Thursday, May 14, 2009

Performance Management and Palliative Medicine

I hear from palliative medicine physicians whose experiences suggest that their successes often go unrecognized, or at best taken for granted, while their failures are highlighted, particularly during times of program evaluation or subsidy renewal. What prompts these misguided views and feelings? Is it numbers-driven executives who see these palliative medicine practices producing revenue that in best cases meets no more than half of the practitioners' salaries? Or is it underperforming physicians whose practices fail to meet productivity standards? Or is it quite simply a misunderstanding of the value of palliative medicine programs in general, and of palliative medicine physicians specifically?
Our study suggests that another factor is at play here. Call it a misalignment of expectations, a misalignment that manifests itself in role confusion. What is role confusion, and why should palliative medicine be more vulnerable than others to this rather abstract influence? The short answer is that most palliative medicine programs were launched on the proverbial shoestring, and when met with growing demand for their services, turned their attention to their most recent referring sources. These new referring sources, of course, were not the ones behind the launch of the program. Additional MD or NP resources to serve this growing demand are months way from being hired, if at all. And so we find role drift, which inevitably leads to role confusion. This is the time, we find, for the introduction of performance management programs.

Showcasing Advanced Palliative Care Communities

To detractors of health reform, universal health care is code for rationing, or "less care". And for those detractors, palliative care is associated with less care. Reform opponents use the argument of rationing because they know that there is little political will to provide "less care".
Yet this argument falls short on two counts. Less care ,or rationing, takes place in the current system, for those who are uninsured, or underinsured. And less care does not have to mean substandard care, as data from the Dartmouth Medical Atlas has shown. Interestingly, those opposing health reform are the same who oppose comparative effectiveness studies, and their deployment to guide clinical practice.
The promises to contain costs advanced recently by the coalition of hospitals, physicians, and pharmaceutical manaufacturers, among others, are surely commendable. But one has to wonder what can these providers and organizations do that hasn't already been tried? Their promises were surely short on details.
When it's time to fill in the specifics, it will be time to take a close look at Advanced Palliative Care Communities (APCCs) see here and here , and how palliative medicine physicians in those communities practice their specialty to produce better outcomes at lower costs.

Monday, May 11, 2009

Responsibility Charts for Palliative Medicine Practices

Palliative medicine programs, and by extension the practices associated with them, are characterized by conflicting demands for their resources. Role confusion often is the result.

The symptoms of role confusion we often find within palliative medicine services are:
-Concern over who makes decisions
-Out of balance workloads
-Lack of action because of ineffective communications
-Questions over who does what (clinical and administrative)
-Multiple “stops” needed to find an answer to a question or gain approval.

Responsibility charting is a management tool we've used effectively to reduce or avert role confusion. This tool can be used either in program development or in established programs. We've found it to be especially useful where an Advanced Palliative Care Organization (APCO) is being assembled through the collaboration of several health organizations and many stakeholders.

Monday, May 4, 2009

Reducing Hospital Readmissions: A Role for Palliative Medicine Physicians

Rehospitalizations among Medicare beneficiaries are prevalent and costly. So concluded a recent study published in the April 2, 2009 issue of NEJM - excellent synopsis here from the Commonwealth Fund. The study found that 20% of Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34.0% were rehospitalized within 90 days; 67.1% of patients who had been discharged with medical conditions and 51.5% of those who had been discharged after surgical procedures were rehospitalized or died within the first year after discharge. Is there a role for palliative medicine physicians? Th experience of Advanced Palliative Care Communities(APCCs), with lower than average rates of hospital readmission and percentage of deaths in a hospital, suggests indeed there is. As does the modest study (abstract cited) below:

Increased Satisfaction with Care and Lower Costs: Results of a Randomized Trial of In-Home Palliative Care
Richard Brumley, MD * , Susan Enguidanos, PhD, MPH † , Paula Jamison, BA † , Rae Seitz, MD ‡ , Nora Morgenstern, MD § , Sherry Saito, MD ‡ , Jan McIlwane, MSW § , Kristine Hillary, RNP * , and Jorge Gonzalez, BA †
* Kaiser Permanente Southern California Medical Group, Downey, California; † Partners in Care Foundation, San Fernando, California; ‡ Kaiser Permanente Hawaii Medical Group, Honolulu, Hawaii; § Kaiser Permanente Colorado Medical Group, Aurora, Colorado.

OBJECTIVES: To determine whether an in-home palliative care intervention for terminally ill patients can improve patient satisfaction, reduce medical care costs, and increase the proportion of patients dying at home.
DESIGN: A randomized, controlled trial.
SETTING: Two health maintenance organizations in two states.
PARTICIPANTS: Homebound, terminally ill patients (N=298) with a prognosis of approximately 1 year or less to live plus one or more hospital or emergency department visits in the previous 12 months.
INTERVENTION: Usual versus in-home palliative care plus usual care delivered by an interdisciplinary team providing pain and symptom relief, patient and family education and training, and an array of medical and social support services.
MEASUREMENTS: Measured outcomes were satisfaction with care, use of medical services, site of death, and costs of care.
RESULTS: Patients randomized to in-home palliative care reported greater improvement in satisfaction with care at 30 and 90 days after enrollment (P<.05) and were more likely to die at home than those receiving usual care (P<.001). In addition, in-home palliative care subjects were less likely to visit the emergency department (P=.01) or be admitted to the hospital than those receiving usual care (P<.001), resulting in significantly lower costs of care for intervention patients (P=.03).

In APCCs, we've found that Palliative Medicine physicians assume a major role in the care (in any setting) of older patients with a hospitalization. What makes these APCCs different? They structure care for those advanced illnesses around the principles of palliative care, rather than hospice eligibility.