Friday, November 26, 2010

Palliative Care and Accountable Care Organizations – A Call for Comments

Accountable care organizations (ACO’s) are coming with a goal of creating a health care system that delivers higher quality care more efficiently. Important to both the palliative care community and the geriatrics community is whether our voice will be heard in developing the standards required of these organizations.  Don Berwick and his crew at CMS is now giving us the chance.

There is a special request for comments regarding certain aspects of the policies and standards that will apply to ACOs participating in the Medicare program under section 3021 or 3022 of the Affordable Care Act. The request can be found at regulations.gov under the document number: CMS-2010-0259-0001.

The dealine for comments is December 3rd, so there is little time to act. Lucky for us, Diane Meier has offered some guidance in formulating a response to three main questions posed in this call for public comments. Here are her possible talking points that you can consider putting in your comment:

Question 1: How should we assess beneficiary and caregiver experience of care as part of our assessment of ACO performance?
  • Require evaluation of patient and family goals of care, using for example POLST and advance care planning
  • Determine patient-family recall of discussions about care goals, and degree to which care actually received is concordant with goals
  • Require access to quality palliative care and Medicare-certified hospices as a condition of participation in an ACO.
  • Assess penetration of and receipt of palliative care among high need high cost patient populations across diagnostic categories.

Question 2: The Affordable Care Act requires us to develop patient-centeredness criteria for assessment of ACOs participating in the Medicare Shared Savings Program. What aspects of patient-centeredness are particularly important for us to consider and how should we evaluate them?
  • The most important aspect of "patient-centeredness" is the degree to which informed and achievable patient and family goals for care are elicited, documented in an accessible and retrievable manner, and actually followed in the care plan.

Question 3: In order for an ACO to share in savings under the Medicare Shared Savings Program, it must meet a quality performance standard determined by the Secretary. What quality measures should the Secretary use to determine performance in the Shared Savings Program?
  • Quality measures should include advance care planning; occurrence and timing of palliative care services among appropriate patient subgroups; occurrence and timing of hospice services among appropriate patient subgroups; symptom burden; patient confidence that someone on the team knows them and can be reached after hours; degree to which patients families believe they know what to expect and are prepared to handle their illness; degree to which family needs are assessed and addressed among appropriate patient subgroups

Dr. Meier makes clear that the goal of our comments should focus on making the point that an ACO must require access to quality palliative care for its sickest high need and high cost patients in order to assure that care is directed by and concordant with patient and family goals, and not by strong ACO incentives for cost containment.

We have little time to act, and action has never been easier.  Just click on the link and submit a comment.  To make your lives a little easier, the following is a draft outline that you can use in your comment:

  1. Introduce yourself as palliative medicine clinician or health professional.
  2. Define palliative care as medical care focused on best possible quality of life, delivered from point of diagnosis of serious or advanced illness whether the goal of care is cure, life prolongation, or achieving a peaceful dignified death. In practice, consists of expert assessment and treatment of symptom distress including pain, anxiety, and depression; conduct of in-depth discussions with patients and families to establish achievable care goals and a care plan that meets those goals; and commitment to continuity of care and relationships across the many care settings that seriously ill patients must traverse over the course of an illness. Palliative care includes end of life care (hospice) but is not limited to it- it is especially important among Medicare and Medicaid beneficiaries with advanced disease and/or multiple chronic conditions with functional impairment- a group who are not predictably dying and who may live for many years with a significant burden of disability and medical needs.
  3. Point out that recent studies demonstrate that palliative care and hospice care (for those in last 6 months of life) have been shown not only to improve quality of life and satisfaction with care, but also to significantly prolong life (see Alex's GeriPal post) and does so at lower cost because it helps patients stay in control and out of hospitals.
  4. The core strategy of palliative care is to help informed patients and families determine their achievable goals for care and then helping to make sure that medical care received helps patients achieve those goals.
  5. The goal of ACOs is to incent quality and not quantity and to coordinate the full range of providers. Because of ACO-associated changes in financial incentives that will reward efficiency and "doing less", the risk of undertreatment- reduced access to needed care- and consequent poor quality of care is greatest for high need high cost patients. To counter that risk, ACOs should be required to provide access to specialists trained in care of this complex high need patient population across diagnostic categories, and specifically trained in the skilled communication necessary to elicit achievable care goals throughout the course of illness. Providers with this training work in palliative care programs (mostly hospital-based) and in hospices.

