Transcript Safety Net Institutions - Coleman Palliative Medicine

Program Development
for Safety Net
Institutions
We Bring HealthCARE to Your Community
Catherine Deamant, MD
Director, Palliative Care Services
Cook County Health and Hospitals
System
Coleman Fellowship Workshop
September 7, 2013
Definition of Safety Net Institution
• Provides significant level of care to low-income,
uninsured, and vulnerable populations.
– Not dependent upon public vs. non-profit
– Core safety net providers: mission to have “open door” to
all regardless of ability to pay (high uninsured, Medicaid,
vulnerable)
• High risk for fragmented care, inadequate
community support & high symptom burden
Palliative Care in Safety Net Setting
• Goals of palliative care are same as all hospitals:
– Provide high quality interdisciplinary care to improve
quality of life for patients with serious illness throughout
the continuum of care with respect and dignity.
• Justifications for palliative care are same for all
hospitals:
– Cost savings
– Patient/family satisfaction
– Quality metrics
Palliative Care in Safety Net Setting
• Know who you serve
• Demonstrate credibility
• Identify unique opportunities
Know who you serve: Patients & Families
• Lack of access to care means late diagnosis
– 40% diagnosed with advanced illness within 3 months of
hospitalization (20% on the index admission)
• Culturally diverse:
– 30% Limited English proficiency
• 60% uninsured at time of admission
– Fear of financial burden
• 8% advanced liver disease (national-2%)
– Limited social support
• Young population
– Average age-58 years
Demonstrate credibility with patients
• Address the barriers to quality end of life care
through palliative care interventions
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Develop relationship with interpreter services
Educate on advance directive as form of empowerment
Address misconceptions of hospice care
Respect wishes for site of death-home is not always a goal
• Trust:
– PC consult for hospice referral
– Build relationship; avoid abandonment
• Facilitate goal of return to home country
– Must be patient’s goal, not institution’s
Impact on Disparities:
End of Life Decisions
Outcome Variable
Overall
PCC
Primary
team
Completed a
Durable Power of
Attorney for Health
Care
DNR Status
126/141
(89%)
118
(94%)
8
(6%)
153/173
(88%)
134/147
(91%)
101
(66%)
37% died
inpatient
hospice
52
(34%)
Hospice Enrollment
173 African-American patients with Cancer seen by PC
Know who you serve: Providers
• Emotionally challenging to care for very young
patients who are dying with limited resources
– Support primary team
– Strategies to reduce burnout (especially for PC team)
• Majority of consultations for goals of care
• Develop hospital-hospice relationship who will share
the mission (unless hospital has own hospice)
– Be comprehensive in your PC role (address issues of
prognosis and resuscitation before referral)
– Serve as attending physician
– Provide medications for transfer home
Hospital Deaths seen by PC
Measurement
2009
2012
Nat’l
% of deaths with PC
consult (any LOS)
71/190 (37%)
166/327 (51%) 13%
% of deaths with PC
consult (LOS <2 days)
6/62 (10%)
14/83 (17%)
% of deaths with PC
consult (LOS >2 days)
65/128 (51%)
149/244 (61%)
Know who you serve: Administration
• Palliative care can facilitate more effective utilization
of scarce hospital resources
– Assist in care planning for chronic, complex patients
– Long Stay Committee; Case Management Rounds; Ethics
– Identify options for right setting of care
• Healthcare Reform
– Patient-Centered Medical Home-Priority for ambulatory
palliative care
– High hospital occupancy rate (challenge for inpatient unit)
• Educational Mission
– Fellowship; Resident Rotation; Medical Student Rotation
CCHHS Palliative Care Impact
Among Medicare
Decedents:
Lowest death rates associated with ICU admission
Second lowest hospital deaths
Second highest hospice enrollment
Highest length of stay in hospice care
JSH
Rush
UIC
Mercy
U of C
Sinai
% of Deaths with
ICU Admission
10
26
25
20
24
28
% of Deaths in
Hospital
29
35
33
25
34
44
Hospice
Enrollment
45
40
40
51
45
23
Hospice Days
(per decedent)
20
11
14
14
15
7
http://www.dartmouthatlas.org, 2003-2007
2012 Statistics: Ambulatory PC
Cost savings-$840,000-1.2 million
Cost Analysis
Hospital Costs
Factors
Cost savings/revenue
Total per day
$3,426
Total inpt cost
$7637-11,063
Potential Costavoidance
Total cost savings (110 pts)
$840,070-1,216,930
Potential Revenue
generation
Revenue in outpatient
$48,290
2012: Total number of paracentesis performed-110 home or clinic
Assumptions: Hospitalization for paracentesis is 2-3 days with admit thru ED
Charge code-49082 at $439