Palliative Consideration Benchmarking: Timing is Everything.


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Mount Carmel Acute Palliative Care : Initial Vision. Ideal agony and indication administration ... MC Acute Palliative Care: Interdisciplinary administer to truly sick ...
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Palliative Care Benchmarking: Timing is Everything Mary Ann Gill, RNMA Executive Director, Palliative Care Services Project Manager, Palliative Care Leadership Center mgill@mchs.com

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Presented at Recovering Our Traditions II—Journey to Excellence A Catholic Health Care Perspective On End-of-Life Care January 26-28, 2006 San Antonio, Texas

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Sponsored by S upportive C will be C oalition Pursuing Excellence in Palliative Care Catholic Health Association of the United States The George Washington Institute for Spirituality and Health

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Outline Palliative Care: Mount Carmel\'s history and development Infrastructure, Models Strategies to accomplish Quality Establishing Benchmarks

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Mount Carmel : Multi-Hospital System with Vertical Integration Serving Columbus, Ohio, for >125 years Three doctor\'s facilities - 53,000+ inpatient confirmations Care Continuum- - Hospice, Homehealth, + College of Nursing, Medical Education ASC\'s and UCC\'s Owned Physician Practices Medicare +Choice Product Member, Trinity Health System

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Mount Carmel Health System Table of Organization and APCS

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The Mount Carmel Hospice Operating subsequent to 1985 Established nearness in wellbeing framework Initiated cooperation re: framework wide agony administration program in 1994 Historic nearness in doctor\'s facility morals boards of trustees Focus of Hospice – care at home

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Mount Carmel Palliative Care Services Palliative Care Hospice Acute Palliative Care Consult Service APC Units

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Mount Carmel Acute Palliative Care : Initial Vision Optimal torment and manifestation administration (physical, passionate, otherworldly) for hospitalized patients with ceaseless propelled illnesses Competent reaction to patient mandates, decisions Timely exchanges from ICU, ED, SNF Concurrent sickness centered treatment + palliative consideration Effective Continuum to Hospice

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Strategy: Understand Chronic Disease Chronic infection is constant with long winded keenness Chronic ailment devours 78% of social insurance uses Characterized by moving seriousness, pace, setting, and treatment So multifaceted must include IDT, care coordination Must have the capacity to mesh the consideration of masters into the general arrangement

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Background : Hospitals\' Current Challenges More incessantly sick patients frequently burning through 10 or more days in ICU Many DRGs spread half cost of ICU, yet advertise presses for more ICUs Boutique clinics drawing in patients Hospitalists supplanting Primary Care doctors Increasing quantities of uninsured or Medicaid

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Background: Hospital Survival Strategies Reduce variable expenses Reduce LOS (particularly ICU) Increase Physician Satisfaction Increase Patient Satisfaction Meet Healthcare report card benchmarks and turn out to be "best doctor\'s facility "

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Background: Hospice and Homehealth Realities and Survival Strategies Earlier referral Appropriate Hospital Discharge Plan Access to patients in doctor\'s facility to arrange affirmation Increase LOS to give care and spread costs Advance Care Planning process set up Adherence to model

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Background: Sources of Evidence SUPPORT Study Dartmouth Studies National Concensus Project, JCAHO

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Background: SUPPORT Recommendations Create palliative consideration in doctor\'s facilities interdisciplinary group process patient and family center torment and side effect administration center prepared access to Palliative Professionals

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Background: Why Palliative Care Is Needed in Hospitals Chronically sick patient volume projections Hospitals battling with how to deal with this populace re: LOS, asset use >50% patients bite the dust in doctor\'s facilities = doctor\'s facilities ought to be most prominent wellspring of Hospice referrals Hospitals need to import Hospice worldview to make powerful administration of unending malady and in-doctor\'s facility mortality.

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Strategy: Articulate a Vision Optimal torment and manifestation administration (physical, passionate, profound) for hospitalized patients with incessant propelled illnesses Competent reaction to patient orders and decisions Timely exchanges from ICU, ED, SNF Concurrent oncology treatment and palliative consideration Seamless continuum to group

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Strategy: Clearly Define Terms Hospice Care: Interdisciplinary look after biting the dust understanding with unsurprising anticipation; likewise for family– otherworldly, enthusiastic backing - basically in home setting including loss bolster MC Acute Palliative Care: Interdisciplinary nurture truly sick patient with unusual forecast amid intense hospitalization ; otherworldly/enthusiastic backing for patient/family; simultaneously planning for development or decay/demise

