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."