Palliative Care in the Nursing Home Janet Bull, MD FAAHPM, HMDC

Transcription

1 Palliative Care in the Nursing Hme Janet Bull, MD FAAHPM, HMDC Objectives Understand nursing hme envirnments, the impact f healthcare refrm, and the alignment f palliative care services Identify ingredients f a successful palliative care prgram Discuss CMS Innvatins mdel f care Define tls, prcess and utcme metrics that are useful in imprving care, and demnstrating success 1

2 What Keeps Yu Up at Night? NH Administratrs Occupancy Decreased reimbursement Dealing with multiple payer surces MA plans Partnerships Star ratings Staff turnver Case mix Readmissins Trends Overall number f nursing facilities decreased by.7% t 15,643 Occupancy decreased frm 85.6 t 83% with decrease in patients frm 1.6 t 1.3 millin Increase in Fr Prfits => 69% Majrity f 65 y => need LTCF fr average f 3 years, and by 85 y, 20% fr 5 years Kaiser Fundatin Overview f Nursing Facility Capacity, Financing, and Ownership in the United States in 2011 Peter Kemper et al., Lng Term Care Over an Uncertain Future: What Can Current Retirees Expect?, Inquiry, 42 (2005):

3 Expected Grwth in Nursing Hmes Understanding Nursing Hme Envirnment Strict regulatry requirements Salaries tend t be lwer Reimbursement declining tight margin Understaffing in RN and CNA psitins Sicker patients secndary t shrtened hspital stays High staff turnver 3

4 Mrtality and LOS in LTCF 25% Americans die in LTCF Half f these died within 5 mnths 65% died within 12 mnths ALOS 14 mnths (ther data 2 years) Males and higher financial wrth had shrter prgnsis Kelly, A J Am Geriatr Sc 58: , Length f Stay fr Older Adults Residing in Nursing Hmes at the End f Life Dementia in LTCF Accunts fr up t 2/3 f all admissins Death rate dubled frm 1996 t 2007 Behaviral issues ften drive NH admissins Staff ften ill equipped t handle 4

5 Bereavement Surveys LTCF 32% patients have pain 24% patients dyspnea 60% inadequate emtinal supprt Only 42% rated quality f care as excellent, as cmpared t 71% with hspice care at hme Ten JM, Family perspectives n end f life care at the last place f care. JAMA 2004; 291:88. 5

6 Affrdable Care Act Triple Aim Palliative Care At least 1/3 f LTCF patients are apprpriate fr palliative care at time f admissin! 6

7 Times are Changing *Physician chice *Physician Accuntability Fee fr Service *Outcmes directed decisin making *Physician Accuntability Pay fr Perfrmance Risksharing/ ACOs *Cst/quality directed decisin making *Grup Accuntability Quality Demnstratin 7

8 Accuntable Care Organizatins Ppulatin health Redesign care prcesses Fcus n pst acute cntinuum Infrastructure develpment Health infrmatin exchange Crdinatin acrss care settings 5 Star Ratings fr Nursing Hme Health inspectins last 3 years Staffing Quality Measures Each categry has 5 star categry and is designed t help cnsumers cmpare LTCF 8

9 Quality Measures Lng Stay falls physically restrained UTIs need help ADLs Md severe pain depressive symptms pressure ulcers influenza vaccine Incntinence pneumcccal vaccine catheter antipsychtic meds weight lss Stay Residents.html Quality Clinical Measures 9

10 Quality Measures Shrt Stay Md severe pain New Pressure ulcers Influenza vaccine Pneumcccal vaccine Antipsychtic med Stay Residents.html Gals fr 2015 Dementia patients n antipsychtics Gal frm 20.3% 19% Pressure ulcer rate Gal frm 6.7% 6.6% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% 20.30% 19.00% 6.70% 6.60% Gal Patients n Antipsychtics Gal Pressure Ulcer Rate 10

11 Quality Metrics fr Nursing Hmes Pay fr Perfrmance Nne f the QM pertain t end f life 2 Prpsed additinal EOL measures Place f death Hspice enrllment prir t death Mukamel,J Palliat Med. Apr 2012; 15(4): , End f Life Quality f Care Measures fr Nursing Hmes: Place f Death and Hspice NH Value Based Purchasing Pilt Pay fr Perfrmance Pilt Virginia, New Yrk, Wiscnsin Staffing, QM, Survey Deficiencies, Hspitalizatins Tp 20% participate in shared savings Hme Value Based Purchasing/ 11

12 Nursing Hme Cmpare 12

13 Readmissins 25% Medicare patients readmitted within 30 days t the hspital 2/3 f transfers are cnsidered avidable NHs will sn be penalized HHS prpsal t decrease payments by up t 3% by 2017 fr NH with high readmissin rates 2018 HHS prpses bundled payment system Readmissin Rates Benchmarks 21% readmitted within 30 days 25.5% wrst ranking facilities 19.8% best ranking 4.3% died within 30 days Lwer readmissins crrelated with better staffing rati, but nt quality indicatrs Neuman, JAMA. 2014;312(15): Assciatin Between Skilled Nursing Facility Quality Indicatrs and Hspital Readmissins American Health Care Assciatin (AHCA) recmmends reductin t <15% 13

14 Dying in America: Imprving Quality and Hnring Individual Preferences Near the End f Life IOM (Institute f Medicine) IOM Reprt Recmmendatins Palliative Care Training/Educatin Symptm Management Effective Cmmunicatin Advance Care Planning Gal based Care Cntinuity acrss settings Cvering Patient s Scial Needs 14

15 A Shifting Paradigm Traditinal Care Transfrmatinal Care Physician led Team led Acute clinical needs Gal directed care Sil care specialists Crdinated health teams Fee fr service Value based purchasing Bundled payments Ging Frm Macr T Micr 15

