Monday, November 28, 2011

Improving Performance in Late-Life Care - A Modest Effort Starts in Philadelphia

I’m working with a small group of Philadelphia-area  hospital executives who have joined together in a campaign to improve late-life care in the region. While recognizing that many factors influence the overall performance of communities in how patients are treated in the final stage of life, these executives appreciate the enormous sphere of influence their institutions exert on their respective communities.

Until shown the DAI Palliative Performance Reports for their respective hospitals, these executives, all of whose hospitals reportedly have a palliative care service, felt  their institutions had been effectively caring for the late-life needs of their patients. Yet the hospitals’ performance lagged behind state and national benchmarks, and well behind the performance of  hospital exemplars.  The Philadelphia region’s performance similarly lagged.

Examples abound.  According to the DAI Palliative Performance Profile (P3) for Philadelphia, a Philadelphia resident will spend 20% more days in a hospital during last six months of life than the national average, and twice as many days as would a resident of the exemplar region of Portland, Oregon. The Philadelphia resident is one-third more likely to die in a hospital than his counterpart in Portland, and twice as likely to have had an ICU stay associated with that terminal hospitalization.  On a positive note, at least one indicator shows Philadelphia to be performing better than national benchmarks – while 41.9% of those who die in the US use the hospice benefit, 44.6% of Philadelphia residents received services from a licensed hospices prior to their death. Yet considerable opportunity  remains for improvement.
How much? Consider that in 10% of communities  across the nation (the exemplar benchmark)  more than 55% of their decedents utilized the hospice benefit.

While few of the executives were surprised by Philadelphia’s poor performance in late-life care, most were surprised by the enormous gaps between the region’s performance and that of exemplar communities. Yet, should we be so surprised? After all, the Dartmouth Medical Atlas (from which the DAI P3 draws its data) has for years documented such variations. In a recent study titled Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness, the authors concluded that  geography continues to play a huge role in late-life care, noting that “care patients received in the months before they died depended largely on where they lived, and widespread variations persist.”

In future posts, we’ll take a closer look at what the DAI Palliative Performance Profiles tell us, and perhaps more importantly, how they might provide sharper focus for performance improvement campaigns, not unlike the modest effort  briefly described above. In the meantime, I invite your comments on the state of late-life care in your region, or the US, in general, and welcome your ideas on the sort of performance improvement campaigns which could make a difference. We’ll also take a closer look at exemplar communities (read here for an earlier blog post on this subject) and how do they do that?

Friday, November 25, 2011

Short-Stay Hospice Patients? Intractable?

Utilization of the Medicare hospice benefit by those dying continues to grow. In 2003, fewer than one out of every three Medicare decedents  received care from a  certified hospice. By 2007, that number had grown more than 30%, as 42% of decedents used  their hospice benefit during their final days (these figures are drawn from the Dartmouth Medical Atlas).

What hasn’t changed over that period are the number of short-stay (those who use the Medicare hospice benefit for a week or less) patients. One of out every three referrals to the hospice benefit.  So, late referrals continue to plague the hospice sector. Why? Theories abound, of course. You know them well, I’m sure.

And surely, it couldn’t be insufficient knowledge of hospice, as most hospices now deploy “community education” specialists to inform potential referring sources of their service offerings.  Prognostication tools have improved, so inability to confirm prognosis probably isn’t an explanation.

A growing number of HPM practitioners offer an intriguing theory.  It is, they say,  because the hospice benefit  does not “enable” concurrent care ,that is, curative treatment along with palliative measures. Patients, families, and physicians are hesitant to make early referrals to hospice  because the patient must choose to forego curative care.  Yet that does not lessen the need for, and the value of, palliative care. It simply means the providers of palliative care must be resourceful in marshaling the resources (reimbursement) to provide palliative care.   Palliative care, to be sure, may be provided under many health  plan benefits, including, of course,  the hospice benefit, the home health benefit, and Medicare Part B, for physician outpatient or home-based  visit coverage.

I'm curious to learn your experiences in this regard. Does this "concurrent care "disabling" theory hold true in your experience? 

Use of Hospice Benefit Grows, Late Referrals Persist

A recent discussion at a regional meeting of Hospice and Palliative Medicine practitioners grew lively when the subject turned to use of hospice, and whether use has grown. Following the meeting,  I reviewed NHPCO reports for 2010 and 2005. Turned out opposing viewpoints were each right, to some extent. Here's what I concluded.
  • 30% growth in the percentage of Medicare decedents using hospice benefit. Impressive! 
  • Short-stay patients (7 days or less) remained level at one-third of total deaths and discharges. Intractable?
  • The size of hospices remained small - nearly 8 out of 10 have fewer than three admissions per week. Subscale?
Got me to thinking. If I was considering hospice care for a family member, aware that there is a one-in-three chance that the episode of hospice care will be no longer than a week, I'd want to select a hospice that admits twenty times the number of patients than the average-sized hospice. I figure that the additional volume would mean greater proficiency in short-stay care.
Does volume matter? No studies to prove either way. What do your professional instincts tell you?

Trends in Hospice and Palliative Medicine (HPM) Physician Compensation

Compensation for expertise does not always follow the supply/demand imbalance. Hospice and Palliative Medicine (HPM) physicians are a current example.

