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Home Based Palliative Care
Richard D. Brumley, MD
Gretchen Phillips, MSW
Kaiser Permanente
Downey, CA
Practice Change Fellows
January 24, 2008
2
Palliative Care Across the Continuum
Primary Care Physician
Subspecialist Physician
Population Care Manager
Geriatric Assessment
Clinic
Palliative CareConsultation Team
Hospitalist Physicians
Discharge Planners
Home Health
Extended Care Facility
Palliative Care
Hospice
Outpatient Inpatient Extended Care Home-Based
3
Challenges to Provide End-of-Life Care
Curative/Restorative Care vs. Palliative Care Acute Care vs. Chronic Care Hospital Care vs. Home based Care Reduce care to Reduce cost vs. Improve care &
Reduce cost One percent of our members create over 30% of our
costs
4
53 years old COPD - 30 years Multiple Sclerosis - 20
years Chronic Stage III decub 66 pounds Full Code
Used with written permission
5
Usual Care
02/02 to 01/03 12 acute admissions
63 days 2 intubations 22 different physicians
admitted/discharged 14 home health
admissions focus on decub care
6
Core Components of Palliative Care
Patient and family unit of care Interdisciplinary team directs/provides care
Physician, Nurse, Social Worker Aide, Chaplain, Volunteer
Home care emphasized all providers make home visits
Plan of care - coordinated and supportive services
7
Core Components of Palliative Care Cont.
Physical, medical, psychological, social and spiritual needs
Pain and symptom management comprehensive primary care to manage
underlying conditions aggressive treatment of acute exacerbation
per patient and family request 24 hour phone support, visits if necessary Volunteer support & Bereavement services
8
Palliative Care Admission Criteria
CHF, COPD, Cancer, or meet Hospice criteria for disease and don’t want to be on hospice program
Expected prognosis <12 months Deteriorating medical condition at risk for needing
symptom management Primary Care Provider when necessary Emphasis of care in the home setting 1-2 or more ED or Inpatient admissions in the last year Palliative Performance Scale < 5 (mainly sit or lie,
unable to do any work, extensive disease, considerable assistance necessary with self-care)
9
Palliative Care Case Load
60-70 patients average daily census Staffing
0.8 Physician 4 Nurses 2 Social Workers 2 Home Health Aides
10
Home Based PC Results
298 patients, multi-site RCT Pts home-bound w/ Cancer, COPD, CHF ALOS 200 days Compared to usual care: Pt/family satisfaction at 60 days and thereafter PC patients more likely to die at home (51% UC vs. 71% PC) Hospital admissions (36% vs. 59%) ER visits (20% vs. 32%) Decreased (32.6%) utilization and costs Total costs $20,221 usual care vs. $12,613 PC (p=.001) Total cost avoidance = $7,552/patient Average cost/day $213 UC vs. $133 PC Patients transfer to Hospice when appropriate
11
Home Health Referrals diverted to Hospice and Palliative Care
Review of 70 referrals for 3 day period 20% possibly appropriate for H or PC Age of Patients with Possible Referral
36 – 45 years old 1 referral 8%
46 – 55 1 8
56 – 65 0 0
66 – 75 3 23
76 – 85 6 46
86 – 95 2 15
TriCentral, February, 2004
12
Hospice & Palliative Care Utilization
12% of H patients switched to PC 7% of PC patients switched to H 3% switched back and forth several times 3% of patients who qualified for H wanted to
be on PC
Snapshot TriCentral May, 2005
13
Hospice vs. Palliative Care Patient Distribution
0
10
20
30
40
50
60
HospicePalliative Care
P
erce
nt o
f P
atie
nts
TriCentral May, 2005
14
Hospice and Palliative Care Deaths vs. Usual Care Deaths
0
50
100
150
200
250
300
350
400
Dea
ths
H and PC BF Total
Bellflower Medical Center 2005
15
Palliative Care Replication Challenges
Who is the champion? Justify new program within constraints of current
budget climate Marketing What End-of-Life “infrastructure” is in place?
Hospice, Bio Ethics Committee, Advance Care Plans, Physician comfort/communication with EOL care
Late referrals Integration within the Continuum of Care
16
Palliative Care References
Your Guide to Creating an Outpatient
Palliative Care Program
Open Society Institute
Project on Death in America
http://growthhouse.org/palliative/
Brumley, R., Enguidanos, S., et al, (2007)
“Increased Satisfaction with Care and Lower
Costs: Results of a Randomized Trial of In-Home
Palliative Care.” Journal of the American Geriatrics
Society, Volume 55, 2007, 993-1000
17
Usual Care
02/02 to 01/03 12 acute admissions
63 days 2 intubations 22 different physicians
admitted/discharged 14 home health
admissions focus on decub care
Palliative Care
02/03 to 12/03 No acute admissions Palliative Care Team
developed plan of care for relief of dyspnea
caregiver support consistent palliative
care team
18
Life is a JourneyLive Long – Thrive – Die Well
Engage patients and families in discussion about goals of care
Discuss likely course of disease
Honor patient preferences
Increase patient, family, physician and staff satisfaction with care