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Vohs
Award Winner: Single-Region Category By Richard D Brumley, MD; Susan Enguidanos, MPH; Kristine Hillary, RN, MSN
A preliminary report of these data was presented at "Promoting Financial Excellence in End-of-Life Care: A Policy Directions Forum," September 9, 2002, Washington, DC, sponsored by The Robert Wood Johnson Foundation. Background: Recognizing the Need for Palliative Care The need to improve health care for Americans as they approach the end of their lives has gained increased attention during the past decade. The imminent influx of "baby boomers" into our elderly population has created an additional burden on our health care system: the need to develop new models for providing cost-effective, patient-centered palliative care at the end of life. Persons older than 65 years--a group that currently represents 12.6% of the US population--will nearly double by 2030 to account for 20.2% of the US population.1 Each year, fewer than 5% of Medicare recipients die. Yet the cost of services in the last year of life for this small segment of enrollees represents 25% of total annual Medicare costs.2 The mean Medicare cost of health care in the last year of life is approximately $26,000--about six times the per capita health care cost for Medicare survivors.2 Unfortunately, current constraints imposed by Medicare regulations serve as enormous barriers to developing models of palliative care for terminally and chronically ill patients. These barriers and numerous barriers to providing hospice services (eg, patients refusing hospice services, physician uncertainty in determining life expectancy, patient unwillingness to forego curative care, negative connotations of hospice care) result in patients dying either in acute care units or in intensive care units, sometimes after receiving medically futile care. In 1996, in the Kaiser Permanente (KP) Southern California TriCentral Service Area (KP TriCentral), 63% of patients who died in the intensive care unit and 54% of those who died in the medical/surgical unit had a primary or secondary diagnosis of one of three commonly fatal, incurable conditions: cancer, congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD). The KP TriCentral leadership subsequently recognized the need to design a program that changed the focus from inpatient to home-based care for patients nearing the end of life. In contrast to traditional models of care--which emphasize curative treatment until death and offer little, if any, palliative care--the program would integrate palliative care into curative care earlier in the patient's disease process. Seriously ill patients needed services to enable them to better manage their own care at home and thus reduce their need for inpatient and emergency services. With this improved model of end-of-life care, we hypothesized that palliative care patients would be more satisfied with their health care and would use fewer medical services than would their counterparts receiving traditional end-of-life medical care. Developing a Palliative Care Program
The KP TriCentral Palliative Care (TCPC) Program began as a pilot study in 1997, and began receiving annual funding in 1998. The TCPC Program is an interdisciplinary, home-based program for patients at the end of life. The program offers these patients enhanced pain control, symptom management, and psychosocial support to improve quality of life and care while reducing the overall cost of care. By blending palliative care and curative measures, the TCPC Program provides gradual transition for patients with a 12-month survival prognosis and thus allows them to retain their primary care physician while receiving home visits from the palliative care team and physician. Abundantly patient-centered, the TCPC Program's mission--consistent with that of the KP Southern California Region--is to achieve the best possible quality of life for patients by relieving suffering, controlling symptoms, and restoring functional capacity while remaining sensitive to patients' personal, cultural, and religious values, beliefs, and practices. The program's interdisciplinary health care team (Table 1) encourages and empowers patients to actively participate and collaborate in designing, evaluating, and revising the patient's plan of care. Structure
and Implementation of the TCPC Program Although modeled after KP's hospice program (which operates within Medicare guidelines), the TCPC Program features three important modifications to overcome current barriers to palliative care:
In addition to these design improvements, the program features five core components, each of which contributes to enhanced quality of care and patient quality of life:
Ongoing
Program Quality Measures All visiting team members assessed pain level during each contact with the patient and ensured that the mean pain rating remained at 3 or lower on a scale of 0 to 10, where 0 was lowest pain rating. This goal has been consistently met for 96% of patients participating in the TCPC Program. The TCPC Program has continued to monitor service use for all patients. By analyzing utilization review reports, staff members routinely count 911 calls and unplanned inpatient admissions, try to explain these calls and admissions, and determine what, if anything, could have been done to prevent them. The program's performance benchmark is to reduce the total number of 911 calls and unplanned admissions to fewer than three per month per 100 patients enrolled in the TCPC Program. The TCPC team has reduced the number of these calls and unplanned admissions to a mean of two to four per month per 100 patients enrolled in the program. TCPC Program Evaluation Methods The TCPC Program was evaluated by Partners In Care Foundation, an external nonprofit health research group, to determine whether the program met the complex physical, emotional, social, and spiritual needs of chronically ill patients at the end of their lives while improving the cost effectiveness of such care. This evaluation was conducted as both a quality assurance measure and as rigorous research investigation of a breakthrough service model. The Kaiser Permanente Southern California Human Subject Protection Committee approved the study. Study
Design and Participants A total of 558 participants were enrolled in the study: 210 patients in the intervention group and 348 in the comparison group. The 73 eligible patients who declined to be interviewed were statistically equivalent in diagnosis, gender, age, ethnicity, and study group eligibility (ie, for intervention or comparison group) to study participants. To ensure that the intervention and comparison groups were comparable, data analyses were conducted among a subgroup of patients: the 298 participants who died during the two years of the study (159 in the TCPC Program, 139 in the comparison group). By selecting participants who met this selection criterion, we could compare similar groups of patients at the end of life. The place of death was also recorded for each patient. Data
Collection Service utilization data were collected from KP administrative databases. These data included number of emergency department visits, physician office visits, hospital days, skilled nursing facility days, home health and palliative visits, and hospice visits. The cost effectiveness of the TCPC model was evaluated using staff costs only.