I’ve  been monitoring compensation practices for full-time HPM physicians for the past five years. Through  2010, I relied upon the Compensation Reports compiled by DAI Palliative Care Group (disclosure: I am employed by its parent company). I now rely upon the recently published report of HPM physician compensation and benefits, drawn from the findings of a survey by the American Academy of Hospice and Palliative Medicine (AAHPM) of its members. Nearly 800 AAHPM physician members responded to the survey conducted in November 2010, providing information regarding their 2009 compensation from practicing Hospice and Palliative Medicine (HPM).

As I review the reports over the preceding five years, several observations come to mind:

  • Compensation for full-time HPM  physicians continues its rise, yet at a  slower pace than one would expect from a field marked by a shallow talent pool.
  • The gap in compensation based upon place of employment is narrowing. Compensation for hospital based HPM physicians is somewhat greater than that for hospice-based physicians, but the difference is decreasing.
  • Differences are insignificant for physicians practicing in urban, suburban, or rural areas. There are some regional differences, yet these too are insignificant. The greatest determinant of higher compensation is practicing HPM in a certificate-of-need state, such as Florida, where there is a concentration of larger-than-average size hospices who are more likely to deploy full-time physicians.
  • Salary compression, unsurprisingly, is characteristic of the specialty. Average compensation for three position layers (team physician, associate medical director, and medical director) are little more than 10 percent.The best way to improve one’s compensation is to move into leadership positions, typically within hospices.
  •  Compensation lags behind that of other specialties and primary care physicians (according to the 2010 AMGA Medical Group Compensation and Financial Survey the median salary for  is $214,000 for internists, $208,000 for family practitioners,  and $267,000 for emergency medicine physicians) .

The 2010 AAHPM report is chockful of information relative to compensation, benefits, and workload. I recommend its purchase (click here).

Wednesday, October 26, 2011

Reducing Hospital Readmissions: A Role for Hospice and Palliative Medicine Practitioners?

Hospices and their palliative medicine specialists have proven, several studies have shown, to be effective at reducing use of hospitals for their patients. In fact, families cite avoiding transitions among multiple settings as one of the benefits of hospice. In a previous post, we've examined the role of palliative medicine physicians in reducing readmissions.
One of the first financial impacts to hospitals resulting from PPACA legislation is a reduction in reimbursement for excessive readmission of Medicare inpatients. Starting with discharges in October 2011, the impact of the payment penalties may be significant.

The Medicare Payment Advisory Commission (MedPAC) has estimated that nearly one out of every five Medicare patients admitted to the hospital is readmitted within 30 days and unplanned readmissions are estimated to cost Medicare approximately $17.4 billion annually. Readmissions have become a widely accepted measure of hospital effectiveness. Although only one of many performance metrics, low readmission rates do correlate with overall clinical excellence.

As part of the CMS value-based purchasing program, 30-day readmission rates are a performance measure already closely watched in the industry. Now PPACA legislation allows CMS to withhold a portion of all inpatient Medicare payments due to excessive readmissions, starting with up to 1 percent in federal fiscal year 2013, and rising to 3 percent in 2015 and beyond.

Hospitals will likely look to post-acute care networks to assist in managing the care of at-risk (for rehospitalization) patients. Should we consider deployment of palliative care specialists (physicians and nurse practitioners) by these networks to visit patients in their homes (especially but not only when a referral has not been made to home health)? If not palliative care practitioners, then who?

Friday, October 14, 2011

Exemplar Hospitals for Late-Life Care

Geisinger Medical Center, in Danville, Pa., has become a favorite of President Obama when he discusses models of health care delivery worthy of emulation (so has Mayo Clinic and several others, but that's a subject for another post). It set me to wondering: how well does their (Geisinger) model translate into late-life care? Using data of palliative outcome measures drawn from the Dartmouth Medical Atlas, the research staff at DAI Palliative Care Group compiled a Hospital Palliative Performance Profile for Geisinger. Not unexpectedly, Geisinger produced a Palliative Performance Score of 105, earning it an A Grade and Exemplar Hospital status. Geisinger scored well in deaths by location (its patients were 8% less likely to die in the hospital than the national average) but where its performance stood out was in avoiding use of the ICU during a decedent’s last six months of life (Geisinger’s rate was less than half of the national average).

The DAI staff identified at least two other Exemplar Hospitals in Pennsylvania – Lancaster General Hospital (Lancaster) and Susquehanna Health System (Williamsport).
Susquehanna’s score dazzled us – 130, one of the highest in the nation. There are seven palliative outcome measures used to develop the Performance Profiles – Susquehanna scored better than the state and national averages in six of seven measures. For one measure, hospital days per decedent during the last six months of life, Susquehanna’s experience was nearly 40% better than the national rate. Surely, there must be lessons to be learned here, practices to be emulated.

Could it be that an Accountable Palliative Care Organization (APCO) has evolved over the past decade, under the leadership of a chief palliative care officer in the Williamsport community? Is there a “bellwether” HPM practice which contributes to the Hospital’s exemplar status? Suffice it to say, for the present, that there are exemplar hospitals and communities whose performance in late-life care suggests that there remains considerable room for improvement for most hospitals, and in most communities.

