N a t i o n a l S u m m i t o n
A d v a n c e d I l l n e s s C a r e
D r i v i n g C h a n g e t h r o u g h
L e a d e r s h i p , E v i d e n c e a n d
A c t i o n
Welcome and Goals
Leonard D. Schaeffer
Judge Robert Maclay Widney Chair and Professor
University of Southern California
M a r c h 2 , 2 0 1 5
Conference Hosts
• Bill Novelli: Board Co-Chair and
Professor, McDonough School of
Business, Georgetown University and
former CEO, AARP
• Tom Koutsoumpas: Board Co-Chair
and President, Caring Foundations
• Jon Broyles: Executive Director,
C-TAC
C-TAC Vision
All Americans with advanced illness, especially the sickest and most vulnerable, will receive comprehensive, high-quality, person- and family- centered care that is consistent with their goals and values and honors their dignity.
Advanced IllnessC-TAC’s Goal
Chronic and Curative Care
Healthy or with
reversible illness
Disease Progression
Advance Directive Advance Care Planning
Early onset, chronic
conditions
Progressive, frequent
complications
Hospice
Eligible
Palliative Care
Hospice
Phase 4Phase 3Phase 2Phase 1
All persons with advanced illness
receive high quality care
Key C-TAC Initiatives
• Comprehensive, Consensus-Based
Policy Agenda: Guides C-TAC’s activities
on the Hill and with Administration
• Proof-in-Concept Community Action
Pilot (Oakland, CA): Fosters partnerships
between health systems and community
organizations to fill gaps in care delivery
• Advanced Care Project: Partnership with
AHIP Foundation to engage health plans and
health systems in implementing advanced
illness care programs
Key C-TAC Initiatives
• Serves as a guide for
transforming advanced
care illness across all
disciplines
• Analyzes key issues,
challenges and solutions
• Identifies action steps for
achieving high-quality,
advanced illness care
• Provides a “Call to
Action”
Conference Goals
• Increase provider and consumer readiness
to implement, evidence-based tools &
approaches to AIC
• Connect consumers, clinicians, health
systems and health plans to deliver high
quality, person-centered care and commit
to improved performance
• Disseminate information and support
implementation of evidence-based AIC
models
We’re here to learn what’s working
and what’s not, and use these
lessons to move forward
• Identify gaps in evidence that need to be
addressed to further the adoption of better
AIC
• Expand comparative effectiveness
research to support transformational
change in the field
Conference Goals
How You Can Contribute Today
One degree of change can make
all the difference
• Be candid about what’s working, what’s
not, and why
• Join in catalyzing action and energy
around effective programs and ideas
• Help identify programs and concepts with
the greatest potential to improve AIC
• Offer ideas on how to scale up what’s
working
IOM (Institute of Medicine). 2014. Dying in America: Improving quality and honoring individual
preferences near the end of life. Washington, DC: The National Academies Press.
Introduction
Please join me in
welcoming:
Victor Dzau, MD
President,
Institute of Medicine
A d v a n c e d I l l n e s s C a r e :
T h e I O M P e r s p e c t i v e
V i c t o r J . D z a u , M D
P r e s i d e n t ,
I n s t i t u t e o f M e d i c i n e
Dr. Victor Dzau, MDPresident, Institute of Medicine
Advanced Illness and End of Life Care: The IOM Perspective
Advanced Illness Care
“Occurring when one or more conditions become serious enough that general health and functioning decline, and treatments begin to lose their impact.
The process that continues to the end of life.”
-Coalition to Transform Advanced Care
Trends & Background
Aging
Americans over age 65
9% in 1960
20% in 2050
Growing ethnic and cultural diversity
Disease Burden
Multiple chronic conditions
2/3 of people over 65
New cancer cases
45% increase from 2010 2030
Alzheimer’s disease and dementias
5.5 million in 2010 8.7 million in 2030
Parkinson’s disease
Prevalence to double in the next 30 years.
Care
People dying in acute care hospitals
Deaths in nursing homes
and hospice
• # of Americans needing long-term care: more than double by 2050 • Medicare deaths in acute care hospitals: 33% 2000 25% in 2009• Growing number of deaths in nursing homes• Hospice care: 1995, 17% of US deaths 2011, 45% • By 2011, 85% hospitals with 300+ beds had palliative care services
Costs
Medicare spent 28 percent of 2011 spending, or about $170 billion, on patients’ last six
months of life.
Decision-Making
40% of adult medical inpatients incapable of making their own treatment decisions
Among nursing home residents, 44-69% cannot make their own medical decisions
70% of decedents aged 60 and older who faced treatment decisions in the final days of their lives were incapable of participating in these decisions
IOM’s Role
Independent, Apolitical | Multidisciplinary | Evidence-based
Maintaining high quality of life until
death
Care Delivery
Clinician-Patient
Communication
Policies and Payment Systems
Professional Education
Research and
Information Sharing
Public Education
and Engagement
Care Delivery
Cover provisions for individuals nearing end of
life
Provide access to palliative care,
with an integrated team
Publically report quality and cost
measures
Comprehensive Care• Seamless, patient-centered,
family-oriented, high-quality, integrated
• Accessible 24/7• Considers physical,
emotional, social, and spiritual needs
• Consistent with individuals’ values, goals, and informed preferences
Care delivery organizations
Government health insurers
Care delivery organizations
Care delivery organizations
Specifically for Children:
• Need clinical practice guidelines and protocols for palliative, end-of-life, and bereavement care that meet the needs of children and families.
Proposed Core Components of Quality EoL Care
• Frequent assessment of patient’s physical, emotional, social, and spiritual well-being
• Management of emotional distress • Offer referral to expert-level palliative care • Offer referral to hospice if the patient has a prognosis of 6 months or less • Management of care and direct contact with patient and family for
complex situations by a specialist level palliative care physician• Round-the-clock access to coordinated care and services• Management of pain and other symptoms• Counseling of patient and family • Family caregiver support• Attention to the patient’s social context and social needs• Attention to the patient’s spiritual and religious needs• Regular personalized revision of the care plan and access to services
based on the changing needs of the patient and family
Clinician Patient Communication
In a national survey, clinicians asked for patients’ preferences in medical decisions only
about ½ the time.
25% of patients reported that their clinician failed to share important information about
their test results or medical history with others involved in their care
Develop
Adopt
Tie to reimbursement
Facilitate tying to reimbursement,
licensing, credentialing
Quality Standards encouraging: • Individuals to
participate in decision-making
• Clinicians to initiate conversations
• Clinicians to revisit discussions
Professional Societies
Professional Societies and others
Payers
Health care delivery organizations
Payers
Specifically for Children:
• Need better policies and procedures to ensure child’s involvement in treatment discussion and decisions.
• Hospitals should not abruptly end contact with the family after the death.
IOM Roundtable on Value and Science Driven Health Care
Evidence Communication Collaborative
Good Communication Needs:• Respectful culture• Nurturing and secure decision making
climates• Good clinician teamwork• Access to high-quality evidence for
decision-making• Transparency and candidness around
constraints and unknowns.
Co-chaired by George Halverson & Bill Novelli
Policies and Payment Systems
Seek and enact
legislation
Implement
Integrated Financingof medical and social services to support care at the end of life.• Financial incentives
for coordinated care• EHR that incorporate
advance care planning
Administration,
Congress
Federal government and.its programs(e.g., Medicare, .Medicaid, VA),Other health care systems
Federal, state, and.private insurance and care delivery programs
Require public reporting on quality, cost,
outcomes
Specifically for Children:
• Clinicians should be reimbursed for fully informing and counseling parents.
• Bereavement services for parents and siblings of children who die should be reimbursed.
Professional Education
Provide training throughout professional
careerRequire
education and experience in
training programs
Strengthened Knowledge and Skills• Palliative care• Communication skills• Interprofessional
Collaboration• Symptom
management
Educational institutions
Professional societies
Accrediting organizations
Certifying bodies
State regulatory agencies
Include in licensure requirements for
health professionals, chaplains, social
workers, etc.
Create pathways to certification
Entities that certify /specialty-level providers
Care delivery organizations, medical centers, teaching hospitals
Increase number of training
positions for specialization
Research and Information Sharing
Research Needs
• Prevalence and nature of care that is neither beneficial nor wanted.
• Effect of palliative care on longevity.
• Elements of palliative care likely to offer the greatest improvements in quality of life.
• Evidence-based measures of quality end-of-life care.
• Family caregivers’ roles, needs, behavior, health risks, success in performance, interaction with other members of the health care team, and use of respite care and other support services.
• Reliable approaches to prognosis that start earlier in the disease trajectory, and assessment of whether more accurate prognoses. lead to improvements in quality of life and other outcomes of care.
• Effects and value of specific types of clinical innovations in delivering end-of-life care.
Research needs for children
• Comparative effectiveness studies of different approaches to symptom management and bereavement support.
• Analyses of care received in emergency departments, outpatient settings, and hospices and through home health agencies.
• Cohort studies examining the effect of palliative care on outcomes and on the patient experience.
• Studies of how best to staff, manage, and finance hospital-based pediatric palliative and community-based pediatric hospice services.
Public Education and Engagement
People don’t speak with loved ones about end of life wishes because…
Too many other things to worry about right now.
Don’t want to think about death or dying.
Family member did not want to discuss it.
Provide information, encourage dialogue
Research consumer
perception, test message
effectiveness
Encourage members to
engage patients
Engaged and Informed Constituents
Civic leaders, governments, community organizations, …faith-based organizations, consumer groups, employers, care providers
Health care
professional
societies
Government agencies
Payers
Moving Forward
Wealth of knowledge How do we act on it?
Many roles Need everyone to contribute
R E S E A R C H T H AT D R I V E S
C H A N G E
Joe V. Selby, MD MPH
Executive Director
Patient-Centered Outcomes Research Institute
W h a t D r i v e s C h a n g e ?
What Drives Change?
• Getting the Research Question Right
• Rigorous Research Methods
• Community-led Dissemination Plan
Engagement is the key to finding the research question that
leads to research that can be disseminated and implemented
Evaluation
Proposal Review; Design and Conduct of Research
Topic Selection and Research Prioritization
Dissemination and Implementation of Results
Rigorous methods - did the intervention
really work – and would it work again?
• Believable Benefit – or Bias?
– Randomization
– Multiple randomized Units
• Compared to What?
