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".

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.

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.

New Considerations for Developing a High-Performing Hospice Medical Staff

Beginning January 1, 2011, face-to-face recertification visits with hospice patients will no longer be simply good practice. The Centers for Medicare and Medicaid Services ("CMS") has implemented certain provisions of the Patient Protection and Affordable Care Act of 2010 and regulates that such visits become mandatory.


Face-to-face encounters may not occur earlier than 30 calendar days prior to the start of the benefit period for which it applies. Certifications may not occur earlier than 15 calendar days prior to the start of the benefit period for which it applies. A required face-to-face encounter must occur prior to its associated certification.

This requirement will better enable hospices to comply with hospice eligibility criteria, and to identify and discharge patients who do not meet those criteria. How to best comply with this regulation will be a determination made upon specific circumstances of each hospice's medical staff, including:

•      variability in clinical commitment of current staff, including nurse practitioners
•      nonclinical commitments that may include administration, teaching, and research
•      productivity data to analyze MD capacity to absorb additional volumes

Several points to keep in mind as you develop a plan to comply with the requirement:

• The face-to-face encounter by the hospice physician or the NP for the purpose of gathering clinical findings to determine continued eligibility for hospice care is NOT billable. The face-to-face requirement is part of the recertification process, and therefore is an administrative activity included in the hospice per diem payment rate.

• The certification or recertification of terminal illness is not a clinical document, but instead is a document supporting eligibility for the benefit and is considered an administrative activity of the hospice physician.

• Providing reasonable and necessary non-administrative patient care services during the face-to-face encounter is billable: If a physician provides reasonable and necessary non-administrative patient care, such as symptom management, to the patient during the visit (for example, the physician decides that a medication change is warranted), that portion of the visit would be billable.

• Billing for medically necessary care provided during the course of a face-to-face encounter should flow through the hospice and be billed as physician services under Part A, as the hospice physician or NP who sees the patient is employed by or, where permitted, working under arrangement with the hospice (for example, a contracted physician).

• If there is a billable portion of the visit, hospices must maintain medical documentation that is clear and precise to substantiate the reason for the medically necessary services separate from the face-to-face encounter related to recertification. Documentation of the face-to-face encounter and any other medically necessary patient care services provided during the visit can be included in one note. Visit documentation should, of course, clearly support any billable services that were provided.

• Medically necessary care provided during the course of a face-to-face encounter by an NP can be billed only if the NP has been designated as the patient's attending physician.

• There is no requirement that the visit must take place in the patient's home---- it could take place in practitioner's office.

• Electronic signatures are permitted on hospice certifications and recertifications. Narrative and the face-to-face attestation are parts of the certification or recertification and may also be signed electronically.

• Use of telemedicine to perform the visit is not permitted.

• Attendings cannot do the face-to-face visit without becoming a "hospice physician".

Much to consider, to be sure. 

Staggering Gaps in Late-Life Care Makes News

A recent post on this blog (read here) commented on the Dartmouth Atlas Project findings of variation in late-life care for advanced cancer patients. While the findings of variation are  not surprising to those who have been following the Project's studies over the past two decades, what did  leave me open-mouthed was the  enormity of these variations. In some communities, more than 70% of patients with advanced cancer did NOT receive hospice care, staggering even when one considers that nationally 45% did not receive hospice care. If hospice care is not provided to nearly half of patients with advanced cancer, what must those figures be for patients with other advanced illnesses for which prognostication is more difficult. Conversely, in some communities, more than 70% of  patients with advanced cancer DID receive hospice care.

I'm encouraged, nonetheless, by the widespread attention given to this study, in both national and regional publications. It's almost as if these study findings have sounded an alert, one that says WE CAN DO BETTER. Much better.

The Los Angeles Times commented  that "the study found that patients in Minneapolis were four times less likely than those in Los Angeles to receive aggressive life-sustaining treatment during their last weeks on earth."  The article went on to bluntly say "In other words, unless people strongly assert their preferences, their end-of-life care will largely be determined by the prevailing customs of their communities."

An article in the Chicago Tribune commented, "the gap was even greater for frail, seriously ill cancer patients who received CPR, mechanical ventilation and feeding tubes — interventions deemed of little value as the end of life approaches. Some 16 percent of these patients got these therapies in Chicago, compared with 9 percent across the U.S."  More from the Tribune, "that analysis reveals some stark differences among Illinois hospitals. Notably, for Evanston Hospital, Glenbrook Hospital and Highland Park Hospital — all part of NorthShore University HealthSystem — only 19 percent of Medicare patients with advanced cancer died in the hospital, compared with 38 percent at Northwestern Memorial Hospital."

The Milwaukee Journal-Sentinel headline read bluntly that late-life care "needs improving".  It offered the following example of variations within the state: "At Columbia St. Mary's two hospitals in Milwaukee, which have since been consolidated, 11.2% of patients with advanced cancer died in the hospital. At St. Mary's Hospital in Madison, it was 16%. In contrast, an average of 37.3% of patients with advanced cancer at Wheaton Franciscan Healthcare-St. Joseph Campus died in the hospital, although this may be because the hospital has an area designed for patients near the end of life who want to be in a residential setting." Perhaps.

