will it provide?
Who will it serve?
How will it be financed?
Who will orchestrate, coordinate,
define services provided (e.g.
Governance)?
22. There’s a Bright Side
There’s a bright side somewhere
I ain’t gonna rest until I find it
There’s a bright side somewhere
There’s more joy somewhere
I ain’t gonna rest until I find it
There’s more joy somewhere
There’s more love somewhere
I ain’t gonna rest until I find it
There’s more love somewhere
There’s more peace somewhere
I ain’t gonna rest until I find it
There’s more peace somewhere
23. Examples
Community-based Hospice care
Hospice “hub” with palliative care community
outreach/clinic: Lexington, KY; Falls Church, VA;
Flat Rock, NC
MD led
Financially challenged
Promotes earlier hospice referrals
Outpatient clinic-based palliative care
Most often affiliated with an oncology practice
Typically subsidized by hospital/health system
Health system integrated palliative care (Kaiser, VA,
Sutter Health, etc.)
Other models (IPA, medical group, home health, etc.)
24. Community Example: Midwest
CareCenter
Community based nonprofit started 1978
Hospice and Palliative care based in Chicago area providing care in
150 Illinois communities
Home based or inpatient hospice
“Your goals=our goals”
Palliative care, hospice care
Organization:
Executive staff, medical staff
Volunteer Board
Advisory Council: Medical/Community Leaders
Service Board: generates funding/community awareness
Cost/Coverage: Insurance, Medicare, charity care, financial
assistance
25. Payer Example: Blue Shield of CA HMO-
Patient-Centered Management (PCM) of
Complex Patients
Complex care team: Goal-oriented care plans for seriously ill
patients
Care manager (RN): onsite assessment/education/ongoing
contact, home visits
Team manager (RN): coordinated team reviews/liaison to
health plan
MD: provided clinical information, anticipated medical
problems, liaison with patient;s treating MD
Not provided: medical treatment, home care, authorization of
medical services
No added expense to patients/families
26. Blue Shield of CA HMO-
Patient-centered Management of Complex Patients-
Intervention
In-Home evaluation: domain weakness,
knowledge, treatment plan, terminal care
plan, benefit plan management, family/living
environment, provider support
Weekly team meetings: link to providers,
health plan
High frequency outbound patient calls (2-3x
wk)
Intervention ended when goals set out at
beginning (understanding, hospice plan) were
achieved
27. Blue Shield of CA HMO-
Patient-centered Management of
Complex Patients: Results
Different treatment choices made
Increase adherence with care
plans/understanding of medications
Decreased use of hospital/ER
Increased use of home care/hospice
Reduced expenses (+ ROI)
Huge patient/caregiver satisfaction
28. You’ve Got a Friend
When you’re down, and troubled
And you need a helping hand
And nothing, no nothing is going right.
Close your eyes and think of me
And soon I will be there
To brighten up, even your darkest nights
When you call out my name
You know wherever I am,
I’ll come running to see you again.
Wintertime, summer or fall,
All you’ve got to call.
And I’ll be there. You’ve got a friend.
30. Working with Payers/Insurers
Find an influential champion (case
manager, medical director)
Identify benefits (eg. medical,
hospice, etc.)
Collaborate on creative solutions
Bundle/package services to work
around non-traditional service
delivery
I have many musician friends in the Bellingham community who influenced my approach to this subject. It may at times seems like a musical journey down palliative care lane so for that, I must apologize.
Ralph Stanley
This is how I approached the subject of palliative care in preparing for this talk
I learned a great deal to change my musical impression and I hope you will too.
In reality, this is the care we should be delivering to all people- I discovered this while researching this topic.
-Any age, any stage, any diagnosis
-Team-based
-Can be provided with treatment
At least 3 types of palliative patients:
those with curable diseases, such as a 23-year-old with leukemia who receives a bone marrow transplant with a 70-percent success rate;
those with serious or complex medical illnesses such as emphysema, MS, diabetes or even Alzheimer's disease that may last for decades;
those with progressive incurable diseases such as metastatic cancer.