– Evaluation vs. research
– Carefully specified, high quality usual care comparator
PCORI-funded Projects
Health System Intervention to Improve Communication About End-of-Life Care for Vulnerable Patients – RCT – Washington State
Improving Palliative and End-of-Life Care in Nursing Homes – RCT - Rochester NY
Improving Advanced Cancer Patient-Centered Care by Enabling Goals of Care Discussions – RCT – New York City
Computerized PAINRelieveIt Protocol for Cancer Pain Control in Hospice – RCT –Chicago
Relapsed Childhood Neuroblastoma as a Model for Parental End-of-Life Decision-Making – Observational and qualitative – Boston MA
Improving Communication in the Pediatric Intensive Care Unit for Patients Facing Life-Changing Decisions – RCT - Chicago
Pragmatic Clinical Studies
Opportunity Snapshot
• Number of cycles per year: two
• Number of Anticipated Awards Per Funding Cycle: Six to Nine
• Funds Available Per Cycle: Up to $90 Million
• Maximum Project Duration: 5 Years
• Costs per Project: Up to $10 million direct costs
Seek to produce information that can be directly adopted by providers:
• Compare two of more options for prevention, diagnosis, treatment, or management of a disease or symptom
• Address critical clinical choices faced by patients, caregivers, clinicians, systems
• Conducted in routine clinical settings
• Protocols less complex than traditional trials
• High-priority topics identified by:
• PCORI’s Advisory Panels
• Institute of Medicine CER 100
• Agency for Healthcare Research and Quality
Contact Us
E n g a g i n g M u l t i p l e
G e n e r a t i o n s
E n g a g i n g M u l t i p l e
G e n e r a t i o n s
I n t r o d u c t i o n b y :
M a r g a r e t M a g u i r e , J D , S V P
C o r p o r a t e A c c o u n t a b i l i t y a n d
C h i e f o f S t a f f
C a m b i a H e a l t h S o l u t i o n s
P r e s i d e n t a n d B o a r d C h a i r
C a m b i a H e a l t h F o u n d a t i o n
Engaging Multiple Generations
• Ellen Goodman, Moderator Co-Founder and DirectorThe Conversation Project
• Kenyon C. Burke, Ed.D.PresidentKenyon C. Burke Consulting
• Rev. Rosemary LloydAdvisor to the Faith-Based CommunityThe Conversation Project
• Lennon FlowersCo-Founder and Executive DirectorThe Dinner Party
T h e I m p e r a t i v e f o r C h a n g e
The Imperative for Change
• Rich Umbdenstock
President and CEO
American Hospital Association
• Jeannine English, CPA, MBA
President
AARP
T h a n k Yo u
A Time for Caring Reception
We look forward to seeing you at tonight’s reception,
located at:
The Four Seasons Hotel
2800 Pennsylvania Avenue, NW
Washington DC 20007
N a t i o n a l S u m m i t o n
A d v a n c e d I l l n e s s C a r e
D r i v i n g C h a n g e t h r o u g h
L e a d e r s h i p , E v i d e n c e a n d
A c t i o n
Welcome and Recap
Leonard D. Schaeffer
Judge Robert Maclay Widney Chair and Professor
University of Southern California
M a r c h 3 , 2 0 1 5
Conference Hosts
• Bill Novelli: Board Co-Chair and
Professor, McDonough School of
Business, Georgetown University and
former CEO, AARP
• Tom Koutsoumpas: Board Co-Chair,
President and CEO, National
Partnership for Hospice Innovation
• Jon Broyles: Executive Director,
C-TAC
C-TAC Vision
All Americans with advanced illness, especially the sickest and most vulnerable, will receive comprehensive, high-quality, person- and family- centered care that is consistent with their goals and values and honors their dignity.
Recap From Day One
• Where advanced illness care is heading
• How to build urgency around change
• How to effectively engage multiple
generations in advanced illness care in
community and clinical settings
• How to build on successful innovations
to achieve further progress
Speaker themes included:
How You Can Contribute Today
One degree of change can make
all the difference
• Be candid about what’s working, what’s
not, and why
• Join in catalyzing action and energy
around effective programs and ideas
• Help identify programs and concepts with
the greatest potential to improve AIC
• Offer ideas on how to scale up what’s
working
Introductions
Please join me in welcoming:
Karen Ignagni, President and CEO, America’s
Health Insurance Plans
Jeff Burnich, MD, Senior Vice President
Medical and Market Networks Sutter Health
Amy Berman, BS, RN, Senior Program Officer
John A. Hartford Foundation
D r i v i n g C h a n g e
A C o m p r e h e n s i v e A p p r o a c h t o
C a r e Tr a n s f o r m a t i o n :
I n t e g r a t i n g C o m m u n i t y a n d
C l i n i c a l M o d e l s
A Comprehensive Approach to Care
Transformation
• Rev. Diane C. SmalleyPatient and Community Engagement Council, Saint Joseph Mercy Hospital, Trinity Health
• Chris Dawe, Managing Director Evolent Health
• Bud HammesDirector of Medical Humanities,Gunderson Health System
• Daniel Johnson, MD, FAAHPMNational Clinical Lead for Palliative Care, Care Management Institute, Kaiser Permanente
• Rev. Cynthia Carter Hill, MPAExecutive Director, Alameda County Care Alliance
H o w a S h a r e d - D e c i s i o n
M a k i n g A p p r o a c h C a n
C o n n e c t t h e C l i n i c a l a n d
C o m m u n i t y
B e r n a r d “ B u d ” H a m m e s , P h D
G u n d e r s e n H e a l t h S y s t e m
w w w . r e s p e c t i n g c h o i c e s . o r g
2014 IOM Report: Dying in America
Shared decision making encompasses:
• Eliciting and understanding the patient’s perspective;
• Understanding the patient’s psychosocial and emotional context;
• Developing a shared understanding of the clinical problem and its appropriate treatment, given the patient’s goals, preferences, and values; and
• Empowerment, which is achieved through active involvement of patients in decision making.
LeBlanc, T. W., and J. A. Tulsky. In press. Communication with the patient and family. In Oxford textbook of palliative medicine, 5th ed., edited by N. Cherney, M. Fallon, S. Kaasa, R. Portenoy, and D. Currow. Oxford, England: Oxford University Press.
This description is useful, but we need
more detail for folks with advanced
illness…
To get to shared decision-making and planning
requires (for persons with advanced illness)…
1. …a shift from a primary focus on goals of
medical care, to a thoughtful exploration and
clarification of personal goals and values;
2. …a specific exploration of fears and concerns
as well as gaps in knowledge and
understanding;
3. …a realization that this not just about the
individual but also about the individual’s
“family” and community relationships.
When Care Planning uses this person-
centered, shared decision-making model,
it can tie the clinical and the community
together in two important, related ways…
Through a common:
1. process and structure of planning and decision
making; and,
2. ethical footing.
A Common Process and Structure for
Share Decision-Making
• Focused on the person and family perspectives,
the planning and any decision that follow
centers around a single, key question: How do
the explored values and goals of the person and
family, tied to the clinical realities, help define
what it means to provide good care for this
person?
• To thoughtfully answer this question requires
the intentional input and contribution of the
person, those closest to this person, their
broader community, and the clinical.
The Shared Ethical Basis:
Care Relationships
The ethical footing of this approach is the ethic of
caring relationships:
Relationship Ethical Value
Health professional/patient Beneficence…acting in the best interest of the patient
Individual/family or loved ones Love
Individual/community Respect, Sanctity of Life
The Respecting Choices® Model
This model is a systematic approach to care planning
that uses person-centered, shared decision-making
decision making and is designed to:
1. Provide a standardized process for care planning
that may be used in both the clinical and
community settings;
2. Build care planning into the routine of all care;
3. Create processes so care plans are stored,
revisited, and communicated so that they are
always available and up-to-date;
4. Prepare both patients and their appointed
surrogates to make decisions when the time arises;
5. Improve care and outcomes for all involved.
Helping Community and Health
Organizations Implement this Model
• Respecting Choices has created a
implementation pathway that provides a means
for health organizations to develop this care
planning approach so that it can become part of
the routine of care and can be integrated into
community engagement.
• RC has been successfully implemented in 5
countries and over 120 health organizations in
the USA.
A C o m p r e h e n s i v e A p p r o a c h
t o C a r e T r a n s f o r m a t i o n :
T h e C l i n i c a l P e r s p e c t i v e
D a n i e l J o h n s o n , M D , F A A H P M
C a r e M a n a g e m e n t I n s t i t u t e
K a i s e r P e r m a n e n t e
William
• 77 y/o male
• Advanced gastric cancer, diabetes, anemia, COPD
• Prior surgery, XRT
• Third line chemotherapy
• Intractable nausea, pain
• Recurrent bleeding
• 3rd admission in 6 w
• Two prior SNF stays
• Request: “No death talk”
“What is spoken of as a
“clinical picture” is not
just a photograph of a
man sick in bed; it is an
impressionistic painting
of the patient surrounded
by his home, his work, his
relations, his friends, his
joys, sorrows, hopes and
fears….”
The Care of the PatientFrancis W. Peabody, MD, JAMA 1927
Edvard Munch, The Sick Child, 1927
“The difficulty is that in the hospital one gets into the habit of using the oil
immersion lens instead of the low power, and
focuses too intently on the center of the field.”
Francis W. Peabody, MD
Daily Bread, Otto Betteman, 1936
Girls at the Piano, Renior, 1892
William – Through a Wider Lens
• Needs transport help
• Recurrent bleeding
• Not filling meds ($$)
• 3rd admission in 6 w
• Greatest joy: dog Max
• Two prior SNF stays
• Hope: back to Iowa
• “No death talk”
• Fears: “quitting too soon”, questions: faith and God
• 77 y/o male
• Lives alone, friends help
• Advanced gastric cancer,
diabetes, COPD, anemia
• Values independence
• Prior surgery, XRT
• Former US Veteran
• On 3rd line chemo
• Helping son “get sober”
• Intractable nausea, pain
• Increasingly anxious
About Kaiser Permanente…
Nation’s largest non-profit health plan
Integrated health caredelivery system
9.1 million members
16,000+ physicians
174,000+ employees(including 48,000+ nurses)
Serving 8 states and the District of Columbia
38 hospitals
More than 600 medical offices
$53.1 billion operating revenue*
Scope includes ambulatory, inpatient, ACS, behavioral health, SNF, home health, hospice, pharmacy, imaging, laboratory, optical, dental, and insurance
Mid-Atlantic Region
Georgia Region
Colorado Region
Northern
California Region
Hawaii Region
Northwest Region
Southern
California Region
*Kaiser Permanente 2013 Press Release
KP-Colorado
Slide 85
Multiple contracts and community partnerships:
Hospitals (2 core + others), SNF (25 facilities), LTACH (5)
Home Health, hospice (7 preferred, PC support)
Integrated system serving over 600K members
Rocky Mountain Front Range
Insured pop: Commercial, Medicare Advantage (90K), Medicaid (50K), Duals (2K)
Case management (adult + kids)
Our Promises
For us to achieve the “best care possible” for persons with serious illness we must:
Deliver,
for each individual,
personalized
“best care”
Palliative and
Community Support
Discover,
for each individual,
what “best care”
looks like
Goal Setting and
Care Planning
AND
87
Building “Layers of Support”
1 2 3 4
Advance Care Planning (ACP)
10 PC
20 PC
Increasing Complexity and Needs →
Sup
po
rt→
LAYER KEY FEATURES
Specialty PC Provide specialized support for most complex needs
Primary PC Assess needs → personalize care; basic support
ACP Assure systematic, competent discussions for all
Population ID Identify risk groups, population-based care
Leveraging Community Resources and Expertise
Foundational Studies of Palliative
Support at Kaiser Permanente
Three randomized control trials of palliative care in
hospital, home and clinic settings – outcomes: Improved patient-family satisfaction
Improved quality (communication, death at home)
Increased hospice admissions and LOS
Decreased hospital, ER utilization and costs
Added matched- controlled analysis of inpatient PC: Less hospital(40%), ICU (56%) and ER (24%) admissions
Higher hospice admissions (51%) and LOS (55%)
Gade G et al. J Palliative Med, 2008. Brumley R. et al. J Palliative Med, 2003. Englehardt
J. et al. J Managed Care, 2009. Bellows J, Johnson D et al, Kaiser Permanente, 2012
A Continuum of
Specialty Support
Hospital
Home
Assisted LivingLong Term Care
LTACSNF
Primary Care Clinic
Specialty Care Clinic
Inpatient PC
Home PC
PC SW
Clinic PC
NH PC
Hospice “One Stop
Shop”
KPCO Specialty Palliative Care ServicesService Setting Team #/year Access Model
IPC Hospital MD, RN, SW, Chap,Pharm
1800 7 d/w with 24/7 call
Hybrid staffing model – KP + hospital; referrals + alerts using LACE
HBPC Home/ ALF
MD, RN, SW, Chap,Pharm
500 7 d/w with 24/7 call
Hybrid staffing model – KP +partner; referrals
CBPC Clinic MD, RN,SW
400 5 d/w KP staff; referrals + integration pilots in high risk pulmonology and oncology
PC-SW Clinic SW 300 5 d/w KP staff, referrals + integration pilots
NH PC (KSS)
SNF/LTC SW, RN or chap prn
400 5 d/w Contracted partners, referrals + integration in LTACH, NH
Hospice All Full IDT 2000 7 d/w Contracted partners, Commercial and Medicare
What Elements Worked (or Not)?
