Pal­lia­tive care boosts ACO re­sults

Modern Healthcare - - BEST PRACTICES - By Bob Her­man

In 2005, Dr. Robert Saw­icki and his staff at OSF Health­Care, based in Peo­ria, Ill., de­cided they needed to do a bet­ter job of car­ing for ter­mi­nally ill pa­tients. This was nearly 10 years be­fore the In­sti­tute of Medicine’s Dy­ing in Amer­ica re­port de­tailed how pa­tients need­lessly suf­fer in their fi­nal days, months and years.

But as lead­ers at the Catholic-based sys­tem ex­plored the is­sue, they dis­cov­ered pal­lia­tive care went far be­yond help­ing pa­tients who were close to death. “We very quickly re­al­ized you can­not do good end-of-life care if you wait un­til the end of life,” said Saw­icki, OSF’s se­nior vice pres­i­dent of sup­port­ive care who prac­tices fam­ily medicine. “You have to start it way up­stream.”

OSF launched a pal­lia­tive-care pro­gram that year, and has since made it an in­te­gral part of its accountable care or­ga­ni­za­tion struc­ture. The pro­gram started at a time when pal­lia­tive care was in its rel­a­tive in­fancy as a med­i­cal spe­cialty and was of­ten mis­tak­enly equated with hospice care. As ex­perts in the field like to say, all hospice is pal­lia­tive, but not all pal­lia­tive is hospice.

Pal­lia­tive care is based on the needs and de­sires of pa­tients, not their prog­no­sis. Doc­tors, nurses, so­cial work­ers and other care­givers work to­gether to of­fer medicine and ther­a­pies to re­lieve pain and im­prove pa­tients’ qual­ity of life. The process is just as ap­pro­pri­ate for Alzheimer’s dis­ease pa­tients with a decade to live as it is for can­cer pa­tients with only weeks to live.

When OSF be­gan its Medi­care Pi­o­neer ACO in 2012, which it still op­er­ates, Saw­icki said pal­lia­tive care im­me­di­ately be­came a big­ger pri­or­ity. ACOs are de­signed to im­prove health­care qual­ity while low­er­ing costs. Stud­ies have shown pal­lia­tive care in­creases pa­tient sat­is­fac­tion, re­duces ad­verse symptoms and has the po­ten­tial to save money.

Pal­lia­tive care is most ef­fec­tive for those who have the most se­ri­ous, lin­ger­ing health prob­lems, said Dr. Diane Meier, direc­tor of the New York-based Cen­ter to Ad­vance Pal­lia­tive Care. Roughly 5% of pa­tients ac­count for more than half of U.S. health­care costs, ac­cord­ing to gov­ern­ment es­ti­mates. The vast ma­jor­ity of those high-cost pa­tients are not in their fi­nal year of life.

So OSF started iden­ti­fy­ing its high­risk pa­tients and ini­ti­ated ad­vance care plan­ning. Linda Fehr, a nurse and direc­tor of OSF’s sup­port­ive-care di­vi­sion, said clin­i­cians fo­cus on pa­tients with high-risk scores based on data from health in­sur­ers. They also ask pa­tients who are ad­mit­ted as in­pa­tients if they have se­ri­ous ill­nesses or un­con­trolled chronic symptoms.

Dur­ing the ad­vance care plan­ning process, clin­i­cians, pa­tients and fam­ily mem­bers meet and dis­cuss is­sues that too of­ten are taboo—their symptoms, spir­i­tual health, what they most value and how they would like to die. Daily or weekly meet­ings pro­vide rou­tine up­dates. “This is every­body in the same room at the same time talk­ing about the same pa­tient,” Saw­icki said. “It doesn’t take that long, but it yields in­cred­i­ble in­sights you wouldn’t or­di­nar­ily get.”

OSF has com­pleted 18,000 ad­vance care plans so far, Fehr said. Early re­sults show OSF’s di­rect costs to de­liver care are $400 to $600 lower per day for pa­tients who re­ceive a pal­lia­tive-care con­sul­ta­tion com­pared with sim­i­lar pa­tients who do not.

The next step is mov­ing more pal­lia­tive care into less-ex­pen­sive home set­tings, which lead­ers hope will pre­vent costly hos­pi­tal­iza­tions. Saw­icki said OSF is con­duct­ing a home-visit pi­lot pro­gram for pa­tients who were hos­pi­tal­ized and had a pal­lia­tive-care con­sul­ta­tion dur­ing that ad­mis­sion. Data are not yet com­plete, but there has been some anec­do­tal suc­cess.

For in­stance, one pa­tient with a se­ri­ous re­s­pi­ra­tory ill­ness had been in and out of the emer­gency depart­ment at one of OSF’s 11 hos­pi­tals roughly 20 times in a six-month pe­riod. While vis­it­ing the pa­tient’s home, care­givers found a cock­roach in­fes­ta­tion. The pa­tient was al­ler­gic to the pests. The home was sprayed with in­sec­ti­cide and the pa­tient has since made far fewer trips to the ED, Saw­icki said.

Meier said OSF is “way ahead” of the rest of the U.S. in in­te­grat­ing pal­lia­tive care into its de­liv­ery sys­tem. She sees the big­gest op­por­tu­ni­ties for health sys­tems and ACOs in ex­tend­ing pal­lia­tive care into pa­tients’ homes. That’s be­cause so­cial de­ter­mi­nants such as poverty, food in­se­cu­rity and poor hous­ing di­rectly af­fect pal­lia­tive-care ef­forts.

But chal­lenges re­main in that area. For ex­am­ple, providers aren’t paid to treat so­cial fac­tors. Medi­care’s pay­ment pol­icy is also very strict and nar­rowly tai­lored to­ward hospice care, Meier said.

Pal­lia­tive care is key to the suc­cess of ACOs, Saw­icki stressed. “You can do good pop­u­la­tion health with­out pal­lia­tive care,” he said. “But it’s go­ing to take a lot more ef­fort and a lot longer.”

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