Friday, October 7, 2011

A Closer Look at an Exemplar Palliative Care Community - How Did They Do That?

Previous posts have taken a look at exemplar palliative care communities (read here , here , and here ) and the factors contributing to their exemplary performance. In this post, let's examine more closely another community (LaCrosse, Wisconsin) whose late-life care practices earned it exemplar status in the DAI Palliative Community Performance Profiles. The aim of our (DAI Palliative Care Group) studies of such communities (and their health care institutions) is to identify communities that have achieved results suggesting high performance in late-life care, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. These studies are intended to enable other hospice and palliative medicine (HPM) leadership to draw lessons from the experience of exemplar performers that will be helpful in their own efforts to become high performers. These communities, and health systems within the communities, we believe, are well-positioned to develop Accountable Palliative Care Organizations (APCOs).

In LaCrosse County, Gundersen Lutheran Health System has a market share of 59 percent of the inpatient cases. Gundersen is a physician-led, not-for-profit integrated delivery system serving an area with more than 550,000 people in a tristate region that includes parts of western Wisconsin, northeastern Iowa, and southeastern Minnesota. The population it serves, which is both urban and rural, is healthier, less transient, and more educated—but older and poorer—than the national median. The hub of the system is a 325-bed teaching hospital, which serves as the western clinical campus for the University of Wisconsin Medical School and the University of Wisconsin–Madison School of Nursing. While the hospital has an open medical staff, fewer than 5 percent of credentialed physicians are non–Gundersen Lutheran employees.

One of the keys to Gundersen Lutheran’s strategy for improving quality of care and lowering its cost is the optimal use of medical resources for patients with complex conditions and minimal social support. Through a care coordination program, the health system identifies patients who are frequently hospitalized—or who make frequent visits to the emergency care or urgent-care clinics, lack strong support at home, or simply have difficulty coping with the complexity of their health care needs—and assigns them to one of 28 registered nurses and social workers who are trained to help them navigate the health care system. The care coordination program has demonstrated significant cost savings. Charges per patient after 12 months in the program have fallen on average by $7,300 (generating net savings of $5,100 after accounting for program costs of $2,200 per patient), as patients are hospitalized less and make less frequent use of the emergency department for care. The hospital uses the program for its health plan members as well as for the fee-for-service population, though doing so reduces its hospital revenue. “This is living up to [the] mission of improving the health of the community,” says Jeffrey E. Thompson, M.D., Gundersen Lutheran’s CEO.

Lutheran has also increased coordination of care at the end of life—a time at which medical expenses rise—by implementing a comprehensive system for understanding, documenting, and honoring patient values and goals for care at the end of life in all health care settings. The documentation begins with the creation of advance directives that spell out what actions should be taken in the event that a patient is incapacitated or is no longer able to make decisions. Advance directives are embedded in the system’s electronic medical records and are made available to all providers in all care settings. Discussions are held and reviewed periodically during many types of patient encounters to make sure that plans remain current.

A strong partnership with other local providers and community groups promotes advance care planning among community members before they become terminally ill.
A training program developed in partnership with a competing local health system, Franciscan Skemp Healthcare (a division of Mayo Health System), and other community groups helps promote a consistent approach to advance care planning among social workers, chaplains, and other volunteers who carry out community education.

Partnership with other hospitals and community groups is essential to ensuring that conversations with patients about treatment preferences at the end of life—and the documentation of them—are consistent across settings and sites of care. Without such assurances, providers are tempted to dismiss documentation of treatment preferences from competitors because they are uncertain of the methods used to collect the information.

A recent study involving 400 deaths of residents of La Crosse County at all health care institutions over seven months in 2007 and 2008 found that 96 percent had either a written advance directive or a Physician Order for Life-Sustaining Treatment (POLST), a standardized medical order that reflects patient choices about key medical treatments often used at the end of life. An internal study among these patients found that those with advance directives used $2,000 less in physician and hospital services in the last six months of life.

In 2005, the health system began offering palliative care services to patients with end-stage disease, which reduced the rate of readmission by nearly two-thirds and lowered hospital-billed costs per patient by approximately $3,500 in the first 15 months of the program. Hospice and palliative providers have access to inpatient and outpatient medical records via the EHR, helping to ensure that patients who have serious and eventually fatal chronic conditions obtain seamless medical care across multiple settings, including home and hospital.

Owing in part to these programs, the cost of inpatient care at Gundersen Lutheran in the last two years of life was $18,359, or 29 percent lower than the national average of $25,860. The number of hospital days in the last two years of life was 13.5, nearly 43 percent lower than the national average of 23.6, according to data from the Dartmouth Atlas of Health Care on chronically ill Medicare beneficiaries.

For physicians who demonstrate leadership potential, the organization has created a physician learning community that helps them understand the strategic and business side of health care. The group meets monthly with the organization’s leaders to discuss institutional challenges and engage in problem-solving. The community also provides an opportunity to learn and practice leadership skills. Gundersen Lutheran does not use an incentive-based compensation system. Instead, salaries are set to be competitive in the market. Physicians are evaluated for productivity and citizenship; the latter is defined by adherence to a physician compact. They are also evaluated on measures of patient satisfaction, disease management, and patient access, which are recorded in the health system’s dashboard. The measurement feedback is critical to improvement.