What Worked…
A compelling “why”
Evidence
Invest – not just “stretch”
Partnership (seek win-win)
Layers and triage
Embedded support
Value team- and self-care
Harness non-PC champions
Think “learning system”
…Not So Much
Seeking perfection
“Prove it” mentality
Silos – thinking too narrowly
Demands on referring MDs
Failing to assess needs
Failing to triage
“Auto-referrals”
Leaving out community
Slow to standardize
or
Examples of Positive Shared Outcomes
Documented goals, values and care preferences
More concordant care (i.e., delivery matches wishes)
Care plan communication across care settings
Increased access to specialty PC support
More hospice use
Less unwanted (by all) hospital, ER or ICU care
Less total costs (for patients, family and system)
Greater meaning around the work we do
Asking and honoring “what matters most”
Rev. Cynthia Carter Hill, MPA
Executive Director
Alameda County Care Alliance
Alameda County Care Alliance
Vision: All those in Alameda County living with advanced illness
will receive person- and family-centered care that acknowledges
their spiritual and cultural integrity, regardless of race, religion,
origin, or creed.
Mission: Build on community-based resources and health
system partnerships to provide a new paradigm of care through:
care coordination, spiritual care, and decision-making support for
the person needing care, their family/caregiver.
ACCA: Who We Are
A dynamic and collaborative partnership among faith-
based and community organizations with long history
of working together to transform the Alameda
Community.
Current focus - Advanced Care:
Launched in 2014
Represents 35,000+ people
Supported by Kaiser Permanente and California
HealthCare Foundation.
ACCA HUB Partners
Strategically located Community Partnerships :
• Allen Temple Baptist Church
• Glad Tidings Church of God in Christ
• Family Bible Fellowship
• Center of Hope
• Greater St. John
• Beebe Memorial
• Community Organizations – Catholic Ecumenical & Asian Health Services
Completed (2/15)
Training of pastors (3/18)
Training of navigators
(3/18)
Patient and Caregiver
enrollment (4/16)
ACCA 18 Month Pilot
Progress and Next Steps
Hub Church surveys
Pastoral training team &
curriculum (Dr. Guess &
team)
Navigator curriculum
Caregiver curriculum and
partnerships (Family
Caregiver Alliance)
Evaluation and key
partnerships (UC Davis,
UC Berkeley-Citris)
ACCA Proposed Outcomes: Process
Strengthening community capacity for
advanced care through:
– Improved decision support for caregivers/and
persons needing care
– Trained clergy, community leaders, Care
navigators
– Identify and Increase access to care services
for caregivers/patients
ACCA Proposed Outcomes: Impact
– Increased care satisfaction among
patients/families
– Reduced caregiving burden for advanced
illness
– Reduced ER visits
– Reduced readmission rates
– Improved Quality of Life for ill person and
caregivers
ACCA Finding #1: Build on Community
Resources
• Integrate current initiatives among faith
communities through collective
commitment and sharing resources such
as trained volunteers across communities.
ACCA Finding #2: Build on Shared
Outcomes Among Health Systems and
Community
Examples:
• Reduced unwanted hospitalizations
• Provide care in the community
• Increased connection to spirituality
• Improved quality of life
ACCA Finding #3: It’s Takes Time: Building
Trusting Relationships between the Medical
and Community Members
• Honor the vast resources within churches
and in community
• Respect culture, spirituality, and traditions
• Transparent communications amongst
stakeholders
Transforming Care and Serving Most
Vulnerable
Whatever you do for one the least of these
my brethren ones, you have done unto me. Matthew 25: 35-40
ACCA Firmly Believes That…..
Ta k i n g E v i d e n c e - B a s e d
M o d e l s t o S c a l e
J e f f S e l b e r g , M H A ,
E x e c u t i v e D i r e c t o r
P e t e r s o n C e n t e r o n
H e a l t h c a r e
M o r n i n g W o r k s h o p S e s s i o n s
L e c t u r e R o o m : C o m m u n i t y a n d F a i t h - B a s e d
P a r t n e r s h i p s
R o o m 1 2 0 : M e t r i c s f o r S u c c e s s
R o o m 1 2 5 : E n g a g i n g P a t i e n t s i n D i s s e m i n a t i o n a n d
I m p l e m e n t a t i o n
C O M M U I T Y A N D FA I T H
B A S E D PA R T N E R S H I P S
Te r e s a C u t t s , P h D
A s s i s t a n t P r o f e s s o r , S o c i a l
S c i e n c e s a n d H e a l t h y P o l i c y
D i v o f P u b l i c H e a l t h a n d t h e M a y a
A n g e l o u C e n t e r f o r H e a l t h E q u i t y
W a k e F o r e s t S c h o o l o f M e d i n c e
R e v . D r . T y r o n e P i t t s
C o - C h a i r I n t e r f a i t h a n d D i v e r s i t y
W o r k g r o u p , C - T A C
T h a n k y o u
M E T R I C S F O R S U C C E S S
Advanced Illness Care Coordination:
A Case Study on Aetna
Compassionate CareSM Program:
What Metrics Can Demonstrate
Randall Krakauer, MDVP, National Medical Director, Aetna
Geriatric Conditions and Quality Scores:1
How Does Advanced Illness Rate?Assessing Care of Vulnerable Elders (ACOVE) quality indicators: in 2000 identified significant quality and care gaps, and opportunities that might be addressed in managing care in Medicare populations
1Wenger NS, Solomon DH, Roth CP. et al. Annals of Internal Medicine. 2003; 139 (9) 740-747. Availableat: www.mms.org/workilies/mmc services/geriatrics/Quality Medical Care Provided Vulnerable-Dwelling Older Patients.pdf. Accessed June 6, 2013.
Geriatric conditions and quality indicators
Condition % QIs Passed
Malnutrition 47
Pressure ulcers 41
Dementia 35
Falls, mobility disorders 34
Urinary incontinence 29
End-of-life care 9
Variations In End-of-Life Care:
Dartmouth Atlas of Health CarePercent of decedents enrolled in hospice during the last 6 months of life (2003-2007)
Rates are adjusted for age, sex, race, primary chronic condition, and the presence of more than one chronic condition using ordinary least squares regression.
Arizona: 54.5%
New York: 23.8%
• U.S. State
Variations In End-Of-Life Care:
Dartmouth Atlas of Health CareHospice days per decedent during the last 6 months of life (2003-2007)
Rates are adjusted for age, sex, race, primary chronic condition, and the presence of more than one chronic condition using ordinary least squares regression.
• Hospital Referral Region
McAllen, TX 3.9 days
Ogden, UT 35.5 days
Where are we?
•Shortage of specialized expertiseCompare: 1 oncologist to every 141 newly diagnosed cancer patients
vs. 1 palliative medicine doctor to every 1,200 patients with serious or life-threatening illnesses.1
•Hospital-based palliative care — increasing access Since 2008, 19% increase in palliative care teams in hospitals.85% of large (>300 beds) hospitals have teams.1
• Resources: Approximately 25-30% of Medicare costs incurred in last year of life; in last month, 80% of expenditures are for hospitalization.2
1 Center to Advance Palliative Care. America’s Care of Serious Illness: A State-by-State Report Card on Access to Palliative Care in Our Nation’s Hospitals. NY: 2011. Available at: reportcard.capc.org/pdf/state-by-state-reportcard.pdf. Accessed May 28, 2013.
2 Lubitz J, Riley GF. Trends in Medicare payments in the last year of life. New England Journal of Medicine1993; 328 (15): 1092-1096. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC2838161/pdf/hesr0045-0565.pdf. Accessed May 29, 2013.
Aetna Compassionate Care (ACCP)
•Goals of the program:
• Provide additional support to members
• with advanced illness and their families/caregivers
• Help them access optimal care
• The goal is not to create or encourage hospice,
although hospice can be a choice when appropriate
and requested by the member.
Holistic, Member-Centric Case Management
Help member understand options, with nurse case managers who are trained to:•Assess and manage members’ care in a culturally sensitive manner •Identify resources to make members as comfortable as possible, addressing pain and other symptoms•Help coordinate medical care, benefits and community-based services•Inform the member about treatment options, continuity of care and advanced care planning•Provide personal support•Consult and coordinate with the members’ treating physicians and staff (including other care coordinators where available)
Results: Member Discussion
Example of Why Compassionate Care
Shows Impact: Depth of Connection•Wife stated member passed away with hospice. Much emotional support given to spouse. She talked about what a wonderful life they had together, their children, all of the people's lives that he touched. They were married 49 years last Thursdayyand each year he would give her a piece of jewelry. On Tuesday, when she walked into his room, he had a gift and card laying on his chest, a beautiful ring that he had their daughter purchase. She was happy he gave it to her on Tuesday--- on Thursday, he was not alert. She stated that through his business he touched many peoples lives, and they all somehow knew he was sick, and he has received many flowers, meals, fruit, cake. She stated her lawn had become overgrow and the landscaper came and cleaned up the entire property, planted over 50 mums, placed cornstalks and pumpkins all around. She said she is so grateful for the outpouring of love. Also stated that hospice was wonderful, as well as everyone at the doctor’s office, and everyone here at Aetna. She tells all of her friends that "when you are part of Aetna, you have a lifeline.” Encouraged her to call CM with an issues or concerns. Closed to case management.
Results
Favorable impact aligning patient goals with outcomes
• 82% of engaged decedents choose hospice
• 82% reduction in acute inpatient days
• 77% reduction in emergency room visits
• 86% reduction in intensive care unit days
Improved quality of life for Aetna members and their families
Data for 2010 Medicare Advantage members enrolled in Aetna’s Compassionate Care program.
Resulting (in Medicare Advantage) in savings of over $12,500 per engaged member
Summary: Metrics Demonstrate Opportunity
• Improving the quality of care for those with advanced illness represents a tremendous opportunity for the country’s health system, for individual patients, and for families and caregivers.
• Programs that provide expert assistance such as Aetna Compassionate Care can increase awareness of the care options available to patients and caregivers, thereby aligning patient choice more closely with desired types of health services and care.
• This care management program favorably impacts advanced illness, with very high rates of satisfaction. Metrics can demonstrate, particularly in Medicare, dramatic impact on Palliative Care and Hospice election, acute and intensive care utilization, cost and other metrics.
• These metrics create an imperative that such services become more widely available.
Quality Measures as Drivers
of Change
National Summit on
Advanced Illness Care
Metrics for Success Workshop
122
Quality Results
Making Hospital Safer
Quality Results
Healing at Home
NQF Action Teams
• Build on NQF’s role as an objective convener
• Leverage NQF’s deep membership of 400+ organizations
• Work collaboratively and in partnership to collectively impact health and healthcare quality
• Promote uptake of existing NQF-endorsed performance measures
• Influence important stakeholders to makemeaningful and authentic commitments to action
NQF Maternity Action Team Results
Measurement Opportunities for Advanced
Illness Care
• Advanced Illness care generally does not follow patient goals and preferences
• Palliative care can be used more broadly to alleviate suffering
• Geriatrics finds that some of the most important care is outside of the traditional organ-system based clinical specialties.
