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Raise Your Palliative Care IQ

 |  By jcantlupe@healthleadersmedia.com  
   April 18, 2013

Care for chronically ill and very sick patients is historically costly and sometimes inexorably linked to unnecessary procedures. Physicians of ten struggle over the question of how much care is appropriate under the circumstances: Should there be another test done? Should there be another surgery?

It's never easy, and of course, it's wrapped around a series of complex issues, among them the wishes of the patients and family and the ethical decision for each case.

Through it all, physicians want to help patients, who are often seeking "a mix of cure and comfort," in the words of Brad Stuart, MD, CMO, Sutter Care at Home, the homecare and hospice provider based in Northern California near San Francisco.

That task may be difficult, at best. Inevitably, healthcare executives often rely on implementing palliative and hospice care to improve quality of life for chronically ill patients, or those nearing death. More hospitals are developing such programs, and the need may be greater in the years ahead, considering the growth of the U.S.'s aging population. By 2030, the number of people in this country over the age of 85, for instance, is expected to double to 8.5 million.

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Palliative care is growing in popularity with its multidisciplinary teams who work to care for patients in efforts to relieve suffering, pain, and even the depression and stress that often accompany chronic illness.

And although palliative care is growing, experts in the field are still struggling to define precisely what it is. They are dealing with what they call "image" or "branding" problems, especially as it relates to hospice for patients who are very sick or dying.

Providers, patients and families are all grappling to understand what this varying level of care is all about.

"Palliative care leaders are trying to distance themselves from hospice because they feel hospice has a branding problem," since it is associated with dying or end-of-life care, says Stuart. Hospice officials believe they have "painted themselves into a bit of a corner in this branding and are trying to move upstream in the care continuum," says Michael Nisco, MD, MBA, medical director of the Saint Agnes Medical Center Hospital and Hospice and Palliative Care Services in Fresno, CA.

Enormous complexities confront health professionals charged with treating complicated illness, and providing end-of-life care.

"We haven't been able to deal with the issues of death and dying very effectively in our culture," says Kathleen Potempa, dean of the University of Michigan School of Nursing. "When you have a very seriously ill person, a physician is trained to do everything to save a life, and the family may be [hoping] that one more thing will be the magic bullet, but that isn't the reality."

Helping patients and their families deal with the stark realities of severe illness and impending death is a growing concern among physicians in general, and the issue is taking center stage within palliative and hospice care communities.

Stuart and Nisco see palliative care as a way for healthcare facilities to broaden services for chronically ill people, while also serving as an important link to hospice care. Palliative care has extended outside the hospital setting to ambulatory and home-based services, Stuart says. Having an integrated program that involves hospitals, medical homes and community-based services helps patients and their families to deal more effectively with late-stage chronic illness, he adds.

That's why Sutter has included its palliative care program under the umbrella of the Advanced Illness Management Program that Stuart created for what he terms a "vulnerable and growing population." While palliative care is often focused on the "relief of symptoms and suffering," Stuart says, "our focus is much more positive."

Multidisciplinary teams include physicians, nurses, social workers, psychologists and nutritionists. Various elements focus on the specific needs, of course—and wants—of patients. While physicians often outline the medication needs for patients, the Advanced Illness Management Program always considers "what does the patient want?" Stuart says. It's the "little things" that matter, too often lost in traditional medical care.

Ultimately, it's personal connections that make palliative care work, Nisco says. "We need to sit down and get to know the person as a person, what are their likes and dislikes," Nisco adds. "It is important "to follow the patient's wishes, and easing their transition of care."

Essentially, "we're helping people live the lives they want, and in so doing we are shifting the focus of care out of the hospital into the home and community," Stuart adds. "And I think what's happening we're developing a much wider and deeper footprint for the healthcare system out in the community."

"We are taking more seriously those little things that a patient wants or needs," Stuart says. "It's like the patient walking to the dinner table with their family, seeing a granddaughter graduate from high school. We make those personal goals the priority and then design care plans to match those," Stuart adds. "That causes a very interesting shift in priorities, not only for the care team but people."

Important clinical procedures, such as patient adherence to a medication regime, "gets a lot easier to accomplish when a person who is ill sees us as the team helps them accomplish what they want to in their lives," Stuart says. "It shifts away from 'here's what the doc wants you to do,' to 'here's what we can do together what you want in your life."

To develop its Advanced Illness Management Program, Sutter received $13 million from the Centers for Medicare and Medicaid Services under a three-year grant for palliative care and advanced care planning for patients with late stage chronic illness. The money came after Sutter's Sacramento region showed positive outcomes from its AIM program, such as reduced hospitalizations and improved care transitions.

From 2009 to 2011, Sutter reports show a 54% reduction in readmissions, an 80% reduction in ICU (intensive care unit) days, and a 26% reduction in hospital length of stays. In addition, there were reduced visits to physician offices, and home health care, Stuart adds. He cites cost savings of more than $500,000.

Sutter has been demonstrating success in its palliative care program for years. Seven years ago, in an extensive study, the Sutter Health Institute for Research and Education, part of Sutter Health in San Francisco, found that palliative care programs at 798-bed California Pacific Medical Center in that city resulted in an estimated annual savings of $2.2 million, with daily costs for palliative care patients estimated at 14.5% lower compared to usual care patients.

The Saint Agnes Medical Center also has found success in reducing costs and in palliative and hospice programs, says Nisco of the Saint Agnes Medical Center Hospital and Hospice and Palliative Care Services. The hospital has saved at least $1,800 per patient in its palliative care versus other programs.

For a hospital system, putting together a palliative care program may become invaluable as the healthcare moves from fee for service to value based systems, Nisco adds. "When you net out all the cost savings, with what you can achieve with a program like this, it's kind of cost neutral: it doesn't wind up costing a lot of money."

Nisco acknowledges that hospital financial chiefs may still be reluctant to embrace palliative care. "It may not immediately result in reduced costs to excite your CFO because everybody is looking for the kind of dollars [in savings] that makes your eyes sparkle," Nisco says.

"But a forward-thinking CFO is going to see this as an important thing to emphasize as the priorities of healthcare change. It is being a little ahead of the curve, having an integrative palliative care program in your healthcare system."

For many, it's simply a matter of "raising their palliative care IQ," Nisco says.

(A HealthLeaders Media Webcast, Develop an Innovative and Integrated Palliative Care Program is slated for Tuesday, April 23, 2013, with Brad Stuart, MD, chief medical officer of Sutter Care at Home in Emeryville, CA and Michael Nisco, MD, MBA, medical director for Saint Agnes Medical Center Hospice and Palliative Care Services, in Fresno, CA.)

Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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