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Strategy: Use Hospital information to decide Need 5% Hospital Admissions yearly Top 20 DRGs bringing about death Readmission rates inside 6 months Number of SNF patients entering ED ICU passings post 5 day LOS

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Strategy: Define Program In-Patient or Out-pt Consult Service? Units? Upstream or End of Life? Managerial Responsibility Location Staffing Routine, Standard Processes Continuum Partners

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Strategy: Describe Tools Needed Standard confirmation requests and criteria Rounds Worksheet Procedures: e.g. Palliative Extubation Educational materials Staff/Students/doctors Patient/family Data Base

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Strategy: Define Routine Processes Interdisciplinary Team Functionality (group rounds, IDT gatherings) Palliative Consultation-doctor, medical attendant clinician parts in coordination, tutoring Intensive torment/manifestation administration/conventions IDT training, competency improvement Data accumulation, examination, criticism Continuum interface

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Strategy: Employ forms for Palliative Chronic Disease Management Care Coordination crosswise over settings Education of patient to decipher indications to group and to give self administration Adaptation by all to changing part of doctor (cardiologist to palliative doctor and group) Emphasis on behavioral systems to comprehend effect of unending illness Problem : None of this is standard in ceaseless infection administration Holman,H. JAMA September 1, 2004, vol 292, no. 9

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Strategy: Differentiate PatientTypes Patients with fuel of interminable sickness who pick palliative life-amplifying treatment Patients getting infection coordinated treatment who may profit by vindication of sx emerging from malady or treatment Patients with genuine, life-restricting ailments for whom hospitalization regularly segue into Hospice Patients with intense occasion, for example, CVA

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Strategy: Determine Referral Source, Criteria, Process, and Management ICU Physicians and Staff ED Physicians and Staff Oncology Physicians and Staff Nephrology Physicians and Staff Case Management Staff Hospitalists Physicians

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Strategy: Create a Palliative Care Continuum Presence/joint effort - healing facility Ethics panels and meetings Develop instruments which bolster continuum- - Develop procedures to recognize continuum patients who enter doctor\'s facility through Emergency Department Explain/Understand Reimbursement consequences fo all accomplices

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Strategy: Build Rapid Cycle, "Natural Quality Processes & Importance of Timing Patient, family, doctor, PC Team decide care arrange simultaneously Plan checked day by day for legitimacy by the palliative consideration group Benefits/weights of treatment measured day by day Plan Changed quickly if showed Family bolster continuous and into loss Discharge arranging started on section

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Strategy: Define Relevant Data Patient demographics Clinical Characteristics Functional status Diagnosis Advance mandate status at time of counsel Presence and timing of DNR requests Pain and different indications Evidence-based Interventions In-doctor\'s facility and ICU passing rate and length of stay Discharge destinations, - hospice, homehealth, SNF, home referrals Readmission Rates

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Outcomes New patients, all patients served Total Admissions to APCUs Most Frequent Symptoms % Cancer/Non Cancer ALOS on APCU or Consultation % from ICU, IMCU ALOS in earlier unit P/F Satisfaction (HCAHPS) "Would you prescribe?"

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Data Cont\'d PPS CMI Variable Cost Savings Contribution to Overhead % exchanged to hospices Hospice ALOS

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Delineate Clinical Benchmarks Accessible, master Advance Care Planning starts at beginning counsel Assessment of patients\' requirements for powerful agony/manifestation administration at every experience Provision of Interdisciplinary mitigation for patients and families inside unequivocal time allotments - Timely exchange of patients from ICU and ED into APCS; from APCUs to Hospice & to different suppliers

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Sample: Diagnosis Types Primary Diagnosis % Cancer 38.6% Non Cancer 61.4% Cardiac 17.0% Pulmonary 15.3% CVA 9.6%

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Sample: Discharge Destinations Continuum (48% Discharged) Hospice Home Hospice 25.2% ECF Hospice 8.8% ECF-Skilled 7.1% Homehealth 3.7% Other 3.9%

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Hospital Reimbursement Basics Medicare Prospective Payment System Major Disease Categories Diagnosis Related Groups Case Mix Index Comorbidities and inconveniences Expected Costs and Expected Payments Based on Bell Shaped Curve Utilization

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Hospital Reimbursement Variables Principal Diagnoses mapping to DRG Co-morbidities & Complications impact installment Impact of Palliative Consultant and Attending Physician Documentation on DRG MedPac Report to the Congress: Medicare Payment Policy March, 2002

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Hospital Costs & Rev versus LO

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