• Experience from caregivers as well as patients
Measurement Challenges for Advanced
Illness Care
• Individual condition-based guidelines often conflict for patients with multiple chronic diseases
• Health affected by sociodemographic factors
• Vulnerable populations may have difficulty accessing consistent source of care
• Coordination of care among multiple sites/providers
NQF’s Aging Related Work
Current Work:
Prioritizing Measure Gaps: Alzheimer’s Disease
and Related Dementias
Measure Applications Partnership (MAP)
Dual-eligibles beneficiary workgroup
Post-acute care/long-term care workgroup
Past Work:
Multiple Chronic Conditions Framework
Nursing home measures
Home healthcare measures
Recent NQF Initiatives to Improve Care for
Advanced Illnesses and Vulnerable
Populations
Current Work:
• Prioritizing Measure Gaps: Alzheimer’s Disease and Related Dementias
• Measure Applications Partnership (MAP)– Dual-eligibles beneficiary workgroup
– Post-acute care/long-term care workgroup
Past Work:
• Multiple Chronic Conditions Framework
• Nursing home measures
• Home healthcare measures
Improving Care for Dual Eligible
Beneficiaries
• Considers the unique needs of population subgroups (e.g., individuals with ID/DD, frail elders)
• Maintains a Family of Measures for Dual Eligible Beneficiaries
• Gathers experience of state agencies, health plans, and other stakeholders in using MAP’s recommendations on measures to make them more accurate and actionable
• Explores quality of life outcomes and how various system stakeholders share responsibility for supporting better outcomes for vulnerable beneficiaries
Big Opportunity Areas in Healthcare:
What the Health System Needs Now
Criteria for ImpactCredible
Timely
Useable
Meaningful
Incubator
Components Concept
Technical expertise
Data sources
Analytics and feedback
Resources
DATA
ANALYTICS
MEASURES
INFORMATION
IMPACT
T h a n k y o u
E N G A G I N G PAT I E N T S I N
D I S S E M I N AT I O N A N D
I M P L E M E N TAT I O N
P a t r i c i a A . G r a d y, R N , P h D
FA A N , D i r e c t o r ,
N a t i o n a l I n s t i t u t e o f N u r s i n g
R e s e a r c h
Research Translation
General Public
Educational
InstitutionsPublic Interest
Groups
Federal Agencies
State AgenciesLocal Agencies
Professional
SocietiesIndustry
Community Groups
Patient Advocacy
Groups
Public Advisory
Councils
Health Professionals
Volunteer
Organizations
ScientistsScientific Advisory
Groups
Stakeholders
NINR’s Areas of Research
Scientific Focus Areas to
Implement NINR’s Strategic Plan
• Symptom Science
• Wellness
• Self-Management
• End-of-Life and
Palliative Care
Advanced Illness Care
NINR Hosts NIH Briefing on IOM Report –
Dying in America
Advanced Illness Care
Hospice enrollment increases
Medicare savings and decreases
hospital usage
Palliative Care Research
Co-Operative (PCRC)
o Comprehensive, multicenter
resource
o Developing structures and
processes to enable and support
end-of-life and palliative care
research nationwide
NINR-Supported Research to Improve /
End-of-Life Care
Implementation and Dissemination
Research Support
Selected NIH-Sponsored
Funding Opportunities• Innovative Measurement Tools for Community Engaged
Research Efforts
• Development and testing of tools to measure trust,
capacity, collaboration, empowerment, sustainability
• Dissemination and Implementation Research in Health
• Understanding and overcoming barriers to translating
research discovery into clinical and community practice
R e g i n a G r e e r - S m i t h ,
M P H F A C H E
Guidance
PCORI’s ENGAGEMENT RUBRIC
PCOR GUIDING PRINCIPLES• Reciprocal Relationships• Co-Learning• Partnership• Trust, Transparency, Honesty
DISSEMINATING THE STUDY RESULTS• “Patient partners are involved in plans for disseminating
the study’s findings to patient, stakeholders, and research audiences so that the findings are communicated in understandable, usable ways.”
Developing Infastructure
From Existing Relationships
and Building Capacity
Partnerships and Collaborations with Stakeholders
For co-learning and trust-building
Development of Programs and Initiatives to enable engagement
activities
Providing resources to empowering Priority Populations including:
• Racial & Ethnic Minorities• LTBT• Persons with Disabilities• Low literary/numeracy• Rural populations
More engagement resources at our website:http://www.healthcarera.com/
Develop Opportunities for
Engagement, Dissemination
& Implementation
Exhibits and In-Person PresentationsSocial Media & Smartphones
Use of Social Networking, Care Giver Support Groups &
S.T.A.R. Initiative Engagement Clusters©
Through partnerships and collaborations with patients, families, caregivers, faith-based partnerships, and all
stakeholders
T h a n k y o u
A f t e r n o o n W o r k s h o p S e s s i o n sL e c t u r e R o o m : S h a r e d D e c i s i o n
M a k i n g
A u d i t o r i u m : T r a n s l a t i n g E v i d e n c eB a s e d P r a c t i c e I n t oC o m p e l l i n g
M e s s a g e s
R o o m 1 2 0 : F a m i l y C a r e g i v e r S u p p o r t
R o o m 1 2 5 : B u i l d i n g t h e B u s i n e s s
C a s e f o r A d v a n c e dI l l n e s s C a r e
S h a r e d D e c i s i o n M a k i n g :
H o n o r i n g I n f o r m e d P a t i e n t
C h o i c e
Practice Variation: Evidence for Poor Decisions
150
Red dots indicate HRRs served by U.S. News 50 Best Hospitals for Geriatric Care
2,500
3,500
4,500
5,500
6,500
7,500
8,500
AS
R A
dju
ste
d M
ed
ica
re S
pe
nd
ing
Forces Sustaining Poor Quality
151
Patients & physicians view trade-offs differently
Decision:
Goal
% top 3
Patient
% top 3
Provider
Surgery: Keep
your breast 7% 71%
Reconstruction:
Look natural
without clothes
59% 80%
Chemotherapy:
Live as long as
possible
33% 96%
Reconstruction:
Avoid using
prosthesis
33% 0%
Sepucha K, et al. Patient Education and Counseling 2008 and Lee et al. 30th Annual Society for Medical Decision
Making Conference, Philadelphia, 2008.
153
154
23 Patient vs. 25 Physician States
2 Hybrids
Patient
Standard
Physician Standard
Hybrid (NM &
MN)
Health Policy Relating to SDM
SDM has become a standard part of the language of US health reform
– Affordable Care Act
– Definition requirement for Medicare ACOs– Requirement for Comprehensive primary Care
Initiatives
– State-based health care reform
– Meaningful use of HIT
– Informed Consent
– Professional societies, practice guidelines
155
WA State Passed Three Bills
• Passed legislation in 2007
• Explicitly recognizes SDM is an enhanced informed consent for Preference-Sensitive Conditions if provider uses a “certified aid”
• Led to Group Health demonstration project
• 2009 Passed Bree Collaborative—SDM promoted
• 2012 Passed legislation allowing CMO of HCA to “certify aids” moving forward with criteria
• Payment of providers for SDM being considered
156
157
Involvement
Values Concordance
Decision Quality
Knowledge
Did the patient know what he or she needed to know?
Did the decision reflect the patient’s goals and concerns?
Did the patient know a decision was being made?
Did the patient know the pros and cons of the treatment options?
Did the provider elicit the patient’s preferences?
Health Policy Reasons for Adoption of SDM on Large Scale
• Ethical imperative to do the right thing
• Perfected Informed Consent-Aligning
preferences, values and lifestyle with
individual’s clinical decision
• Bridging Health Disparities
• Conservative Utilization of surgical
interventions
W h a t M a t t e r s t o Y o u
M a t t e r s t o U s
H M S A’ s A C P V i d e o P r o j e c t
R a e S e i t z , M D
M a r c h 2 0 1 5
HMSA’s ACP Video Project
• How the ACP Video Project advances HMSA’s mission
and vision of keeping members at the center of, in
control of, and responsible for their own well-being
• Review some preliminary outcomes
• The strategy applied to spreading the use of ACP video
decision aids
• What have we learned about ACP, what works and what
challenges remain
0%
10%
20%
30%
40%
50%
4Q2012 1Q2013 2Q2013 3Q2013 4Q2013 1Q2014 2Q2014
Advance Care Planning at a Hospital “A”N=2668 across all time periods
Percentage of Discharged with Completed POLSTS
Percentage of Patients Discharged with Referral to Hospice
VideosIntroduced
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
4Q2013 1Q2014 2Q2014
POLST CompletionAmong Seriously Ill Patients
N=845 across all time periodsConversation + Video vs Conversation Only
ACP Video Use in Palliative Care Pilot (n=56)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
PC Patient
POLST Before POLST After
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Before After
Life Prolonging Limited Comfort
Advance Care Planning Completion Rates for Members 75+
HMSA P4Q Measure 10/1/2013 to 9/30/2014
0%
10%
20%
30%
40%
50%
Medicar Advantage PPO/HMO
Using Video Not Using Video
37 Doctors identified using the videos; 250 doctors not using the videoDenominator include 18000 for Medicare Advantage; 20,000 PPP/HMO Members
Our Approach
Co-opetition
Setting Standards
Small Scale
Testing & Spread
Hospital/Hospice/SNF
Health Plans
Primary Care
Community
A new video campaign gives patients a voice on treatment options By Susan Essoyan
D i s c u s s i o n P o i n t s ?
ICU Code Order ChangesAfter Patients/Families Watch ACP Videos
n=14
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pre-Video Post-Video
Full Code Partial Code DNR
Advance Care Planning Outcomes
ACP Outcomes
Death at
Home Hospice Use
EOL ICU Days
EOL
Inpatient Use
EOL
ED UseTreatment at EOL
EOL QOL
FAMCARE
Decisions
Honored
ACP Docum
ents
T r a n s l a t i n g E v i d e n c e - B a s e d
P r a c t i c e s i n t o C o m p e l l i n g
M e s s a g e s
Better Stor ies ,
Best Pract ices
success starts with the story you tell
• stories change brains, beliefs and behaviors
• stories are survival instruments
• storytelling is a competitive sport
• if you want to change your outcome, start
by changing your narrative
I think we’re gonna need a better narrative
If we want to do better, first we have to feel better
Change begins when you give people a new feeling about the issue. In this case, we
want to replace fear of loss and helplessness with a promise of power, purpose and
hope.
Engage the Emotions
AIM Strategies
176
Engage the adversary: the
revolving door
The deep need: Reconnect
with the “why”
Capital Caring Strategies
177
Envision our success: provide
personal stories of positive
outcomes
Speak to identity: we are
innovators
Stories are survival instruments. After you get the audience emotionally engaged, you have to give them practical tools to drive change.
Stories are first and foremost survival instruments for a VUCA world. And advanced
care - serious illness, the probable “third act” of life — is possibly the greatest VUCA
of all. It requires that we come to terms with our ultimate mortality, life’s ultimate
unknown, and it sets up a series of obstacles (financial, practical, emotional, physical)
that make it hard for us to perform at the time we most need to.
Empower Action
179
A new model: Built on patient
experience and needs, not
system structure
Eliminate uncertainty:
one way, one team
AIM Strategies
180
Empower caregivers, Build confidence
Capital Caring Strategies
• allow autonomy with caregivers in implementing the program
• build mastery: program builds confidence with caregivers
• each positive interaction creates
confidence and a better
outcome
Build Resilience
Stories are setbacks.