16 Opprtunities fr Palliative Care Prjected 40% f all deaths in NH by 2020 Pr pain and symptm management High degree f scial and spiritual islatin Inadequate physician invlvement in care Exclusin f resident/family in treatment decisins Benefits f Palliative Care Palliative care imprves quality f care Crdinated care Higher cmpletin f Advance Care Planning Reduce hspital transfers Higher family and patient satisfactin Imprved staff satisfactin with educatin cmpnent and availability f prviders 16

17 Miller, Lima, Intratr, Martin, Bull, Hansn, 2015, Brwn Schl f Public Health, preliminary research results. Screening Tl fr PC Cmpleted by MDS/admissins crdinatr n all NH admissins Identifies all patients with a cancer diagnsis Identifies all patients with end stage disease, such as CHF, COPD, dementia, ESRD Identifies patients withut Advance Directives Identifies patients with pain r symptm needs Identifies multiple hspitalizatins If psitive screen, call is placed t attending fr PC cnsult 17

18 Defining Eligibility Define yur prgram parameters. Dn t try t be all things t all peple. It is better t under prmise and ver deliver. Eligibility criteria patients with serius r life limiting illnesses Excluded chrnic pain, i.e., quadriplegic pst surgical substance abuse acute pain (rthpedic) Risk Stratificatin Demgraphics Diseases Clinical signs and symptms (ADLs, cgnitive and nutritinal decline) Adverse events (hspitalizatins, ER) Prck,D. Jurnal f Gerntlgy, 2005, Vl. 60A, N. 4, Predicting Death in the Nursing Hme: Develpment and Validatin f the 6 Mnth Minimum Data Set Mrtality Risk Index 18

19 Prgnsis NH Patients MDS Mrtality Rating Index Scring system based n 10 factrs and ADLs assistance Prck,D. Jurnal f Gerntlgy, 2005, Vl. 60A, N. 4, Predicting Death in the Nursing Hme: Develpment and Validatin f the 6 Mnth Minimum Data Set Mrtality Risk Index 19

20 Develping Referral Surces RELATIONSHIPS Physician and facility preference lists Develping yur message hw d yu benefit them with yur services? Humble attitude in a hst envirnment Plan fr educating their staff Runding tl cmmunicate frequently Create a win win situatin Key Nursing Hme Persnnel Directr f nursing Charge flr nurses MDS crdinatr Admissins crdinatr MD directr Ancillary staff (dietary, PT, OT) Nursing hme administratr 20

21 INTERACT Cmmunicatin Care paths r clinical prtcls Advance Care Planning Available fr LTCF, ALF, hme health, and ACO (under develpment) Interventins t reduce acute care transfers INTERACT Cmmunicatin Tls SBAR tl Medicatin Recnciliatin Stp and Watch early warning n changes with residents Transfer frms/checklist 21

22 INTERACT Care Paths Fever Dehydratin Dyspnea CHF GI sx nausea, vmiting, diarrhea Respiratry Illness Altered mental status Change in behavir UTI Advance Care Planning Tls ACP tracking tl Cmmunicatin guide Cmfrt care rder sets Decisin abut hspitalizatin Feeding tube educatin CPR 22

23 QTC Quality Transitinal Care Pilt Crdinatin with hspital discharge planners, primary care prviders, hme heath, NH, and ALF s RN cntacts pt/families within 48 hurs f discharge Medicatin recnciliatin Patient educatin Symptm assessment QDACT Tl Schedules PC visit based n acuity RN case manager in facility < 2x week Results Patients Within 30 days % 5 0 Readmissin Befre QTC Readmissin After QTC 23

24 CMMI Rund 2 Innvatin Grant The Innvatin Mdels are rganized int seven categries. Accuntable Care Bundled Payments fr Care Imprvement Primary Care Transfrmatin Initiatives Fcused n the Medicaid and CHIP Ppulatin Initiatives Fcused n the Medicare Medicaid Enrllees Initiatives t Speed the Adptin f Best Practices Initiatives t Accelerate the Develpment and Testing f New Payment and Service Delivery Mdels Palliative Care Teams PC Admin (scheduling, HIM, billing) PC NP (1:100) PC RN (1:300) PC SW PC MD/DO versight fr team All patients have QDACT Assessment Eligibility: 65 y, Medicare 24

25 Palliative care in the SNF Staffing ratis Caselad NP caselad 100 patients Prductivity 6 8 visits/day Billing Intensity > Time based billing Supprt Staff Scheduling, HIM, IT, Billing, Admin Rle f the Nurse Practitiner Understands nursing hme envirnment and spends time with relatinship building Understand state and federal regulatins Respnsible fr risk stratificatin Assigned t 1 2 nursing hmes t keep cnsistent care Prvide frmal educatin quarterly with runding tls daily Available by phne 24/7 25

26 Palliative Care Prgress Nte Written with the MDS in mind Dcument: Pain scres and interventins Symptm assessment Cntinence issues Cgnitive status Behaviral issues and need fr antipsychtics Oral intake/weight and interventins Patient/family gals Prgress r lack theref f PT/OT Crdinatin with NH plan f care Align with NH Quality Metrics Patients prefer t avid hspital deaths Hspice patients quality f care Better pain cntrl Less physical restraints Lwer use f feeding tubes Higher patient/family satisfactin 26

27 Building a system QDACT v 2 Metrics t Track Hspice Transitins LOS average and mean Hspital Readmissins Symptm Scres ACP Patient/family Satisfactin Billing Intensity > Time based billing 27

28 Prpsing a Payment Mdel Questins? jbull@furseasnscfl.rg 28