To address this, Gundersen Lutheran uses data on clinical and financial outcomes to set goals for physicians to aspire to. Department chairs and administrators are also evaluated on such measures, which may include disease management targets and patient satisfaction measures, as well as measures of financial efficiency.

Gundersen has received national recognition and ratings, and The Commonwealth Fund Commission on a High Performance Health System identified Gundersen as a health sytem providing high-value care.

Several points come to mind. The power of partnerships and collaboration across the community. The influence of a palliative care network that spans acute, outpatient, and home settings. The importance of setting ambitious targets, and then monitoring and measuring performance. For LaCrosse, it took 15 years to become an overnight success. For most other communities, time is not on their side. HPM leaders would do well to accelerate their efforts to build attractive and influential palliative care "enterprises."

Tuesday, September 27, 2011

Tracking HPM Physician Performance - Physician Value Index

At a recent regional symposium  for  hospice executives and chief medical officers, following a presentation on the building blocks of a high-performing medical staff,  I was asked  how I would assess if the performance of a hospice medical staff is "high-performing". Of course, there is no single answer, but we (DAI Palliative Care Group)  have developed a tool that has successfully been used to benchmark performance.

Many factors weigh in upon the performance of HPM physicians within a hospice setting. Some factors can be quantified, many cannot not. So, based upon years-long study of hospice physician practices, our research group developed  a metric we refer to as the HPM Physician Value Index , or HPM-PVI. As with other indices, such as an economic index used to track changes in the economy, the HPM-PVI is a single number calculated from an array of figures. In other words, it is a statistical composite that measures changes from one period to another, and can be used to help answer a question often posed by hospice executives - "how can I  determine if I'm getting a reasonable return for the investment (physician compensation) in the medical staff"?

The HPM-PVI has served as a useful metric because it assigns a value to one of a hospice physician's principal activities - oversight of an interdisciplinary team. I invite your feedback and participation in our ongoing efforts to spread the use of this HPM physician value index.

Hospice and Palliative Care - Diffusing the Health Innovation

A graduate student in a Health Policy program asked me during a Q&A session at a national colloquium why I characterize end-of-life care in this country as three parts potential for two parts accomplishment. I've been asked similar questions before, but what gave me pause this time was the context of the query (the workshop was addressing the issue of access to hospice). The previous speaker had just presented a strong case statement on why access to hospice has been threatened by the "cap". And why the main reason for the decelerating growth of hospice was poor reimbursement.
I replied that the delivery system for late-life care is fragmented, and there is insufficient collaboration among providers within most communities. Thus, conditions are uninviting for the "spread of the science" (palliative medicine and nursing). The Center to Advance Palliative Care (CAPC) has effectively spread the science throughout the hospital sector, as it relates to hospital-based palliative care services. No small accomplishment, to be sure. But the other major palliative care providers (hospices) have been slow to scale, in part because hospices have taken competitive stances to protect their market share rather than the collaborative approach which studies have shown to be more conducive to the dissemination of best practices. A recent post described the current structure of the hospice industry. Communities known as providing high-value late-life care are characterized by several attributes - one of the most defining is a coalition (some might say network) of palliative care stakeholders (organizations and individuals) which come together to deliver care across settings and boundaries. The beginning of an Accountable Palliative Care Organization (APCO), some speculate.

The structure of the social system can facilitate or impede the diffusion of health care innovation, concluded Thoms Bodenheimmer, MD, in a September 2007 report for the California Health Care Foundation on how innovations in health care become the norm. Do the current social systems in our communities best position HPM leaders to 'spread the science"? As always, your comments are invited.

Tuesday, July 19, 2011

Improving Late-Life Care - Do We Know Exemplary Performance?

We're starting to learn more about late-life care, thanks in large measure to the Dartmouth Atlas Project.

For example, in a recent report  Trends and Variation in End-of-Life Care for Medicare Beneficiaries
with Severe Chronic Illness (read here),  we learned more about the final 30 days of life of a patient with cancer. More than half (54.7%) were hospitalized during that period. 5.6% received life-sustaining procedures. Half of the final month was spent in hospice (11 days) and an acute-care hospital bed (4 days). Interesting, but without context. Likely, the past 10 years has seen considerable improvement in these measures. How much more improvement should we expect? Can hospitalizations be cut in half? If so, what might be the most effective methods? A transitional care document , like POLST? A provider reimbursement structure where collaboration, rather than procedures, is more highly valued? A community palliative care officer who's accountable  for late-life care across settings within a specific community or region? Any of these, or all of them?

And how much better can the health care system do to encourage earlier referral to palliative services, so that greater than 11 days out of the final 30 can be spent under hospice care?  As always, your ideas and opinions are invited.

Thursday, May 26, 2011

What Do Hospice and Palliative Medicine (HPM) Physicians Look For in a New Opportunity

I'm often asked what has made us (DAI Palliative Care Group) successful  in recruiting palliative medicine physicians. There are, of course, a number of reasons. Experience is one. Our experience "informs" our recruitng efforts. We've made a study out of understanding what physicians look for. We've come to appreciate "What's Important in a Practice Opportunity to Palliative Medicine Physicians".