The last act of life is not easy. There will be suffering. There will be sorrow. And no matter how powerful your program, there will be setbacks.
People are often tempted to give up when they have a bad experience. Much of what we as leaders can do is to build resilience in ourselves and our communities, to help persevere through the hard times. The growth mindset is about getting people to recognize the truth that failure is a necessary stepping stone on the way to success.
182
Coach the growth mindset:
“We’re all still learning how to
do this.”
Everyone worries about
risk. The best strategy is
to tell the truth.
AIM Strategies
183
Openly share successes and
setbacks - address issues
Remember we are all learners
and teachers
Capital Caring Strategies
• set clear, immediate metrics
• be transparent in identifying what doesn’t work
• be proud in reporting on what
does
Capi ta l Car ingF o r n e a r l y 4 0 y e a r s , c o o r d i n a t e d , c o m p a s s i o n a t e
c a r e w h e r e v e r o n e c a l l s h o m e
Capital Caring at a Glance
• One of the nation’s oldest and largest non-profit providers of hospice and palliative care, Capital Caring cares for over 1,200 families each day.
• Our service area includes The District of Columbia, Northern Virginia, and Prince George’s County, Maryland.
• World-class, high quality care is at the heart of our business strategy.
• Our mission? To simply improve care.
A commitment to people
• In order to ‘simply improve care’- and with high-quality care at the heart of our strategy, Capital Caring’s key metrics allow us to measure and demonstrate improving care.
- e.g. Capital Caring is committed to reducing a patient’s pain to a
comfortable level within 48 hours; we achieve this in nearly every case.
• We focus on culture, people development & training- Capital Caring instituted Standards – clear, impressive, and sustainable rules for achieving world-class care and results
- We are committed to meeting 100% of our standards, 100% of the time
C a p i t a l C a r i n g : I n n o v a t i o n s
i n C a r e
Capital Caring is committed to innovation. • In 2014, we opened our state-of-the art Adler Center for Caring on the Van
Metre Campus in Loudoun County, Virginia. This first-of-its-kind in the nation facility is home to Capital Caring’s Center for Pain and Palliative Care, a 21-bed world-class inpatient facility, Capital Caring’s home care team and palliative care. The Center even boasts a spa and gift shop.
• Capital Caring’s Center for Pain and Palliative Care (CPPC) is on the forefront of innovation. The Center’s ability to perform procedures using state-of-the-art real-time imaging to alleviate debilitating pain on-site, complementing or even replacing pharmacotherapy, provides a vast improvement for patients dealing with pain associated with an advanced illness.
TeleCaring ™
• In 2011, Capital Caring launched TeleCaring™, an innovative care support program, where trained professionals, including nurses, place proactive, outbound calls to patients and caregivers.
• TeleCaring™ is an extension of Capital Caring’s home care team that empowers caregivers—and provides rapid response to emerging issues or to answer questions.
“I feel like every one of them is an extension of our family. Sometimes, when we have questions, when the Telecaring nurse calls, they take 5 minutes, 10 minutes to help me focus and address what matters most. The calls reassure me, and are a valuable extra layer of care.”-----
Barry, Caregiver
Caring in the nation’s capital
-By virtue of being in the nation’s capital, Capital Caring’s mission to simply improve care includes public education and advocacy to expand access to person-centered hospice care.
-Since 2006, hospice utilization in D.C. has increased from 2% to over 30% in part because of our Hospice Comes to Washington awareness event. Our “In Good Faith” initiative has been instrumental in building trust among faith community leadership, their ‘parishioners’, and Capital Caring, in order to identify patients/families at risk in order to increase timely access to palliative care and hospice services.
-Our program is centered on earlier, easier access to care with clearly defined standards and measurable quality of care as our business strategy.
Overview of AIM®
Where we are today within Sutter Health
• Betsy Gornet, FACHE
• Sutter Health and Sutter Care at Home
• March 3, 2015
“This publication was made possible by Grant Number 1C1CMS331005 from the Department of Health and Human Services, Centers for Medicare & Medicaid
Services.”
"The contents of this publication are solely the responsibility of the authors and do not necessarily
represent the official views of the U.S. Department of Health and Human Services or any of its agencies."
HEALTH CARE INNOVATIONS AWARDS
• Non-for-Profit health system serving
Northern California
• Includes 24 hospitals and over
5000 aligned physicians
• Sutter Center for Integrated Care
• Health care research,
• 28 Home Care locations
• AIM – System level; over 7300
Enrollments through Dec 2014; plus
1500 during pilot
192
SUTTER HEALTH AT A GLANCE
Pending Luanch
Defining Advance Illness Management (AIM®)
AIM is a Care Management Model that Employs Evidence Based Principles of:
Care Coordination & Transitions Management
Palliative CarePatient
Engagement
Health Literacy
Self Management
Support
193
What Else Defines AIM?
Improve Patient/Family/Caregiver Experience& Provider Experience; All payers, all diseases
Fill in Gaps of Care – Between MD appointments and Between Home
Health Care and Hospice
Strengthen Relationship Between
Patient & Physician
Focus on Personal Goals and Revisiting
Them as Illness Progresses
Focus on Last 12-18 Months of Life
Coordinate Care Across all Sites of Care; Continuous; Team Navigation
194
• AIM Home Health (Skilled Episode)
• AIM Transitions (Non-Skilled Care needs, short term)
AIM In-Home Visit Based Care
• Outbound, frequency acuity adjusted; Some inbound
• Maintains MD Connection
AIM In-Home Telesupport • Hospitalization
• ED Visit
• AIM Care Liaison
AIM Acute Care Support
• AIM Home Health (Skilled episode)
• AIM Transitions (Non-Skilled Care needs, short term)
AIM In-Home Visit Based Care
Maintain Physician Communication and Connection with Patient;
AIM Triage After Hours and Weekends
IF
Then cycle repeats
CLOSER LOOK AT INTEGRATION
Advance
Care
Planning (Personal
Goals)
Dual Approach to Care: Curative + Palliative
Red Flags &
Symptom
Management
Plans
Medication
Management
Follow Up
Visits
Patient
Engagement
& Self
Management
Support
AIM Care Pillars
196"The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department
of Health and Human Services or any of its agencies."
Key AIM Outcome HighlightsResults not yet validated independently by CMMI
Results July 2012- June 2014
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Q3 2014
74%
62%
91%
Advance Care Plan (ACP) Documentation
% of AIM Patients withACPs at Enrollment
% of AIM Patients withACPs at Enrollment whoMade Modifications tothe ACP within 90 Daysof Enrollment
% of AIM Patients whohad ACPs DocumentedWithin 90 Days ofEnrollment (Target =90%)
0
200
400
600
800
1000
1200
1400
1600
1800
Hospitalizations ED Visits ICU Days
Change in Utilization 90 Days Post AIM Enrollment9 of 10 Sites Reporting; Q3 2013 - Q2 2014; n=1761Results not yet validated independently by CMMI
Pre
Post57%
Reduction
22% Reduction
66% Reduction
The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies."
Health Care Innovations Awards
•“The project described was supported by Grant Number 1C1CMS331005 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services.”
B u i l d i n g t h e B u s i n e s s
C a s e f o r A d v a n c e d I l l n e s s
C a r e
Tr a n s f o r m i n g t h e C a r e o f
S e r i o u s I l l n e s s : T h e
B u s i n e s s C a s e
Diane E. Meier, MD
Director, Center to Advance Palliative
Care
www.capc.org
www.getpalliativecare.org
@dianeemeier
No Disclosures
Objectives
• The case for integrated palliative care
strategies
• What works to improve quality and
subsequently reduce costs for vulnerable
people?
• How to face outwards towards needs of:
– Our patients, their families
– Policymakers, payers, health system
leadership
Concentration of Spending
Distribution of Total Medicare Beneficiaries and Spending, 2011
10%
63%
37%
90%
Total Number of FFS Beneficiaries: 37.5 million
Total Medicare Spending: $417 billion
Average per capita Medicare spending (FFS only): $8,554
Average per capita Medicare spending
among top 10% (FFS only): $48,220
NOTE: FFS is fee-for-service. Includes noninstitutionalized and institutionalized Medicare fee-for-service beneficiaries, excluding Medicare managed care enrollees. SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost & Use file, 2011.
Concentration of Risk/$
Concentration of Risk/$
Value = Quality/Cost
Because of the Concentration of Risk and
Spending, and the Impact of Palliative
Care on Quality and Cost, its Principles
and Practices are Central to Improving
Value
Mr. B
• An 88 year old man with
dementia admitted via the ED for
management of back pain due
to spinal stenosis and
arthritis.
• Pain is 8/10 on admission, for
which he is taking 5 gm of
acetaminophen/day.
• Admitted 3 times in 2 months for
pain (2x), falls, and altered
mental status due to
constipation.
• His family (83 year old wife) is
overwhelmed.
Mr. B
• Mr. B: “Don’t take me to
the hospital! Please!”
• Mrs. B: “He hates being
in the hospital, but what
could I do? The pain was
terrible and I couldn’t
reach the doctor. I
couldn’t even move him
myself, so I called the
ambulance. It was the
only thing I could do.”
Modified from and with thanks to Dave Casarett
Before and After
Usual Care
• 4 calls to 911 in a 3 month period, leading to
• 4 ED visits and
• 3 hospitalizations, leading to
• Hospital acquired infection
• Functional decline
• Family distress
Palliative Care
• House calls referral
• Pain management
• 24/7 phone coverage
• Support for caregiver
• Meals on Wheels
• Friendly visitor program
• No 911 calls, ED visits, or hospitalizations in last 18 months
The Modern Death Ritual:
The Emergency Department
Half of older Americans visited ED in
last month of life and 75% did so in
their last 6 months of life.
Smith AK et al. Health Affairs 2012;31:1277-85.
Who Are These Patients?
• Functional Limitation
• Frailty
• Dementia
• Exhausted overwhelmed family caregivers
• +/- Serious illness(es)
Gómez-Batiste X, et al. BMJ Supportive & Palliative Care 2012;0:1–9. doi:10.1136/bmjspcare-2012-000211
Functional Limitations as a
Predictor of Risk
http://www.cahpf.org/docuserfiles/georgetown_trnsfrming_care.pdf
Dementia As A Predictor of Risk
• Prospective
• Cohort of
community
dwelling older
adults
• Callahan et al.
JAGS 2012;
60:813-20.
Dementia No Dementia
Medicare SNF use 44.7% 11.4%
Medicaid NH use 21% 1.4%
Hospital use 76.2% 51.2%
Home health use 55.7% 27.3%
Transitions 11.2 3.8
Dementia And Total Spending
• 2010: $215 billion/yr
• By comparison: heart disease $102
billion; cancer $77 billion
• 2040 estimates> $375 billion/yr
Hurd MD et al. NEJM 2013;368:1326-34.
In case you are not already worried…
The Future of Dementia Hospitalizations
and Long Term Services+Supports
10 fold growth in dementia related
hospitalizations projected between 2000 and
2050 to >7 million.Zilberberg and Tija. Arch Int Med 2011;171:1850.
3 fold increase in need for formal LTSS
between now and 2050, from 9 to 27 million. Lynn and Satyarthi. Arch Int Med 2011;171:1852.
Why? Low Ratio of Social to Health Service
Expenditures in U.S.
Bradley E H et al. BMJ Qual Saf 2011;20:826-831
Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.
Surprise! Home and Community Based
Services are High Value
• Improves quality: Staying home is
concordant with people’s goals.
