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".