We 've learned from our experiences in HPM physician recruiting that most prospects evaluate practice opportunities through four filters. Let's refer to these filters as:

  • Rewards (monetary) 
  • Community/environment (supportive culture of teamwork and recognition of contribution by HPM physicians) 
  • Workload schedule (manageable workload and sustainable schedule) 
  • Autonomy/control (ability to impact key factors that affect job performance).

Of course, each physician will place his or her own value upon each of these criteria in career decision-making.  The key to recruiting physicians (particularly in a market  where demand far exceeds supply) is to create a practice opportunity that recognizes and addresses all four filters in a balanced way.
Future posts will offer more detail into each of these filters and recommendations on how to create the "balanced" HPM practice opportunity.




Wednesday, May 25, 2011

Recruiting in Markets Where Demand Exceeds Supply

From time to time, clients inquire how they might best recruit a talented palliative care specialist. I've found success by utilizing recruitment approaches that have produced results in other markets where demand for talent exceeds its supply. In such markets, the scales are tipped in favor of the professional, in this case, the palliative medicine specialist.

How to best restore a balance? By understanding how specialists in short supply make career decisions, and then using methods that can best reach those "passive" candidates. The most commonly used method - job board postings - are most effective in reaching "actively-looking" candidates, usually in markets where supply exceeds demand. Such postings will typically not work in reaching "passive" candidates, since these individuals know well that, because of their relative scarcity, securing a new position is relatively easy.

Candidates in short supply need to be "approached and asked" and then "sparked and nurtured". This process is very demanding of time on the part of the hiring company /manager, and so frequently the "inside" recruitment team will be strengthened on an adhoc basis by bringing on a recruitment specialist with insider knowledge of the particular market.

Sunday, May 22, 2011

When to Add a Hospice and Palliative Medicine (HPM) Physician to your Practice

Most hospice and palliative medicine (HPM) programs and practices are experiencing growing demand for their physician services. These growing pains, obviously, can put a strain on current staff and the practice's infrastructure. A physician practice that is stretched beyond capacity because of an unfilled position cannot carry the patient and on-call load of a larger group for an extended period of time. The overtaxed and overwhelmed physicians are prime candidates to leave the practice, seeking opportunities where they can find better control over their workload. In other words, unfilled positions beget unfilled positions. That is why turnover is often referred to as the "silent killer" of a practice.

One of the most challenging tasks for a HPM medical director or practice manager is determining how many physicians are needed to staff the program. Since most HPM practices do not generate revenue greater than their compensation, knowing when to add a full-time physician is not an easy decision to make. But it is important to consider the costs and lost revenue associated with an unfilled position as well as the salary it takes to fill it. Take a hospital inpatient palliative care consult service, for example. A 2008 study by the National Palliative Care Research Center found that savings from palliative care consults for hospital inpatients ranged from $1,500 to $5,000 per admission. A palliative medicine physician who performs 40 such consults per month will produce savings of at least $60,000 per month for the hospital. Or take a hospice program with a palliative care consultation service and a physician making home visits to palliative care patients. One-third of those patients can be expected to transition to the hospice benefit, generating, on average, $1,500 in hospice revenue per patient. An HPM physician visiting 30 patients per month on the palliative service will produce $15,000 in patient service revenue for the associated hospice.

While these guidelines are handy in building a case, alone they do not make a clear case for when a physician should be added. Nor will the conceptual approach, projecting the work for a time period (e.g., 5,000 home visits/year) and dividing that projection by the amount of work performed by one FTE HPM physician (e.g., 920 home visits/year). Careful consideration of several other factors will also enhance the decision-making process: use of non-physician providers, such as nurse practitioners; variation in workload (need to staff higher than the average to address spikes in service demand); expectations around nonclinical commitments that may include administration, teaching and research; and the need for off-hours coverage, vacations and the like. The right timing in adding a physician to a HPM practice will likely accelerate success. Mistiming will stymie program (and practice) growth. In future posts we will look more closely into effective ways to attract the right candidates to your practice.

Wednesday, May 11, 2011

Palliative Care Grand Rounds - May 2011

Hiatus over. Welcome to the May edition of Palliative Care Grand Rounds (PCGR), a monthly (now appearing the second Wednesday of each month) summary, or mash-up, of interesting, thought-provoking, timely, relevant, humane, and exceptionally well-written postings from the blogosphere.
Several topics dominated the news, and thus the blogs, covering palliative care. Prescription opioid abuse is one, and Drew “Feeling Grumpy” Rosielle addressed this subject in his post on the blog Pallimed.

Also, on the 16th of last month bloggers united around the 2011 Blog Rally for National Healthcare Decisions Day (NHDD). Nathan Kottkamp founded NHDD back in 2008 as a nationwide advance care planning awareness initiative. Larry Beresford, accomplished hospice journalist, took up the torch in posting a personal story about completing his own advance directive. In the blog Hospice Doctor, a palliative medicine specialist muses about the decision-making process (for clinicians and family) behind the care of an 88-year woman whose death in a hospital followed 11 days there with considerable (some futile?) treatment.