• Reduces spending: Based on 25
State reports, costs of Home and
Community Based LTC Services
less than 1/3rd the cost of Nursing
Home care.
Study: Having meals delivered to
home reduces need for nursing
home
10/14/2013 | HealthDay News
A study published today in Health Affairs found if all 48 contiguous states increased by 1% the number of elderly who got meals delivered to their homes, it would prevent 1,722 people on Medicaid from needing nursing home care. The Brown University study found 26 states would save money because lower Medicaid costs would more than offset the cost of providing the meals.
What is Palliative Care?
• Specialized medical care for people with serious illness and their families
• Focused on improving quality of life as defined by patients and families.
• Provided by an interdisciplinary team that works with patients, families, and other healthcare professionals to provide an added layer of support.
• Appropriate at any age, for any diagnosis, at any stage in a serious illness, and provided together with disease treatments.
Definition from public opinion survey conducted by ACS CAN and CAPC http://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-research/2011-public-opinion-research-on-palliative-care.pdf
Conceptual Shift for Palliative Care
11%
49%
40%
Costliest 5% of PatientsIOM Dying in America Appendix E http://www.iom.edu/Reports/2014/Dying-In-America-Improving-Quality-
and-Honoring-Individual-Preferences-Near-the-End-of-Life.aspx
Last 12 months oflife
Short term high $
Persistent high $
Palliative Care Improves Value
Quality improves
– Symptoms
– Quality of life
– Length of life
– Family satisfaction
– Family
bereavement
outcomes
– MD satisfaction
Costs reduced
– Hospital cost/day
– Use of hospital,
ICU, ED
– 30 day
readmissions
– Hospitality mortality
– Labs, imaging,
pharmaceuticals
Palliative Care Improves Quality in
Office
Randomized trial simultaneous standard cancer care with palliative care co-management from diagnosis versus control group receiving standard cancer care only:
– Improved quality of life
– Reduced major depression
– Reduced ‘aggressiveness’ (less chemo < 14d before death, more likely to get hospice, less likely to be hospitalized in last month)
– Improved survival (11.6 mos. vs 8.9 mos., p<0.02)
Temel et al. Early palliative care for patients with non-small-cell lung cancer NEJM2010;363:733-42.
Palliative Care at
Home for the Chronically Ill Improves Quality, Markedly Reduces Cost
RCT of Service Use Among Heart Failure, Chronic Obstructive Pulmonary Disease, or Cancer Patients While Enrolled in a Home
Palliative Care Intervention or Receiving Usual Home Care, 1999–2000
13.211.1
2.3
9.4
4.6
35.0
5.3
0.92.4
0.9
0
10
20
30
40
Home health
visits
Physician
office visits
ER visits Hospital days SNF days
Usual Medicare home care Palliative care intervention
KP Study Brumley, R.D. et al. JAGS 2007
46 High Quality Studies
2002-11 Palliat Med 2014;28:130-50.
46 Studies: Across settings, patient populations,
and palliative care delivery models, palliative care
improves quality and in so doing, reduces costs.
What Do Patients Want?
Survey of Senior Center and Assisted Living subjects,
n=357, dementia excluded, no data on function.
Asked to rank order what’s most important:
1st Independence (76% rank it most
important)
2nd Pain and symptom relief
3rd Staying alive
Fried et al. Arch Int Med 2011;171:1854
How Can We Help Families Help Patients
Stay Home?
Partner with our
payers.
Innovative Payer Toolkit
• Talk to your payers!
• But first, read this:
• Predictors of successful payer-ACO-provider initiatives
• Case studies
• Checklists
• Worksheets
• Resources
231
www.capc.org/payertoolkit
Payers Are Bringing Palliative Care Home
www.theatlantic.com 02.25.13 MA Full Risk PMPM contract with HealthCare Partners/DaVita 15%+margin. >700K patients
“Now instead of 30-40 patients/day, Dr. Dougher sees 6-8.”
Treating the person beyond the
disease
T h a n k y o u
F a m i l y C a r e g i v e r S u p p o r t
F a m i l y C a r e g i v e r S u p p o r t
Susan C. Reinhard, R.N., Ph. D., FAAN
Family Caregivers Taking On More
Complex Tasks
• Partnership between the
AARP Public Policy
Institute and the United
Hospital Fund
• Funded by The John A.
Hartford Foundation
Almost Half of Family
Caregivers Perform Medical/Nursing
Tasks
Medical/Nursing Tasks
Caregiver Advise, Record, Enable (CARE)
Act
What does the CARE Act Do?
• Designation
– Record the name of the family caregiver upon admission into the hospital
• Notification
– Contact the family caregiver(s) prior to discharge to another facility or
home
• Consultation
– Hospital consults with caregiver on discharge plan,
taking into account the caregiver’s capabilities and limitations
• Training
– Hospital gives caregiver the opportunity to receive instruction on all after-
care tasks included in the discharge plan to be performed by the caregiver
Caregiver Advise, Record, Enable (CARE)
Act
• Gives support to nurses
and other health and
social service
professionals to do what
professional standards of
practice require them to
do
• Stimulates new thinking
on how to anticipate
patient and family
questions and pro-actively
support them
• Reduce hospital re-
admissions
Caregiver Advise, Record, Enable (CARE)
Act
Passed and signed in…
It has been introduced in sixteen states (CT, HI, IN, KS, MA, MD, MN, MS, NH, NM, NY, ND, PR, VA, WI, WV).
Reimbursement for Educating Family
Caregivers?
• 2010 Invitational meeting with CMS (Centers for Medicare & Medicaid Services) and other stakeholdersFocus:
– Participants included leaders from nursing and social work professions, family caregiver advocacy organizations, and federal government agencies
– The agenda explored policies around caregiver assessment and reimbursement for caregiver counseling.
– Goal was to provide participants with relevant data on the use of Medicare reimbursement codes for the counseling of family caregivers of Medicare recipients.
Reimbursement for Educating Family
Caregivers?
• AARP Public Policy Institute worked with CMS to provide data on use of existing reimbursement codes.– Determine the past and current use of the
reimbursement codes,
– What healthcare professionals (Physicians, Nurse Practitioners, etc.) were using codes
– If usage was low, why?
– What regions of the country were codes used
Reimbursement for Educating Family
Caregivers?
• Data run not completed due to
regulations around privacy of Medicare
beneficiary and provider data
Medicare Payment for Clinicians
• The following provide payment for clinicians doing care coordination including family caregivers– Chronic Care Management Fee
– Post-Discharge Transitional Care Management
– Home Health Services for Caregivers of Alzheimer’s Patients
– Patient-Centered Medical Home (Advanced Primary Care Practices)
– Medicare Community-Based Care Transition Program
Care Recipient
Family
Caregiver
CARE TRIANGLE
HealthcareProfessional
“It will take a
movement to join the
three corners of the
care triangle: people
who need care,
families who care for
and about their
members, and people
who give care for a
living.”
Deborah Stone, The Nation,
March 13, 2008
F a m i l y C a r e g i v e r S u p p o r t
Gail Gibson Hunt
President and CEO
National Alliance for Care Giving
About Alliance
Non-profit coalition of over 50 national organizations focused on family caregiving issues
Established in 1996 to support family caregivers and the professionals who work with them
NAC Activities: Conduct research and policy analysis;
Develop national programs;
Strengthen state and local coalitions;
Increase public awareness;
International work and awareness.
Demographics of Care Giving
65.7 million caregivers make up 29% of the US adult population and 31% of households
48.9 million care for only adult recipients, including people with disabilities
Portrait of Caregiver:
48-year-old woman who works and cares
Average of 20.4 hours of care per week for her mother for an average of 4.6 years
34% care for two or more people
86% provide care for a relative
Who Are Caregivers?
Caregiver Financial Burden
Caregiving costs U.S. employers between $17.1 and $33.6 billion in lost productivity annually
Over $5,500 out of pocket expenses
Seven in 10 working caregivers make workplace accommodations
Loss of wages, pension, Social Security: $324,044—women; $283,716—men
43% of caregivers were affected financially (AHA/ASA 2005)
PCORI End of Life Research
Several studies from PCORI on end-of-life care and caregiving
Includes cancer and heart failure treatment
Pediatric end-of-life care received grants to examine care preferences and communication on care
Shared decision making with patients, families and medical professionals
Impact on caregivers:
• Caregiver burden
• Decision-making (aggressiveness of care, etc.)
• Reduce caregiver conflict/regret
Federal Caregiving Legislation
Previously introduced legislation – yet to be introduced in current term
“FAMILY Act” – Family And Medical Insurance Leave Act of 2013, would create a self-sustaining insurance fund through a payroll tax to provide paid family and medical leave similar to the California Paid Leave program.
Caregiver Corps Act of 2014 (Sen. Casey-PA) and the National Care Corps Act (Rep. Grisham-NM), propose to create volunteer corps to help support families that do not have caregivers to meet long-term care needs
Mental Health Support for Veteran Families and Caregivers Act of 2013 (Sen. Sanders), would have created educational programs to support caregivers and vets with mental health disorders through the VA’s vet centers
In Home CARE Act (Sen. Booker-NJ, Rep. Pascrell-NJ), would have provided in-home caregiver education and training and an assessment with referral to resources for physical and mental Health for both the caregiver and the care recipient
Active Caregiving Initiatives
White House Conference on Aging
Older Americans Act Reauthorization
21st Century Cures
• Accelerates innovation for diseases with unmet needs
President’s Budget
• Proposed increases in NFCSP and Lifespan Respite, among others
• New ACL Family Support Program ($15,000,000)
Thank you
Gail Gibson HuntPresident & CEO
National Alliance for Caregiving4720 Montgomery Lane,
Suite 205Bethesda, MD 20814
www.caregiving.org
T h a n k y o u
T h e C o n t i n u u m o f C a r e :
P a n e l D i s c u s s i o n
The Continuum of Care:
Panel Discussion
• Brad Stuart, MDC-TAC
• Samira K. Beckwith,President and CEO,Hope Healthcare Services
• Robert Sowislo,Board and Government AffairsU.S. Medical Management
• Jean Kutner, MD, MSPH, CMOProfessor of Medicine and Associate Dean for Clinical AffairsUniversity of Colorado School of MedicinePast President AAHPM
• Cheryl Phillips, MD, SVPAdvocacy and Public Policy, Leading Age
• Randy Axelrod, MD, EVPClinical and Patient Services, Providence Health Services
M o d e r a t o r :
B r a d S t u a r t , M D
C - T A C
Toward A Person-Centered
Continuum of Care
Person
Community
HH, Hospice
HealthSystem
MedicalGroup
Agencies
Church
PrivatePayers
LTCare
Government
Physician
Hospital
H o s p i c e A s A n A g e n t f o r
C l i n i c a l I n t e g r a t i o n
S a m i r a K . B e c k w i t h
P r e s i d e n t a n d C E O
H o p e H e a l t h c a r e S e r v i c e s
Hope
Comfort
Care
Hope
PACE
Hope
Healing
HeartsHope
Hospice
Hope
Visiting
Nurses
Hope
Connections
Hope
Parkinson
Program
Hope
Kids Care
Patients
and
Families
U S M M / V P AH o m e B a s e d P r i m a r y C a r e
C o n t i n u u m o f C a r e
R o b e r t S o w i s l oE V P A d v o c a c y / G o v e r n m e n t A f f a i r s
Who We Are…
USMM is the nation's largest physician led provider of in-home medical services for high-risk populations:
• Provide 15% of all in-home physician visits nationally
• Serve over 50,000 complex patients on an annual basis
• Operate >100 local offices across 14 States
Delivers a physician-driven, fully-integrated continuum of care model
~ 225 full time
Physicians, NPs
and PAs
Engage in over 400,000 physician house call visits, 39,000 podiatric house call visits, 139,000 home health visits, and 380,000hospice patient days annually
Centralized administrative, data management, and call center operations
24x7 response to urgent escalations in illness and medical crises
Shared Savings Programs
Provide enhanced access to health services and quality of life for complex populations by removing barriers to receiving care
Pioneer ACOIndependence
at Home
30%
30%
50%
Top Decile
Top Quintile
17% / year
Not
Published
• Reduction in All-Cause 30-Day Readmissions
• Reduction in Hospital Admissions for Ambulatory-Care Sensitive Conditions
• Reduction in ER Visits for Ambulatory-Care Sensitive Conditions
• Patient Satisfaction Scores (CAHPS)
• Quality Scores (ACO Measures / IAH Quality Metrics)
• Cost Reduction (Pioneer 3 Yrs. Experience / IAH Year 1 Not Published)
Results and Outcomes
• Opportunity to expand shared savings participation to remaining FFS population through current CMS MSSP ACO program (First Home Based Primary Care ACO in the U.S.)