Not all of the local news reports focused on laggards. The St. Petersburg Times found that study results in that community were generally better than national averages. And the Globe Gazette (Iowa) highlighted  the exemplary performance of Mason City, Iowa in most indicators.

Future posts will take closer looks at communities and hospitals with exemplary performance in an effort to answer the question:  How Did they Do That? In the meantime, I invite your thoughts.

Accountable (Palliative) Care Organizations - A Call for Comments

Blogs Pallimed and GeriPal have posted very recently about an opportunity to influence the development of  an organizational model that some consider to be a prototype of the next decade's health care delivery system. Accountable Care Organizations (or ACOs).    The shift accountable care organizations will bring from pay-for-volume to pay-for-value — and their focus on total population management, closely aligned incentives and a degree of coordination among providers not typically seen in most markets — cuts to the heart of  the health care institutions within most communities . In the cards, some suggest, are:  fewer hospital admissions, shorter lengths of stay, fewer emergency department visits, and fewer procedures and tests. Hospice and palliative care advocates, take note, this is our opportunity.
There is a special request for comments regarding certain aspects of the policies and standards that will apply to ACOs participating in the Medicare program under section 3021 or 3022 of the Affordable Care Act. The request can be found at regulations.gov under the document number: CMS-2010-0259-0001.


The dealine for comments is December 3rd, so there is little time to act.  Diane Meier has offered some guidance in formulating a response to three main questions posed in this call for public comments. Here are her possible talking points that you can consider putting in your comment:

Question 1: How should we assess beneficiary and caregiver experience of care as part of our assessment of ACO performance?

•Require evaluation of patient and family goals of care, using for example POLST and advance care planning

•Determine patient-family recall of discussions about care goals, and degree to which care actually received is concordant with goals

•Require access to quality palliative care and Medicare-certified hospices as a condition of participation in an ACO.

•Assess penetration of and receipt of palliative care among high need high cost patient populations across diagnostic categories.


Question 2: The Affordable Care Act requires us to develop patient-centeredness criteria for assessment of ACOs participating in the Medicare Shared Savings Program. What aspects of patient-centeredness are particularly important for us to consider and how should we evaluate them?

•The most important aspect of "patient-centeredness" is the degree to which informed and achievable patient and family goals for care are elicited, documented in an accessible and retrievable manner, and actually followed in the care plan.

Question 3: In order for an ACO to share in savings under the Medicare Shared Savings Program, it must meet a quality performance standard determined by the Secretary. What quality measures should the Secretary use to determine performance in the Shared Savings Program?

•Quality measures should include advance care planning; occurrence and timing of palliative care services among appropriate patient subgroups; occurrence and timing of hospice services among appropriate patient subgroups; symptom burden; patient confidence that someone on the team knows them and can be reached after hours; degree to which patients families believe they know what to expect and are prepared to handle their illness; degree to which family needs are assessed and addressed among appropriate patient subgroups

Dr. Meier makes clear that the goal of our comments should focus on making the point that an ACO must require access to quality palliative care for its sickest high need and high cost patients in order to assure that care is directed by and concordant with patient and family goals, and not by strong ACO incentives for cost containment.

There is little time to act. Just click here and submit a comment. To make your lives a little easier, the following is a draft outline that you can use in your comment:

1.Introduce yourself as palliative medicine clinician or health professional.

2.Define palliative care as medical care focused on best possible quality of life, delivered from point of diagnosis of serious or advanced illness whether the goal of care is cure, life prolongation, or achieving a peaceful dignified death. In practice, consists of expert assessment and treatment of symptom distress including pain, anxiety, and depression; conduct of in-depth discussions with patients and families to establish achievable care goals and a care plan that meets those goals; and commitment to continuity of care and relationships across the many care settings that seriously ill patients must traverse over the course of an illness. Palliative care includes end of life care (hospice) but is not limited to it- it is especially important among Medicare and Medicaid beneficiaries with advanced disease and/or multiple chronic conditions with functional impairment- a group who are not predictably dying and who may live for many years with a significant burden of disability and medical needs.

3.The core strategy of palliative care is to help informed patients and families determine their achievable goals for care and then helping to make sure that medical care received helps patients achieve those goals.

4.The goal of ACOs is to incent quality and not quantity and to coordinate the full range of providers. Because of ACO-associated changes in financial incentives that will reward efficiency and "doing less", the risk of undertreatment- reduced access to needed care- and consequent poor quality of care is greatest for high need high cost patients. To counter that risk, ACOs should be required to provide access to specialists trained in care of this complex high need patient population across diagnostic categories, and specifically trained in the skilled communication necessary to elicit achievable care goals throughout the course of illness. Providers with this training work in palliative care programs (mostly hospital-based) and in hospices.


More on Accountable Care Organizations, and the role of hospice and palliative medicine, in future posts.