Which leads me to the third subject in the April palliative care news stream. The Dartmouth Atlas of Health Care has released a new report, "Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness," documenting trends in the care of chronically ill patients in the last six months of life. This report was covered extensively in the mainstream media, less so in the blogosphere. You can check the PBS NewsHour coverage of this story in this post on its blog.
Then see the comments this blogger posted  regarding the huge and persistent variations across hospitals, communities, regions, and states. If you agree that these variations in late-life care practice appear intractable, share with us your thoughts—what do you think can be done?

GeriPal bloggers Drs. Eric Widera and Alex Smith were themselves featured in a New York Times blog post.  Together with colleague Dr. Sei Lee, they are developing a Web site that offers individual prognoses based on 18-20 different geriatric prognostic indices. When you visit the blog post, be sure to spend a few minutes reviewing the comments. Here’s a topic that apparently resonated with many readers.

And speaking of the blog GeriPal, congratulations on being chosen as the Best Clinical Weblog of 2010. In one of its April posts, it looks more closely at the results of a study on nurse practitioner models of palliative care. And Geripal blogger Alex Smith jumped over to another blog, Kevin MD, to comment on
the hospice and palliative care community’s unrelenting yet fruitless search for a simple and consistent message. Speaking about a message that benefits from consistency, and also at the blog KevinMD (its tag line is “social media’s leading physician voice”), a geriatric psychiatry fellow posts that palliative care and medical interventions are not mutually exclusive.

Many thanks to Christian Sinclair for originating Palliative Care Grand Rounds several years ago, and for sustaining it since. But to state the obvious, PCGR’s continued publication depends upon fellow bloggers…like you. Do let Christian know of your interest in adding your incisive post.

Friday, April 15, 2011

National Healthcare Decisions Day - April 16

This post is part of the 2011 Blog Rally for National Healthcare Decisions Day. If you have a blog please post it and leave it up on the front page through April 16th. -Ed.

Rallying to Encourage and Empower Us All to Make Our Healthcare Decisions Now for the Unknown Later…

College education. Career path. Relationships. Starting a family. Buying or selling a house. Vacations. Retirement. From the age that we’re old enough to understand, most of us are taught and accept that these are the markers in life that we plan for. However, there’s one key marker that’s all-too-often missing from this list: healthcare decision-making. Like planning for these other life events, planning for the time (or times) that we are unable to express our healthcare wishes is of the utmost importance. It is something that should be well thought out, documented and revisited at different points in life to reflect any change in our desires or family situation or the person we wish to advocate for us. Unfortunately, it is a planning point that that majority of us have missed. As a consequence patients’ families suffer the added burden of having to guess when a health crisis happens. That’s why Nathan Kottkamp founded National Healthcare Decisions Day (NHDD) back in 2008 and why this nationwide advance care planning awareness initiative is as important as ever. So this year, I’ve joined my fellow bloggers throughout the country to spread the word about the importance of advance care planning with this special NHDD edition blog.

NHDD, which happens every April 16, is a collaborative effort of national, state and community organizations as well as dedicated individual advocates committed to ensuring that adult Americans – like you and me —have the information and opportunity to communicate and document their healthcare decisions.

 Here are some things you can do for yourself and your loved ones to prepare for NHDD 2011:

Lead by example. Schedule time with your loved ones  to “Have the Talk” and complete your own advance directive. There are many tools, including free forms, you can use to walk you through the process and make your wishes known; access them through the NHDD Public Resources page.

Encourage your loved ones and friends to learn more about advance directives and to complete their advance directives. You can forward this link: to them. Or, encourage them to find a nearby participant and attend a local NHDD event.

Share your advance directive with your healthcare providers and make sure it is on file in the event it is needed.

Already had the conversation with your loved ones, but want to do more? Here a few suggestions to rally support for NHDD and encourage even more action:

Like the NHDD Facebook fan page and share it with your Facebook friends

On Twitter? Follow @NHDD and share the information with your followers.
Send an email to your friends, staff, colleagues, lodge/social club members, and/or house of worship, telling them that you are participating in NHDD and encouraging them to do the same. Share the information above with them and/or use this template email:

April 16 is National Healthcare Decisions Day, and I hope that you will join me in taking this time to discuss and document your healthcare wishes. We all need to be prepared in the event of a health crisis, and having the talk is easier than most people think, but many of us need a little inspiration or a reminder to do it. I hope that this message and National Healthcare Decisions Day are all you need. Please mark your calendar for April 16 to have the talk with your loved ones. There are all sorts of free resources, including free advance directive forms for each of the 50 states, on the NHDD website: Additionally, please help me spread the word with Twitter, Facebook, and LinkedIn. Advance care planning is something we ALL should do and encourage others to do, regardless of age or current health. Discussing your wishes can be one of the most important gifts you ever give your loved ones.

Act now and grow this rally further: use and share the resources available through the NHDD website and encourage and empower us all to make our healthcare decisions now for the unknown later.

Wednesday, April 13, 2011

Variations in Late-Life Care Persist - What Can Be Done? And By Whom?