• Launched in January 2015; enrolled 20,000+ beneficiaries out of existing USMM/VPA
USMM Accountable Care Partners, LLC
J e a n K u n t e r , M D , M S P H , C M O
P r o f e s s o r o f M e d i c i n e a n d
A s s o c i a t e D e a n f o r C l i n i c a l A f f a i r s
U n i v e r s i t y o f C o l o r a d o S c h o o l o f
M e d i c i n e
P a s t P r e s i d e n t , A A H P M
L o n g - t e r m C a r e a n d
C o m m u n i t y C o n n e c t i o n s
C h e r y l P h i l l i p s , M D
S V P, A d v o c a c y a n d P u b l i c P o l i c y
L e a d i n g A g e
I n t e g r a t e d H e a l t h S y s t e m s
R a n d y A x e l r o d , M D
E V P, C l i n i c a l a n d P a t i e n t S e r v i c e s ,
P r o v i d e n c e H e a l t h a n d S e r v i c e s
A Snapshot of Providence
Caregivers (all employees) 73,018
Employed physicians 3,389
Employed advanced practice
clinicians923
Registered nurses 25,478
Physician clinics 475
Acute care hospitals 34
Acute care beds (licensed) 7,932
Providence Health Plan members 390,596
Hospice and home health programs 19
Home health visits 633,364
Hospice days 640,409
Assisted living and long-term care
facilities (free standing and co-located)22
Supportive housingFacilities: 14
Units: 693
Unique patients served 2,483,462
Community benefit and
charity care costs$951 million
Data is consolidated for Providence and its affiliates based on financial reporting.272
Ques t i on & Answer
Pane l D i scuss ion
F e d e r a l I n i t i a t i v e s
t o D r i v e C h a n g e
Federal Initiatives to Drive Change
• Tom Daschle,
Former U.S. Senator (D-SD)
Founder and CEO,
The Daschle Group
CMS Innovation and Health Care Delivery
System Reform
Dr. Patrick Conway, M.D., MSc
CMS Chief Medical Officer and
Deputy Administrator for
Innovation and Quality
Director, Center for Medicare
and Medicaid innovation
Director, Center for Clinical
Standards and Quality
Better Care, Smarter Spending,
Healthier People In three words, our vision for improving health delivery is about better,
smarter, healthier.
If we find better ways to deliver care, pay providers, and distribute
information, we can receive better care, spend our dollars more wisely,
and have healthier communities, a healthier economy, and a healthier
country.
We understand that it’s our role and responsibility to lead … and we will.
What we won’t do – and can’t do – is go it alone. Patients, providers,
government, and business all stand to benefit if we get this right, and this
shared purpose calls out for deeper partnership.
So we will continue to work across sectors for the goals we share: better
care, smarter spending, and healthier people.
Overview
Early Results
CMS Innovation Center
Delivery System Reform and Our Goals
CMS Support of Health Care Delivery
System Reform Will Result in Better Care,
Smarter Spending, and Healthier People
Historical state
Key characteristics
Producer-centered
Incentives for volume
Unsustainable
Fragmented Care
Systems and Policies
Fee-For-Service
Payment Systems
Evolving future state
Key characteristics
Patient-centered
Incentives for outcomes
Sustainable
Coordinated care
Systems and Policies
Value-based purchasing
Accountable Care Organizations
Bundled payments
Medical Homes
Quality/cost transparency
Population-based
payments
Public
and
private
sectors
Improving the way providers are incentivized, the way care is delivered, and the way information is
distributed will help provide better care at lower cost across the health care system.
Encourage the integration and coordination of clinical and support
services
Improve population health
Promote patient engagement through shared decision making
Pay
Providers
Create transparency on cost and quality information
Bring electronic health information to the point of care for meaningful
use
Focus Areas Description
Deliver Care
Distribute
Information
Promote value-based payment systems
– Test alternative payment models
– Increase linkage of Medicaid, Medicare FFS, and other payments
to value
Bring proven alternative payment models to scale
Delivery System Reform Requires Focusing
On the Way We Pay Providers, Deliver Care,
and Distribute Information
Source: Burwell SM. Setting Value-Based Payment Goals ─ HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online
first.
CMS Has Adopted a Framework That
Categorizes Payments to Providers
Description
Medicare
Fee-for-
Service
examples
Payments are
based on
volume of
services and
not linked to
quality or
efficiency
Category 1:
Fee for
Service – No
Link to Value
Category 2:
Fee for Service
– Link to
Quality
Category 3:
Alternative Payment
Models Built on Fee-for-
Service Architecture
Category 4:
Population-Based
Payment
At least a
portion of
payments vary
based on the
quality or
efficiency of
health care
delivery
Some payment is linked to
the effective management of
a population or an episode
of care
Payments still triggered by
delivery of services, but
opportunities for shared
savings or 2-sided risk
Payment is not directly
triggered by service
delivery so volume is not
linked to payment
Clinicians and
organizations are paid
and responsible for the
care of a beneficiary for
a long period (e.g., ≥1
year)
Limited in
Medicare fee-
for-service
Majority of
Medicare
payments
now are
linked to
quality
Hospital value-
based
purchasing
Physician Value
Modifier
Readmissions /
Hospital
Acquired
Condition
Reduction
Program
Accountable Care
Organizations
Medical homes
Bundled payments
Comprehensive Primary Care
initiative
Comprehensive ESRD
Medicare-Medicaid Financial
Alignment Initiative Fee-For-
Service Model
Eligible Pioneer
Accountable Care
Organizations in years
3-5
Maryland hospitals
Source: Rajkumar R, Conway PH, Tavenner M. CMS ─ engaging multiple payers in payment reform. JAMA 2014; 311: 1967-8.
During January 2015, HHS Announced
Goals for Value-Based Payments Within the
Medicare FFS System 30% of Medicare payments are tied to quality or value through
alternative payment models (categories 3-4) by the end of 2016,
and 50% by the end of 2018
85% of all Medicare fee-for-service payments are tied to quality or
value (categories 2-4) by the end of 2016, and 90% by the end of
2018
Goals
Purpose Set internal goals for HHS
Invite private sector payers and Medicaid to match or exceed
HHS goals
Stakeholders
Consumers
Businesses/Purchasers
Payers
Providers
State partners (including Medicaid programs)
Next steps Testing of new models and expansion of existing models is
critical to reaching incentive goals
Creation of the Health Care Payment Learning and Action
Network to align incentives and identify best practices
50%
Target Percentage of Payments in ‘FFS
Linked to Quality’ and ‘Alternative Payment
Models’ by 2016 and 2018
~20
0%
CMS Increasingly Linking FFS Payments to
Quality or Value
1
2
2
1
2
2
1
2
1.75
2
3
2
3
2
2
CMS is Aligning with Private Sector and
States to Drive Delivery System Reform
Convening Stakeholders
Convened payers in 7
markets in
Comprehensive Primary
Care
Convening payers,
providers, employers,
consumers, and public
partners through the
Health Care Payment
Learning and Action
Network
CMS Strategies for Aligning with Private Sector and States
Incentivizing Providers
Pioneer ACOs agreements
required 50% of the ACO’s
business to be in value-
based contracts by the end
of the second program year
Partnering with States
The State Innovation
Models Initiative funds
testing awards and model
design awards for states
implementing
comprehensive delivery
system reform
The Maryland All-Payer
Model tests the
effectiveness of an all-
payer rate system for
hospital payments
Early Results
CMS Innovation Center
Delivery System Reform and Our Goals
Source: CMS Office of the Actuary
9.24%
5.99%
4.63%
7.64%7.16%
*27.59%
1.98%
4.91%
4.15%
1.36%
2.25%
1.13%0.35%
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
11%
12%
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Medicare Per Capita Growth Medical CPI Growth
*Medicare Part D prescription drug
benefit implementation, Jan 2006
28%
27%
Results: Per Capita Spending Growth at
Historic Lows
Pioneer ACOS were designed for organizations with experience in
coordinated care and ACO-like contracts
Pioneer ACOs showed improved quality outcomesQuality outperformed published benchmarks in 15/15 clinical quality measures
and 4/4 patient experience measures in year 1 and improved in year 2
Mean quality score of 85.2% in 2013 compared to 71.8% in 2012
Average performance score improved in 28 of 33 (85%) quality measures
Pioneer ACOs generated savings for 2nd year in a row
$384M in program savings combined for two years†
Average savings per ACO increased from $2.7 million in PY1 to $4.2
million in PY2‡
Pioneer ACOs Provided Higher Quality and
Lower Cost Care to Medicare Beneficiaries
in Their First Two Performance Years
19 ACOs operating in 12 states (AZ, CA, IA, IL, MA, ME,
MI, MN, NH, NY, VT, WI) reaching over 600,000 Medicare
fee-for-service beneficiaries
Duration of model test: January 2012 – December 2014;
19 ACOs extended for 2 additional years
† Results from regression based analysis
‡ Results from actuarial analysis
CMS convenes Medicaid and commercial payers to support primary
care practice transformation through enhanced, non-visit-based
payments, data feedback, and learning systems
Across all 7 regions, CPC reduced Medicare Part A and B
expenditures per beneficiary by $14 or 2%*
Reductions appear to be driven by initiative-wide impacts on
hospitalizations, ED visits, and unplanned 30-day readmissions
Comprehensive Primary Care (CPC) is
Showing Early Positive Results
7 regions (AR, OR, NJ, CO, OK, OH/KY, NY)
encompassing 31 payers, nearly 500 practices,
and approximately 2.5 million multi-payer
patients
Duration of model test: Oct 2012 – Dec 2016
* Reductions relative to a matched comparison group and do not include the care management fees (~$20
pbpm)
Spotlight: Comprehensive Primary Care,
SAMA HealthcareSAMA Healthcare Services is an independent four-physician family
practice located located in El Dorado, a town in rural southeast Arkansas
“A lot of the things we’re doing now are
things we wanted to do in the past… We
needed the front-end
investment of start-up
money to develop our teams
and our processes”
-Practice Administrator
Services made possible by CPC
investment
Care management
Each Care Team consists of a doctor, a
nurse practitioner, a care coordinator, and
three nurses
Teams drive proactive preventive care for
approximately 19,000 patients
Teams use Allscripts’ Clinical Decision
Support feature to alert the team to missing
screenings and lab work
Risk stratification
The practice implemented the AAFP six-
level risk stratification tool
Nurses mark records before the visit and
physicians confirm stratification during the
patient encounter
Partnership for Patients Contributes to
Quality Improvements and Cost Savings
Ventilator-
Associated
Pneumonia
Early
Elective
Delivery
Central Line-
Associated
Blood Stream
Infections
Venous
thromboembolic
complications
Re-
admissions
62.4% ↓ 70.4% ↓ 12.3% ↓ 14.2% ↓ 7.3% ↓
Data shows a 17% reduction in hospital acquired conditions across
all measures from 2010 – 2013
‒ 50,000 lives saved
‒ 1.3 million patient harm events avoided
‒ $12 billion in savings
Many areas of harm dropping dramatically – patient safety
improving
Leading Indicators, change from 2010 to 2013
Medicare All-Cause, 30-day Hospital
Readmission Rate is Declining