Data
Analysis
Results of TCPC Program Evaluation High
Patient Satisfaction Our data analysis of patients who died during the study enabled us to compare place of death for intervention and comparison groups (Figure 2); significantly more patients in the intervention group died at home (87%) than in the comparison group (57%) (p < .001). Effective
Cost Management For the TCPC group, per-patient cost reduction was seen across diagnoses (range $3514 to $8293) but was significant for patients who had cancer (p = .001) or COPD (p = .02) (Figure 4). Per-patient costs for the intervention group averaged $6580 less than for the comparison group, a significant reduction of 45% (p <. 001). Because our cost-effectiveness calculation did not include fixed costs (such as building maintenance), which are higher for acute care services compared with home-based services, the cost reduction results are extremely conservative. Discussion The results of this study indicate that enrollment in the TCPC palliative care model produced lower costs of care as well as higher patient satisfaction than did enrollment in usual health care services. These findings remained highly significant even after the data were controlled for days of service, severity of illness, and having a CHF diagnosis. The primary innovations of the TCPC Program were development and implementation of a new model of health care in which services are provided to chronically and seriously ill Health Plan members over an extended period of time. Instead of patients experiencing an abrupt transition from curative care to palliative care--a situation that exists under Medicare guidelines in most care settings--the TCPC Program ensures continuity between traditional medical care and hospice care through gradual transition from a curative focus to increasing palliative measures. In addition, the KP fiscal structure--currently limited by traditional Medicare financing--was reorganized to support development of an outpatient palliative care model. Because cost savings were realized in an inpatient setting, financial support was transferred from inpatient budgets to support the TCPC home-based program. These organizational and fiscal difficulties are encountered by most Health care systems; therefore, few similarly comprehensive models of care anywhere in the United States can compare with the KP model. This study offers tremendous implications for health care. As noted in this study, the palliative care model reduced by 45% the cost of services received by patients at the end of life. Given the high cost of health care in the last year of life, this cost reduction represents tremendous savings.
In addition
to being costly, acute care at the end of life is not always preferred
by patients who are near death. The SUPPORT Investigators4
found that although most patients studied desired to die at home, about
60% of deaths occurred in the hospital, and 18% occurred in nursing homes
or hospice. In addition, many patients who receive acute care treatment
at the end of life receive aggressive and futile forms of treatment.5
Thus, the palliative care program provides an ethical alternative to traditional
end-of-life care by allowing patients an opportunity both to die without
pain and to remain in the comfort of their own home. The lower use of
emergency care, hospital, skilled nursing facility, and physician office
visits among members of the intervention group compared with the comparison
group illustrates the TCPC Program's ability to effectively transfer end-of-life
care from a high-cost, acute care setting to a lower-cost, home-based
setting that allows patients to die in the comfort of their own home.
The substantially higher satisfaction reported by patients in the intervention
group at baseline and at each follow-up--as long as 60 days after study
enrollment--supports a recommendation that care be transferred from a
hospital setting to the home environment.
The study provided the conclusive evidence needed to increase the standard of care to seriously ill KP members by integrating the TCPC model into usual care within the KP Southern California TriCentral Service Area. An unexpected benefit of the study was heightened consciousness--and acquisition--of improved end-of-life skills by physicians and other health care professionals who do not directly provide palliative care services. In addition, the TCPC team members learned not only to work together as a group but also to develop the skills necessary to plan, implement, test, and improve the quality of end-of-life care. Team members continue to use these skills as they seek further avenues for enhancing the quality of care. Our evaluation was limited by its research design; to further test this model and to strengthen the validity of the findings, randomized controlled studies are needed. In addition, the potential for generalizing this model to other sites and populations is limited because the study was conducted within a closed-system managed care organization and because the sample was drawn from the Southern California area only. Multisite studies are needed to test the ability to generalize this model to other organizational systems, populations, and communities.
Future
of Palliative Care In April
2001, the Project on Death in America (conducted by the Open Society Institute,
New York) named Dr Brumley and Ms Hillary to its Faculty Scholars Program.
This program provides national recognition to outstanding faculty and
clinicians who are working to improve end-of-life care. Dr Brumley and
Ms Hillary have developed a comprehensive "toolkit" that includes
all the support materials needed to implement the TCPC Program. To benefit
the largest professional audience possible, the toolkit is available on
the Web for general public access at: www.growthhouse.org/palliative.
Together, this multidisciplinary team contributed to success of the TCPC Program by integrating clinical, financial, service delivery, and research methods. These rigorous methods ensured ongoing success of the TCPC model and facilitated its replication within and beyond the KP system. Presentations on the TCPC Program have been delivered at professional meetings and conferences internationally. Moreover, Dr Brumley has served as faculty member--and TCPC staff participated--in an Institute for Health Improvement national collaborative on improving end-of-life care. The TCPC model has been shared with more than 200 health care teams and agencies throughout the United States. In addition, two articles6,7 have been published in professional journals, and another8 is in press. Dr Brumley has testified in Washington, DC, before a congressional subcommittee examining end-of-life health care issues. The purpose of this invitational forum was to assemble key policymakers, government officials, and leaders in health care to discuss the national implications of recent demonstration projects in end-of-life care and to determine next steps toward improving access to services and quality of care for dying Americans and their families.
To be published in a revised version as: Brumley RD, Enguidanos S, Cherin DA. Effectiveness of a home-based palliative care program for end-of-life. J Palliat Med 2003 Oct;6(5). Reproduced by permission of the publishers, Mary Ann Liebert, Inc.
a Continuing Care Services, Kaiser Permanente Montgomery Park, Portland, OR Acknowledgments The program was funded by the Garfield Memorial Fund. Funding for support material was provided by the Project on Death in America, Open Society Institute, New York. David Cherin, PhD, provided the research design, overview of the study, and assistance with data analysis. References
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