A recent blog post commented on the enormous clinical variation in late-life care. Another blog post remarked on the difficulty of "spreading the science of palliative care" because of the fragmented system delivering palliative care. And this week The Dartmouth Atlas Project  issued a study - "Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness" - which further documented the enormous clinical variations across the nation as late-life (final six months) care is provided. The differences among communities is staggering, and these variations persist. For example, in 2007, chronically-ill patients in Manhattan spent, on average, 20.6 days in the hospital during their last six months of life, almost four times more than patients in Ogden, UT, where the average was 5.2 days. Chronically ill patients in Fort Lauderdale were half as likely to die in a hospital than similar patients in and around New York City. Is there a question as to which region's late-life care practices better comply with patient and family preferences?
The report documents trends from 2003 to 2007 in the use of medical resources to treat Medicare patients at the end of life at hospital referral regions and at 94 academic medical centers. The study found that Medicare patients diagnosed with severe chronic illness were less likely to die in a hospital and more likely to receive hospice care. They also had many more visits from physicians, particularly medical specialists, and spent more days in ICUs. The overall picture, one could say, is mixed; although patients experienced fewer hospital days and more hospice care, at the same time therre was an increase in the intensity of care for patients who were hospitalized.

"In addition to its effects on patients' quality of life, unnecessarily aggressive care carries a high
financial cost. About one-fourth of all Medicare spending goes to pay for the care of patients in their last year of life, and much of the growth in Medicare spending is the result of the high cost of treating chronic disease," said David C. Goodman, MD, lead author of the report, in a media release. Elliott S. Fisher, MD, report author and co-principal investigator of the Dartmouth Atlas Project, perhaps put it best, "While current trends demonstrate that change is occurring in many regions and at many institutions, it is not always in the direction that patients may prefer." Dr. Fisher went on to say more work needs to be done "to ensure that future variation in care reflects the well-informed preferences of patients."

Chronically ill patients were significantly more likely to be treated by 10 or more doctors in the last six months of life in 2007 than they were in 2003. Visiting such a number of physicians certainly must place a premium on effective care transitions. Is our current system well structured to enable effective and coordinated patient transitions?

Future posts on this blog will take a closer look at the findings of this Dartmouth study, and examine those regions, and academic medical centers, that may offer promising approaches. In other words, we'll identify exemplars.

We need to be better at disseminating the science and art of palliative care to reduce these clinical variations. But how to do that, and who should be leading the effort? Should we take a closer look at a national campaign to improve late-life care, like the 30/30/30 Campaign described in a previous post on this blog. Your thoughts are invited.

Thursday, March 17, 2011

30/30/30 Campaign to Improve Late-Life Care

A Palliative Care Summit was recently convened in Philadelphia by the School of Population Health at Thomas Jefferson University. It was described as the “First National” and the “Leading Forum on Palliative and End-of-Life Care”.

An impressive array of speakers over the two days. Diane Meier,MD, Sean Morrison, MD, Don Schumacher, David Wennberg, MD, Christine Richie, MD, Terri Maxwell, PhD,APRN, James Cleary, MD.,Todd Hultman,PhD,APRN to name but a few. A roster of thought leaders in the field. Compelling cases were made during the presentations on why hospice and palliative care (is/are?) the solution to many of the health care industry’s woes. Meanwhile, just next door, other industry thought leaders were offering compelling cases on why “medical homes” or ‘expanded chronic care models” or “mobile technology” were desirable solutions for transformation of the health care system.

In other words, competing, or one might say, conflicting visions. These competing/conflicting visions exist across specialties, and within them. Dr. Morrison addressed this issue when he stated that the public and professionals are confused by references to hospice and palliative care , as if these were two distinct fields or sectors.

While my training is as a health executive, I’ve spent much of my professional career advancing the work of palliative care/hospice professionals and organizations. So I pay closer attention to the hospice/palliative care field, and how it may best fit into the larger health care system. And as Dr. Morrison stated directly, and others commented more indirectly, while progress has been made over the past 15 years, the institutional culture of dying in the US has not dramatically changed. I refer to palliative care as one parts accomplishment for every three parts of potential. Yes, we have a long way to go, indeed.

At the end of the Summit, I was left with a nagging question: If hospice and palliative care are such an obvious solution, then why hasn’t the “art” and “science” of hospice and palliative care spread more quickly and widely than it has? No simple answers to be sure. Yes, many of the speakers offered calls (some powerful) to action. Yet calls for action have been sounded for the past 15 years, with some, but most would argue, insufficient progress. Why? The promise of palliative care to improve late-life care has been stymied by a highly fragmented field of hospice and palliative care where stakeholders are perpetually “staking” out their ground.

Some suggestions for the Second National Palliative Care Summit. Let’s have discussions around:

  • How nursing AND medicine can best collaborate to improve access to palliative care in all settings across the community.

  • What NEW organizational models might best bring together key stakeholders in late-life care within a community?

  • What can be learned from communities whose late-life care practices make them exemplars?
Finally, we need a unifying campaign to improve late-life care in the US. Here’s a suggestion. The 30/30/30 Campaign. A national campaign carried out locally/regionally.

Something like the following:

  • No more than 30% of deaths occur in hospitals.
  • At least 30% of deaths in hospital are consulted by palliative care specialists.
  • No more than 30% of patients who die will be enrolled in hospice for 10 days or less.
Your comments, ideas, feedback are, as usual, invited.

