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?

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.

The Unofficial Role of a Community Chief Palliative Care Officer

In a recent post (see here) I commented on the exemplary performance of Susquehanna Health System (in Williamsport, Pa.) in its end-of-life care practices, according to the DAI Palliative Care Group Hospital Performance Profile. In researching communities and health systems whose palliative practices have earned them an A grade, we're finding several common attributes. One of these attributes is the presence (usually unofficial or sometimes formalized) of a chief palliative care officer. Below are excerpts of an interview with Alexander Nesbitt, MD, chief of palliative care and hospice for the Susquehanna Health System, which appeared in a recent issue of HPM Practitioner.

Dr. Alexander Nesbitt was an established family practice physician and very part-time hospice medical director in Williamsport, PA, when he heard a 2003 presentation by Dr. Diane Meier, director of the Center to Advance Palliative Care (CAPC). "I had never heard of palliative care, but I became convinced that it was a really good idea, and that somebody in Williamsport should do it." He attended the Program in Palliative Care Education & Practice at Harvard Medical School (www.hms.harvard.edu/Pallcare/PCEP.htm) and began working toward board certification in HPM, earning that credential in 2004. He pursued an expanded role in Susquehanna Hospice and started advocating for a palliative care consultation service at 180-bed Williamsport Hospital & Medical Center. Both belong to the local Susquehanna Health System."The idea of starting a new program, which included hiring a full-time nurse practitioner to staff it, was an uphill push. I had to convince the hospital's administration that we should spend the money, even though the system was undergoing financial difficulties. Fortunately, CAPC has highly practical tools to use, well adapted to just that purpose." Dr. Nesbitt is an employee of the health system, which employs about half of the physicians in its region. "I had been working with administrators every step of the way, persuading them of the importance of this work - for patients and families, as well as for the system - and sharing outcomes data." When it came time to transfer full-time to hospice and palliative care, the various responsible parties were ready to sign off on the change. Dr. Nesbitt's salary is based in part on billing income from palliative care and inpatient hospice consultations, annualized, as well as an hourly rate for dedicated administrative responsibilities, which amount to nearly half of his roughly 50-hour week. "Although initially I wasn't so sure, I felt I could set it up piece by piece, and make a job of it," with the combination of hospice and palliative care a good package for the system, he says. "There's increasing information out there that this work is beneficial for the patient and family, for the reputation of the hospital, for customer satisfaction, for the bottom line, and for readmission rates."
In the beginning, Dr. Nesbitt took the lead on hospital palliative care consults, but as the program established its credibility, the nurse practitioner now makes over half of the visits. Another palliative care physician joined the team in 2007 and sees patients in affiliated, rural Muncy Valley Hospital, 10 miles away, and in the region's nine long-term care facilities. In addition to the hospital-based nurse practitioner, there is a second nurse practitioner based in the nursing homes, and an advanced practice nurse who sees patients in nursing homes and coordinates professional education events."Within the (HPM) team, each of us has a primary base, but we also work to float extra team time to wherever it is needed," he explains. The five members meet monthly to discuss practice issues. Growing demand for services is a problem, and the team tried to manage growth in sustainable ways while it extended services into the long-term care setting. Recently, it was decided to limit weekend palliative care consults to emergency cases only. "Sometimes we're really busy on the weekends, so we're working to make that part of this work more manageable," Dr. Nesbitt says. Dr. Nesbitt starts a typical workday by rounding on patients in the inpatient hospice unit, and then, depending on demand for palliative care that day, goes to the hospital. He makes occasional home visits to hospice patients and sees some patients in his office in the medical building. So far there is no formalized outpatient clinic setting or schedule for palliative care, although that may change in the next year, perhaps in conjunction with the system's Cancer Center. Dr. Nesbitt takes night and weekend call every third week, and he also meets regularly with various administrators within the health system's organizational chart. He spearheaded a POLST (physician orders for life-sustaining treatment) initiative in the region, working with the hospitals and nursing homes. The State of Pennsylvania does not give legal recognition to POLST, but a study group is working toward initiating a statewide form. He also chairs the hospital's ethics committee.

Surely, there are many factors contributing to the success of health systems and communities in their provision of late-life care to their patients and residents. I don't mean to ovrsimplify, but it's becoming apparent to us that the role of full-time HPM physicians is one of those influences.
I'm interested to learn of similar examples. Or, am I exaggerating the influence of HPM physician practices?

Hospital Palliative Performance Profiles

Since 1996, the Dartmouth Atlas of Health Care has tracked patterns of health care delivery, practice and quality across the country. Its massive pool of national, regional, local and provider-level health care utilization and cost data, derived from the Medicare database, has documented striking geographical variations in the delivery of health care services. But it has also changed our understanding of the efficiency and effectiveness of health care delivery and demonstrated that more medical care does not necessarily mean better care—that the wide disparities in health care spending and utilization do not track with measurable improvements in health care quality. In fact, higher utilization at the end of life may represent both harm to patients and billions of dollars in wasteful and unnecessary health care spending.

The Dartmouth Atlas Project, founded by Dr. John E. Wennberg, is based in the Dartmouth Institute for Health Policy and Clinical Practice at Dartmouth University. Its databases are used by health care policy-makers, analysts, health care executives, researchers, and, increasingly, palliative care advocates seeking to plan or justify the need for palliative care services to help their hospitals better manage these high-need, high-cost, high-utilization patients.
“Concern about overly aggressive care for patients at the end of life has sparked increased interest both in palliative care and in aligning the kinds of services provided to dying patients with their well-informed preferences,” the report states. “Patient wishes may have less influence on intensity of care than the practice patterns of the hospital where the care is given.”

Taken together, these figures start to sketch a picture of how much potentially futile or ineffective care a hospital or a region provides to patients during their final months of life or during the hospitalization in which death occurs—as well as creating an opportunity to compare performance on these variables among peers.

Our analyses show there is great variation in end-of-life care across regions and states. Digging deeper, our research group has identified that those hospitals with high performance scores (100 or above) have adopted advanced palliative care organizational (APCO) principles in which there are what we refer to as “learning communities”. This learning community is essentially a group of palliative care stakeholders who "join" together and are driven by a desire to share problems, knowledge, experiences, insights, templates, tools, and best practices around palliative care.

I'm interested to hear from those involved in learning communities sponsored by APCOs.