Palliative care is “values-based care”
Catherine Follmer, RN, BSN, MBA/HCM, is Mercy Health’s Vice President of Care Continuum
Mark Binstock, MD, MPH, is Mercy Health’s Associate Medical Information Officer
This is a typical change management story in many ways. It involves organizational, cultural and practice workflow change. The thing that makes this story different is that it involves an issue that, even in the science-minded, clinical world, is emotionally charged: End-of-life care.
We are a Catholic healthcare ministry serving Ohio and Kentucky. With more than 34,000 employees in seven markets, we’re the largest healthcare system in Ohio. Our stated, organizational values include the sacredness of life. Those values also include compassion and human dignity. To us, palliative care sits at the intersection of all those values.
Attitudes about palliative care
When we evaluated the care we were providing to the sickest among our patients, we saw an opportunity to improve quality through palliative care.
We define palliative care as a journey that can include treatment, but that focuses on relief of pain and suffering. However, even among experienced providers, there were some who equated palliative care with hospice – with a proverbial, “I give up, illness wins.” So, we have our work cut out for us to establish, advocate for and institutionalize a palliative care program.
Variation in palliative care
When we first tackled this challenge in 2006, we discovered at least seven different palliative programs across our system, each program at a different level of maturity. We quickly realized that the key to standardization was going to be data — credible, actionable data. So in 2012, we implemented an electronic solution with an embedded Gagne Index feature.
The Gagne Index calculates a patient’s risk of mortality in the upcoming twelve months. We initiated an ongoing educational campaign to assure our providers that this index is a validated tool that will help them deliver effective care. We explained that through our analytics solution, our claims and clinical data combine to inform the Gagne Index, resulting in a credible Gagne score.
The Gagne Mortality Score is designed to be used with populations age 65 and older. So while our goal is to look at all the populations in our care, we started with a focus on our two at-risk programs – Medicare Advantage and Medicare Shared Savings Program (MSSP).
Our Chief Quality Officer’s approach is to enable our primary care providers to have meaningful discussions with patients about palliative care, rather than hiring additional palliative care staff. We’ve made a considerable effort to educate our primary care teams about how to leverage the score to identify patients for follow up and how to approach these discussions with patients. We’re also working to provide support to primary care physicians, so that a palliative care nurse, an RN, care coordinator and/or a social worker, can be part of that conversation with the patient if needed.
Our efforts have been bolstered by the Centers for Medicare & Medicaid’s decision to reimburse for advanced care planning conversations with patients, but we found that reimbursement alone isn’t as meaningful to providers as the evidence based Gagne score.
Transparency’s role in palliative care
There’s no question that our providers and their patients needed more education about the role and value of palliative care. We’ve had some growing pains along the way. For example, our analytics tools include alerts that display to providers when Gagne scores are high. In these alerts, we used the term “one-year mortality” rather than Gagne. We have “open notes” sharing of labs with patients. And in one of our regions, the provider workflow was such that patients and providers shared a view of the chart during visits, so patients saw their one-year mortality alerts on the screen at the same time the providers did. This spurred debate among providers who wanted to soften the wording or adjust the workflow to protect the patient from that information. But equally vocal was the other side saying we need to be transparent about a patient’s risk of dying. So, we have collaborated with teams and sites to reduce variation, while also honoring different practice styles.
We expect the health havoc wreaked by the opioid epidemic to increase the need for palliative care, and as such we expect to expand our services (while also striving to address this epidemic through prevention and treatment).
Technology’s role in palliative care
The ability to pull data from our electronic health record and integrate the Gagne Index into our advanced analytics has given us a critical tool to prospectively identify patients who may benefit from a change in their care plan. We look forward to the evolution of artificial intelligence that unearths additional insights, and incorporates them into the provider workflow, offering a more sophisticated risk score and further supporting patient-centered clinical decision making.
For example, a recent Stanford University pilot program leveraged a deep learning predictive algorithm, which enabled the palliative care team to proactively engage in care, rather than waiting for referrals. We see the potential value of this shortened timeline to effective care. However, given our own experience, we also see the need for significant culture conditioning required to help primary care physicians feel comfortable with an algorithm that removes referral to specialty care.
Values-based care
Partnering with the provider, patient, and caregivers to objectively consider the need for adding palliative care early in the patient’s treatment plan can be an effective population health strategy, leading to improved decision making and patient management.
In 2017, we performed a small analysis of 2,245 patients who had passed away and had met at least one of the diagnosis criteria we had identified as appropriate for palliative care. Those patients received a palliative care order more than 120 days before death. In our analysis, we saw a $400 reduction in per member per month payments for those patients in palliative care.
In 2018, Mercy Health will measure our patient population greater than age 65 who have had an advance directive – specifically, we’ll evaluate the cost and quality of care received by patients with chronic obstructive pulmonary disease or chronic heart failure who had a Gagne score that led to a palliative care consult and an advanced care plan.
We are also in the process of developing a palliative care dashboard to assess changes in practice patterns. In particular, we are monitoring and promoting the use of advanced directives among all patients age 65 and over and in particular among those with higher Gagne scores. In addition we are expanding the use of all of these tools beyond our MSSP population.
Value-based care is generally defined as higher quality at lower cost. Values-based care aims to achieve those same goals, but through a process that considers and applies the values of your organization, your providers and your patients. Our goal is to create a values-based palliative care program, and through the use of both data and careful culture conditioning, we are getting closer to achieving our goal.
For more information, including a five-step checklist to assess your organization’s palliative capabilities, download this whitepaper: Driving compassion and value at the end of life.