Bill Withers showed what we have to offer in delivering quality palliative care
Hospice= palliative care for patients with < 6 month prognosis
Notice the absence of the hospital
There are many care players in palliative care and as you may imagine, this sometimes can be quite challenging. I will return to this later
Rodgers and Hammerstein- amazing this was for the musical Carousel
Inspirational in nature and the theme, “you’ll never walk alone” is the back drop behind the care support for patient and family
So if you truly understand what palliative care is all about, these statistics demonstrate that there are clearly not enough palliative care specialists available to meet the needs of all Americans with complex chronic and serious illnesses
In a 2012 AARP survey, :
-78% of family caregivers who provided medical/nursing tasks were managing medications, including administering intravenous fluids and injections
-38% of those caregivers providing wound care wanted more training
-Most family caregivers who provided help with medical/nursing tasks believed they were helping their family member avoid institutionalization
More than 1/3 of patients had hospice referrals so late in the course of their illness that they and their families had little time to benefit from the services
Abbreviated Paul Simon
So what are the challenges for palliative care today given these trends and statistics?
Other challenges:
-Evidence-based showing positive outcomes is lacking including cost-reductions
-No benchmarks/normative data for staffing or best practices
-Who benefits from the care besides the patient/family enough to pay for the services?
-Lack of qualified/credential personnel
-Unclear relationship between primary and specialist-level palliative care
Studs Terkel
October 2001 Issue
On December 23, 1999, as I was beginning to interview people for a new book on death and dying, my wife, Ida, died. She had been my companion for sixty years. She was eighty-seven. A few months later a friend of mine, disturbed by my occasional despondency, burst out, "For chrissake, you've had sixty great years with her!" Ida had lived seventeen years beyond her traditionally allotted three score and ten, though on occasion I'd heard her murmur in surprise, "Why do I still feel like a girl?"
They were roller-coaster years we shared, after I first spotted her, in a maroon smock, in 1937. She was a social worker during most of those tumultuous years: the Great Depression, World War II, the Cold War, Joe McCarthy, the sixties, the civil-rights and peace movements. She was, as they say, "involved." Garry Wills remembers her greeting him, years after the Vietnam War had ended, with "Oh, we were arrested together in Washington."
A year or so before Ida's death Laura Watson, a neighbor, "looked out the window and saw this slim young girl in jeans, with a flower in her hair, plucking out weeds in her garden." The girl looked up. "It was Ida, of course." Yes, she did live to the ripe old age of eighty-seven, but it doesn't cut the mustard, Charlie. I still see that girl in the maroon smock who liked yellow daisies. Each week there is a fresh bunch of yellow daisies near the windowsill. On the sill is the urn containing her ashes. On occasion, either indignant or somewhat enthusiastic about something, I mumble toward it (her), "Whaddya think of that, kid?"
Naturally, when I pick up a newspaper these days, the first place I turn to isn't sports, or arts, or the business of business, or the op-eds. I immediately turn to the obituaries. The old doggerel with which many mature readers may be acquainted has become my mantra.
I wake up each morning and gather my wits, I pick up the paper and read the obits. If my name is not in it, I know I'm not dead, So I eat a good breakfast and go back to bed.
Consensus Guidelines from National Quality Forum (2006)
Community-based palliative care: outside the hospital, outside of regulatory and reimbursement structures of hospice care under Medicare
Medicare’s reimbursement does not support registered nurses, social workers, bereavement counselors, other kinds of therapists, and the administrative staff needed for an effective advanced illness management program. Given the unreliability of philanthropic or grant funding, many community-based programs struggle for survival.
More joy, more love, more peace- indeed these are the goals of palliative care
Community-based palliative care programs are often not part of integrated health care systems or medical centers which can subsidize its affiliated programs. Supporting a multi-disciplinary team, thesine qua non of quality palliative care, cannot be achieved with traditional Medicare fee-for-service reimbursement alone
James Taylor, Carole King: The anthem of palliative care?
This reflects my changed attitude towards palliative care. I hope you agree
Monthly case rates, that is, fixed amounts paid each month for all services provided, could potentially fund community-based, non-hospice palliative care. This approach is a viable alternative to fee-for-service. . A monthly rate that averages $800-$900 can support the entire team and meet the needs of a patient and his or her family to achieve an optimum level of independence in the community.
High case rates for adult and pediatric palliative care are justifiable if there are substantial savings from reduced hospital admissions, ICU use, readmissions, and emergency department visits; and quality indicators indicate high patient and family satisfaction as
