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.

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.

Palliative Care Grand Rounds - July MMX

Read here for this month's PCGR, hosted at the GeriPal blog. You'll find an interesting, enlightening, and well-rounded mash-up of the best from the blogosphere.