In the first part of our series we explored the current research surrounding end-of-life care. Part II focuses on three innovative programs in this area to better understand how the research is being implemented: Kaiser Permanente’s In-Home Palliative Care Program, Sutter Health’s Advanced Illness Management (AIM)® Program, and Providence Hospice and Home Care and Everett Clinic’s Palliative Care Program.
A Focus on Core Objectives
These programs were all designed to address a set of challenges that these providers face in offering care to seniors near the end of their lives.
All three programs cited the lack of adequate care and support for those facing chronic diseases and advanced illnesses. Oftentimes these patients continue aggressive treatment, for lack of knowledge about their alternatives, though their appetite for such continued care is often weak. Under current circumstances, very little emphasis is placed on discussing options with patients and taking into account their preferences and wishes towards the end of life.
In many cases, with continued aggressive care, patients end up dying in acute care settings rather than in their homes – which is where most patients prefer to spend their last days. Finally, all programs recognize that the current process takes an immense toll on the health care system and is ultimately inefficient and ineffective in delivering end-of-life care.
Similar Blueprints and Processes
Each of the programs contained a similar set of key elements including the way they recruit participants, structure their teams and deliver care.
The programs rely on the input of several team members, including physicians, hospital discharge planners, nurses, social workers and home care providers, to identify candidates. In some cases, such as with the Sutter Health AIM Program, program representatives are present in clinical settings, observe patients as they come and go, and identify potential participants in this manner.
Candidates typically must suffer from multiple chronic conditions, be in poor or declining health, and be near the end of life (2 years to live or less, depending on the program) to qualify.
Unlike with hospice programs, these programs allow participants to continue pursing curative care in addition to receiving palliative care. This entices a wider pool of people to participate in these programs as they do not have to make a choice on “giving up” on treatment and having access to more comprehensive care.
Another integral component of these programs is a patient care initiative led by a varied and comprehensive team. The interdisciplinary team is critical to delivering well-rounded care, including pain and symptom management, emotional and spiritual support, as well as any necessary medical interventions. These teams include physicians, nurses, and social workers, all of whom are typically trained specifically in palliative care. In some cases, a chaplain, therapists, aides and health coaches also get involved as necessary.
Most often nurses operate in a “case manager” type of role, serving as the most frequent point of contact for the patients, sharing information as necessary with other members of the care team, and alerting the appropriate physician should the patient’s condition deteriorate or if some complication arises.
Initiation of Care
The programs generally start with a thorough walk-through of what the program entails and how the team will work with the patient and the patient’s family. Following this is an initial assessment, conducted in the patient’s home, where the patient’s needs, goals and wishes are thoroughly evaluated in order to develop an appropriate plan of care. The needs assessment portion typically includes a patient history and medication review and a patient and home safety assessment.
Either during this initial phase, or soon thereafter, the patient’s preferences for end-of-life care are examined. This may include documenting an advance directive, a living will and/or a Physician’s Order for Life Sustaining Treatment.
On an on-going basis, care typically consists of periodic home visits by one or more members of the care team, phone check-ins by the team nurse and coordination of services and treatment if the patient requires any specialized type of care (e.g. home care, hospice). As and when the patient’s status or needs change, his or her plan of care is also adjusted accordingly.
Aside from an interdisciplinary team deeply engaged in the patient’s care, having a “nurse on call” feature is a driving factor in the success of these programs. Without a qualified person readily available in the event of a medical episode, seniors often end up in the emergency room for lack of an alternative. In these palliative care programs, the participants have someone who is familiar with their situation that they can reach out to as needed. The nurse can then help determine the appropriate next steps, which rarely includes a visit to the emergency room.
Results to Date Show Promise in All Three Programs
Kaiser Permanente In-Home Palliative Care Program
The results described are based on one randomized controlled trial (RCT) and one comparative study.
With regards to the RCT, the palliative care group outperformed the usual care group in terms of patient satisfaction, ability to die at home (the preferred location) and lower average costs per patient:
- 80% and 93% of the palliative care patients reported that they were very satisfied with their care at the 30- and 90- day period, respectively, compared to 74% and 81% in the usual care group
- 71% of the palliative care patients died at home compared to only 51% in the usual care group
- The average cost of care for the palliative care patients was $12,670 compared to $20,222 for the usual care group
The comparative study reinforced the higher likelihood of patients dying at home and the lower costs of care for patients in the palliative care group versus the usual care group:
- Likelihood of dying at home: 87% vs. 71% for cancer patients; 92% vs. 37% for COPD patients; 87% vs. 47% for congestive heart failure patients
- Lower costs of care: 35% lower for cancer patients; 67% lower for COPD patients; 52% lower for congestive heart failure patients
Sutter Health’s Advanced Illness Management Program
The results described are based on preliminary, unpublished data from November 2009 through September 2010.
Patients who lived at least 90 days into the AIM program were hospitalized at a much lower rate (54% lower) than prior to program enrollment. Intensive care unit days were also reduced by 80% and the length of stay upon subsequent hospital admissions was reduced by 26%.
A 52% reduction in physician office visits was also reported, however phone calls between physicians and patients were found to have increased by 10%. Furthermore, approximately two thirds of the patients enrolled in AIM chose to receive hospice care going forward.
Due to a reduced need for services, the program realized an average cost savings to Medicare of $760 per AIM patient per month. Adjusted for all revenues and costs in the care ecosystem (hospital, physician, home health, hospice), the savings was $213 per patient per month.
Overall, the program resulted in high satisfaction amongst patients, their family members and physicians.
Providence Hospice and Home Care and the Everett Clinic
The results described are based on 140 patients over 65 years of age who passed away between August 2004 and January 2006.
Of those who participated in the program, 53% were not admitted to the hospital in their last 60 days, compared to 28% in the control group. Among those who were admitted to the hospital, palliative care patients stayed an average of 1.9 days compared to 2.4 days for the control group.
Participation in the palliative care program was also found to increase the use of hospice. The median hospice stay for palliative care patients was 47 days compared to only 6 for the other patient group.
Looking Ahead: An In-Depth Look at Kaiser Permanente’s Program
The next part of our series will be a Q&A with Susan Enguidanos, Ph.D. where we will discuss Kaiser Permanente’s palliative care program in-depth and explore the challenges when it comes to building these kinds of programs more broadly.