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The Palliative Care Option

Joe Cantlupe, for HealthLeaders Media, July 13, 2012
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Over the past three years, Gundersen Lutheran has enlisted 300 of its palliative care patients in the outpatient program under the advanced care demonstration project with CMS. The program started slowly because of contract problems with CMS, but has revved up, Hammes says. Reviewing patient electronic medical records, Gundersen Lutheran partners with primary care doctors to enlist would-be patients into the palliative care program. The idea is to improve care for patients to reduce readmissions, medical procedures, or pharmaceutical costs, says Hammes.

A team of primary care physicians, nurse care coordinators, palliative care providers, social workers, pastoral care counselors, and other professionals provides the disease coordination services, according to Hammes.

The palliative care team arranges meetings and phone calls with the patients and their families to help identify and manage symptoms and other kinds of medical care. "The goal is to help people with advanced conditions live successfully and with functionality as much as possible in their homes. We make sure they stay on their medications if need be, and prevent unnecessary acute illnesses," Hammes says.

"Let's say someone has heart failure, and under other circumstances, they might call their doctor, who might say, 'Come to the hospital.' Instead, the palliative care team will have an assessment over the phone, there would be someone for this person to call, and help them manage the disease over the phone.

"This model of care targets patients with advanced illness, patients who know they are going to get progressively worse," he adds.

"We feel these patients may see their primary care physicians, but the doctor is often so busy, that the patient isn't given that extra layer of support," Hammes says. "There may be a pain the patient can't deal with. We can dramatically decrease the need at this stage of their lives for this person to come to the hospital, and decrease the number of hospital days. We are offering them a very in-depth discussion about their goals and preferences for future care."

Hammes refers to an extensive study on palliative care, published in 2009 that showed that advance care planning "assists in identifying and respecting patients' wishes about end-of-life care, improves such care from the perspective of the patient and the family, and diminishes the likelihood of stress, anxiety, and depression in surviving relatives."

A more recent study, published in The New England Journal of Medicine last year, showed that getting early palliative care, in addition to regular medical treatment, helped people with lung cancer live three months longer compared to those given standard care. The study focused on 151 patients.

"We believe people want to stay functional in their homes," Hammes adds. "That's the goal. It's not only better for the patient but also turns out to be cheaper for healthcare. You invest this time, it's relatively low-tech and low-cost care, and you prevent three days of hospitalization and you come out ahead. That's not too difficult to figure out. We realize there are limits to how much a patient wants."

Success key No. 2: Palliative care across service lines
Whether it's massage therapy or harp music to soothe patients, the 739-staffed-bed University of Rochester (N.Y.) Medical Center includes varied services in its palliative care department, which has 12 private rooms. But a key element of the program involves serving a variety of other service lines, such as neurology and oncology.

"We are involved earlier and earlier in patient care in the hospital. We started in the cancer service. Now we're also seeing heart failure patients and neurological patients, and in the ICU, the full gamut," says Timothy E. Quill, MD, director of the center of ethics, humanities, and palliative care at the medical center.

In addition, the medical center has found that early palliative care interventions can reduce the length of stay for seriously ill patients in the medical intensive care unit by more than seven days without having an impact on mortality rates.

Rochester officials several years ago discovered that proactive palliative care consultation in the ICU has an unintended benefit of financial savings.

In its most recent study in 2007 at the medical center, Rochester found the palliative care intervention saved about 1,400 ICU patient days, at an average of about $450 a day.

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