Legend: CL: control limit; UCL: upper control limit; LCL: lower control
limit
Readm
issio
n R
ate
Beneficiaries Move to MA Plans with High
Quality Scores Sent prompt to
beneficiaries
enrolled in
plans with 2.5
star rating or
lower
Letters only
sent to
beneficiaries in
consistently
low-rated plans
Switch rate
44% (prompt)
v. 21% (no
prompt)
9% 9%9%
2012
20%
61%
29%
57%
20142013
9% 5%
45%
45%
1%
5-star
4-star
3-star
2-star
Medicare Advantage (MA) Enrollment Rating Distribution
29
%
71
%
37
%
63
%
55
%
45
%
% 4 or 5 star
% 2 or 3 star
Early Results
CMS Innovation Center
Delivery System Reform and Our Goals
The CMS Innovation Center Was Created By
the Affordable Care Act to Develop, Test,
and Implement New Payment and Delivery
Models
The Innovation Center Portfolio Aligns With
Delivery System Reform Focus Areas
CMS Has Engaged the Health Care Delivery
System and Invested in Innovation Across
the Country
Models run at the state levelSites where innovation models are being
tested
Source: CMS Innovation Center website, January 2015
Accountable Care Organizations:
Participation in Medicare ACOs Growing
Rapidly
ACO-Assigned Beneficiaries by County
424 ACOs have been established in the MSSP and Pioneer ACO programs
7.8 million assigned beneficiaries
This includes 89 new ACOS covering 1.6 million beneficiaries assigned to the shared
saving program in 2015
The bundled payment model targets 48 conditions with a single
payment for an episode of care
Incentivizes providers to take accountability for both cost and quality of care
Four Models - Model 1: Retrospective acute care hospital stay only
- Model 2: Retrospective acute care hospital stay plus post-acute care
- Model 3: Retrospective post-acute care only
- Model 4: Acute care hospital stay only
102 Awardees and 167 episode initiators in phase 2 as of January 2015
85 new awardees and 373 new episode initiators will enter phase 2 in
April 2015
Bundled Payments for Care Improvement is
Also Growing Rapidly
Duration of model is scheduled for 3 years:
Model 1: April 2013 to present
Models 2,3,4: October 2013 to present
* Current as of January 2015
CMS is testing the ability of state governments to utilize policy and
regulatory levers to accelerate health care transformation
Primary objectives include
Improving the quality of care delivered
Improving population health
Increasing cost efficiency and expand value-based payment
State Innovation Model Grants Have Been
Awarded in Two Rounds
Six round 1 model test states
Eleven round 2 model test states
Twenty one round 2 model design states
Round 1 States Are Testing and Round 2
States Are Designing and Implementing
Comprehensive Reform Plans
Round 1 States testing APMs
Arkansas
Maine
Massachuset
ts
Minnesota
Oregon
Vermont
Patient
centered
medical
homes
Accounta
ble care Episodes Near term CMMI objectives
Establish project
milestones and success
metrics
Support development of
states’ stakeholder
engagement plan
Onboard states to
Technical Assistance
Solution Center and
SIMergy Collaboration site
Launch State HIT
Resource Center and
CDC support for
Population Health Plans
Round 2 States designing
interventions
Maryland is the nation’s only all-payer hospital rate regulation system
Model will test whether effective accountability for both cost and quality
can be achieved within all-payer system based upon per capita total
hospital cost growth
Quality of care will be measured through
Readmissions
Hospital Acquired Conditions
Population Health
Maryland is Testing an Innovative All-Payer
Payment Model
Maryland has ~6 million residents*
Hospitals began moving into All-Payer Global Budgets in July
2014
- 95% of Maryland hospital revenue will be in global
budgets
- All 46 MD hospitals have signed agreements
Model was initiated in January 2014;
Five year test period* US census bureau estimate for 2013
Awards tested service delivery and payment models that improved
quality and decreased cost in communities across the U.S.
Over 140 projects awarded in round 1 and 2
Ideas tested include
- Enhancing primary care
- Coordinating care across multiple settings
- New types of health care workers
- Improving decision making
- Testing new service delivery technologies
Health Care Innovation Awards Tested A
Broad Range of Delivery System Innovations
Approximately 575,000 Medicare, Medicaid, and CHIP
beneficiaries served
Projects were funded in all 50 states*
Awards ranged from ~$1 M to $30 M
* Darker colors on map represent more HCIA projects in that state
Independence at Home (IAH)• This delivery model utilizes physician and nurse practitioner
directed primary care teams to provide services to certain
Medicare beneficiaries in their homes.
• Participating practices are accountable for providing
comprehensive, coordinated, continuous, and accessible
care to a maximum of 10,0000 high-needs beneficiaries at
home and coordinate health care across all treatment
settings.
• Practices may share in any savings under the Demonstration
program, if specified quality measures and savings targets
are achieved.
Medicare Care Choices Model• Allows terminally ill Medicare beneficiaries to receive
palliative care and hospice services without having to forego
further treatment for their terminal condition
• Designed to test impact of model on patient and family
satisfaction, timing of patients’ enrollment in hospice, and use
of non-palliative services at end of life
• Open to hospice-eligible Medicare beneficiaries with heart
failure, COPD, terminal cancer, or HIV
• Hospices to be paid monthly fees for case-management,
palliative care and related services
Accountable Health Communities• Recognizes that health care costs are influenced by drivers
outside the formal health care delivery system
• Tests whether systematically identifying and addressing
beneficiaries’ health-related social needs (e.g., housing
instability, food insecurity) reduces emergency department
utilization and inpatient hospitalizations.
• Engages payers, local government, and clinical and
community-based service providers in a coordinated effort to
align resources to improve the health of high risk Medicaid
and Medicare beneficiaries, with investments in infrastructure
and data tools to support continuous quality improvement
Transforming Clinical Practice Initiative is
Designed to Help Clinicians Achieve Large-
Scale Health TransformationThe model will support over 150,000 clinician practices over the next four
years to improve on quality, lower costs, and enter alternative payment
models• Two network systems will
be created
1) Practice Transformation
Networks: peer-based
learning networks
designed to coach,
mentor, and assist
2) Support and Alignment
Networks: provides a
system for utilizing
professional associations
and public-private
partnerships to drive
improvement
Phases of
Transformation
We are focused on:
Implementation of Models
Monitoring & Optimization of Results
Evaluation and Scaling
Integrating Innovation across CMS
Portfolio analysis and launch new
models to round out portfolio
Innovation Center – 2015 Looking
Forward
Eliminate patient harm
Focus on better care, smarter spending, and healthier
people within the population you serve
Engage in accountable care and other alternative
payment contracts that move away from fee-for-service
to model based on achieving better outcomes at lower
cost
Invest in the quality infrastructure necessary to improve
Focus on data and performance transparency
Test new innovations and scale successes rapidly
Relentlessly pursue improved health outcomes
What Can You Do to Help Our System
Achieve the Goals of Better Care, Smarter
Spending, and Healthier People?
Contact Information
Dr. Patrick Conway, M.D., M.Sc.
CMS Acting Principal Deputy Administrator and
CMS Chief Medical Officer
410-786-6841
310
S t a t e I n i t i a t i v e s
t o D r i v e C h a n g e
State and Local Operating Balanceas a percentage of GDP
State and Local Health and Non-Healthas a percentage of GDP
314
State Spending by Major Category(In billions of current dollars)
Medicaid
K-12
Corrections
Transportation
GAO Conclusions on Long-Term Fiscal
Outlook
“We calculated that closing the fiscal gap would
require action to be taken today and maintained for
each year equivalent to an 18 percent reduction in the
state and local government sector’s current
expenditures.”
“A primary driver of the decline in the…operating
balance long term is the rising health-related costs of
state and local expenditures on Medicaid and the cost
of health care compensation for state and local
government employees and retirees.”
0% 7% 14% 21% 28% 35% 42% 49% 56% 63% 70% 77% 84% 91% 98%
Medicare-$10,115Average --- $9267 -------------------------------------------------------------------------------------------
Medicaid--$8164
Per Capita Health Costs2013
Percent of U.S. Population
•Average age 49•Percent female 62•Average monthly cost $3,908•Hospital admission 2.6 per year•Hospital bed days 12•Emergency room visits 7 per year•Primary care visits 10 per year•Specialists visits 20 per year•Percent with 5 or more prescriptions 87%•Percent with co-morbidities 100%•Diabetes 51%•Behavioral health diagnosis 73%
Characteristics of Medicaid High-Utilizers
State Policy
Levers
State Purchasing
Power
Governors as
Conveners and
Consensus
Builders
State Wellness
and Prevention
Efforts
State Health Care
Regulation
Education and
Workforce
Market
Competition and
Consumer Choice
Health Care Focus Areas
Core Focus Areas Support and Build on Each Other
Winter
•Webinar on Section 1332 ACA Waiver
•Webinar on Health Insurance Marketplace Issues
•Convening of Existing and New State Innovation
Model (SIM) Testing States
•Montana SAS Project (moving to phase 2)
Spring
•Launch of Medicaid Leadership Institute
•50 State Convening -- Learning from Each Other,
the Role of States In Transforming Health Care
•Maternal and Child Health Learning Collaborative
•Launch TA Bench for Transformation
•Super Utilizer 1.0 and 2.0 Policy Academies
•Coverage Convening (State-Based Marketplaces)
Summer
•Health Policy Advisor Institute
•Medicaid Vendor Policy Academy
•Maternal and Child Health Learning Lab
•Expert Roundtable Population Health
Fall
•Convening of Governors on Health Care
•Completion of Medicaid Transformation Policy
Academy
•Completion of Workforce Policy Academy
Winter 2015
•Launch of Workforce Policy Academy
Ongoing
•State Health Care Leadership Retreats
•Instate TA Visits Population Health
•Learning Labs on Population Health
Papers
Workforce
Prescription Drug Abuse
Super Utilizer Data
New generation drugs
NGA Health Activities
Notes on State Activity for EOL
• Medicare dominant for EOL…in-patient and hospice
• Committee/task force…best practices on palliative care
• Tension between pain meds and abuse of
pharmaceuticals
• MA requirement for conversation on EOL treatment
• ACO’s coordinated care for EOL…reduced intensity and
increased patient satisfaction
P o l i c y F o r u m
Policy Forum
• Leonard D. Schaeffer
• Sen. Johnny Isakson (R-GA)
• Sen. Mark Warner (D-VA)
• Sen. Sheldon Whitehouse (D-RI)
W h a t ’ s N e x t
B i l l N o v e l l i
T o m K o u t s o u m p a s
C o - C h a i r s , C - T A C
N a t i o n a l S u m m i t o n
A d v a n c e d I l l n e s s C a r e
D r i v i n g C h a n g e t h r o u g h
L e a d e r s h i p , E v i d e n c e a n d
A c t i o n
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