Thursday, March 10, 2011

Improving Performance in Late-Life Care

I’ve now been involved in hospice and palliative care for 25 years, on the management rather than clinical side. During that time, I’ve seen how the principles of palliative care can improve care for those with advanced or serious illnesses. While hospice has been the organized vehicle through which much of this care has been applied, and there’s no disputing that improvements in late-life care have been made over the past couple of decades, hospice does have its linmitations. And so, I’ve spent much of my time studying organizational and business models that can successfully "distribute"  palliative care principles across a larger population.

Part of that study has involved benchmarking on an organizational level, that is, using benchmarking principles to improve the performance of individual hospices. As a hospice executive, this exercise certainly has value.

There’s another measure of performance improvement. The firm with which I’m associated assists palliative care organizations in crafting medical staff development plans. These are staffing plans that are aligned with the organization’s objectives and the community’s needs. We’ve determined that one of the best ways to identify a community’s needs for palliative care is to use available data about the community’s practices around palliative care. The best source , we’ve found, of such information, is the Dartmouth Medical Atlas. The Dartmouth Medical Atlas began in 1993 out of Dartmouth University as a study of utilization of health care resources, generally inpatient resources, in geographic markets across the US. The study uses Medicare claims data. The Dartmouth research group has been updating and expanding its studies. Recently, a study was conducted of Medicare beneficiaries who died (decedents) between 2001 and 2005. This study analyzed use of resources (inpatient, outpatient, home, and long-term care facility), in the final two years of life. The results begin to answer the question of how we care for those with advanced illness.

The researchers concluded, among other things, that there is enormous variation (across regions, and across hospitals within those regions) in how people are cared for near the end of life. When one considers that 75% of Medicare resources are spent to care for those in the last two years of life,  I would be understating to say there is great interest among Medicare officials and other payers on how care is provided. In fact, one of the calls to action the researchers recommended is that pay-for-performance programs should reward those practices that improve system-wide efficiency in providing care for those with chronic illness.

The goal of performance improvement as it applies to healthcare systems is to reduce variability in the way care is provided. And a key factor in closing the gap between best practice and common practice is the ability of health care providers and their organizations to rapidly spread innovations and new ideas. I'm interested to learn how palliative care specialists are "spreading the science".

Thursday, January 13, 2011

How Often Should Patients with Advanced Illness Be Visited By a Physician?

We believe the role of the physician within hospices has been undervalued, and we would like to see the physician's participation increase in the care of long-stay patients.  That’s one of the messages to take away from the CMS regulation mandating physician (or nurse practitioner) face-to-face encounters to certify a patient’s continued hospice eligibility. The Medicare program reimburses a hospice nearly $30,000 over a six-month period to provide for the total healthcare needs of a patient with advanced illness– a single physician visit to that patient’s residence over that period isn’t too much to require, is it?

To me, it seems likely that such patients would benefit from a care planning visit by a physician. After all, the distinguishing feature of hospice care from most other care covered by Medicare is its collaborative nature, and the primacy of the interdisciplinary team. Such care, of course, lies at the core of palliative medicine.

Rather than treating this regulation as a compliance issue, hospice executives, and physicians, would do well to incorporate physician recertification visits into their clinical practice patterns. One can be confident that patients, and their families, will appreciate the value of these visits.

Recently, a family member passed away after a broken hip confined her to a skilled nursing facility.  A hospice program served her during her final three months. During that time, she was not seen by a hospice and palliative medicine physician. And while her (and the family's) hospice experience was positive, the interdisciplinary team concept seemed incomplete without a single bedside appearance from the physician.

Saturday, January 8, 2011

HPM Physician Performance Management

At a recent regional assembly of hospice executives and Hospice and Palliative Medicine (HPM) physicans who had gathered to strategize about the advantages (and disadvantages) of building a provider network for late-life care, I was asked what tools are available to measure performance of HPM physicians (and nurse practitioners).  I suggested turning to the Joint Commission's standards on OPPE (which I have written about previously, read here) for a closer look into how hospitals are expected to evaluate  their medical staff practitioners. How might these standards be applied for HPM physicians in the hospcie setting?  Here's one approach to applying physician performance core competencies to HPM practitioners we've found successful:  
Patient Care. Providing patient care that is compassionate, appropriate and effective for managing
late-life care.

Medical/Clinical Knowledge. Degree of knowledge of established and evolving practices and principles of HPM, as well as the application of that knowledge to patient care and the education of others.

Practice-based Learning and Improvement. Use of scientific evidence and methods to investigate, evaluate and improve late-life care practices.

Interpersonal and Communication Skills. Establish and maintain professional relationships with patients, families and other members of health care teams.

Professionalism. Commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity, and a responsible attitude toward  patients, the profession and society.

Systems-based Practice. Understanding of the contexts and systems in which palliative care is provided and the ability to apply this knowledge to improve late-life care.

Of course, specific metrics need to be developed to evaluate performance in each of these domains.  The metrics  will vary from organization to organization and are  less important than the process of sitting down to develop the metrics. Yet,  doing so will take executives and physicians a long way toward satisying one of the building blocks of a high-performing HPM medical staff -  to  foster an unswerving commitment to performance improvement to minimize unwarranted practice variation, reduce regulatory risk, and win the confidence of referring sources.