Act now and comment at at regulations.gov.

by: Eric Widera (with input from Diane Meier, Alex Smith, Christian Sinclair, and Phillip Rodgers)


7 comments:

Jeanne Lahaie, GCNS-BC said...

This request couldn't come at a better time, as I sit here finishing a chapter on iatrogenesis in the care of older adults for NICHE that I am co-authoring with Deborah Francis, a geri CNS at South Sac Kaiser. Greenwood (2007) (http://www.ncbi.nlm.nih.gov/pubmed/17897166) differentiates between "patient-centered care" and the "gift of caring" in a way that we found expressed the recognition of the humanity of the older adult better than what we had seen written on patient-centered care. Here is an excerpt from our application of this concept: Nurses must distinguish between “care as discipline” and "the gift of care," defined by Fox as the relationship between the patient and the provider that is mediated by love, generosity, trust, and delight. The danger in the former lies in labeling a recipient of care who has impaired cognition as a “dementia patient,” or a patient with multiple admissions as a “frequent flier,” thus diminishing sensitivity to the humanity of the individual who is hospitalized.

"First do no harm" is not advice followed consistently in the health care community where older adults are concerned. Sadly, there is a lack of recognition that older adults are as different from middle-aged adults as pediatric patients are from middle-aged adults. One size does not fit all. That's not to say that healthy older adults cannot recover from surgery, for example, as well as their younger counterparts. But recognition of the common physiological differences (lower GFR, for example) and knowledge of medications that can contribute to delirium in older adults (ex. diphenhydramine, oxybutynin) seem to be sorely lacking.

Certainly, any hospital participating in NICHE, with nurses certified in the care of older adults, could better serve its patients aged 65 and over. In addition, the "Try This" series (http://consultgerirn.org/resources) offers many tools that can be used to assess the health status of older patients and how to involve the caregiver or family member in assessment, care, and decisionmaking.

Certainly any ASO would be well advised to coordinate care with senior-friendly community resources, such as adult day health care and senior centers. The Bayview Hunters Point Adult Day Health Center partners with physicians and NPs around the Bay Area, and it seems to help compliance with a successful plan of care as well as to resolve problems sooner rather than later. A team approach to complex problem solving like this, such as with an isolated senior having difficulty with medication management because of impaired cognition and/or financial management, can literally mean the difference between life and death. ADHC staff usually includes social workers, nurses, therapists (psychological, physical, occupational, activities, sometimes speech), financial managers (through AARP), and transportation coordinators. Some include podiatry.

To sum up, seniors' needs before, during, and after hospital discharge are often unmet for a variety of reasons. Training and resources, such as those mentioned above, can improve patient satisfaction, lower CAUTIs, and lower readmission rates, among other positive outcomes. The gift of caring can indeed have long-reaching implications.

Accunurse said...

Thanks for the information, we'll definitely be sharing this with our followers.

Alex Smith said...

I submitted a comment just now. Not enough room to get in all the points I wanted to make. So I trimmed it to what I considered the essentials. Here is what I said, feel free to borrow and modify:

I am a physician-researcher at the University of California, San Francisco. My clinical work and research focuses on the palliative care for older adults. Palliative care is a discipline of care focused on matching treatment to patient goals. The practice of palliative care exemplifies the best aspects of patient centered care, including communication skills to elicit patient and family goals and preferences, and a strong clinical foundation in attention to physical, psychological, and other sources of suffering that patients care about. Palliative care programs have been shown to save costs, and in one single institution study, to prolong life.

In my clinical practice attending on our hospital's palliative care service, I see many and perhaps most of our hospitals high need patients. Patients who have been in and out of the hospital multiple times, including the intensive care units and emergency departments. These patients are not only some of the highest need patients, in terms of goal setting and treating sources of suffering, they are also some of the highest cost patients.

I believe it is essential that palliative care be incorporated into Medicare regulations for Accountable Care Organizations (ACOs). ACOs must be prepared to care for high need/high cost patients that palliative care providers see every day. I worry that the incentives are aligned to cut costs for these patients by not providing them access to high quality palliative care services. I believe in the long run, this would lead to higher costs and worse patient outcomes. However, I also believe that without safeguards to ensure access to high quality palliative care, this period of "discovery" will be a painful learning process for ACOs, patients, and families.

Therefore, I urge you to adopt language in the Medicare Regulations ensuring that access to high quality palliative care is part of the ACO regulations.

Sincerely,
Alexander K. Smith, MD, MS, MPH

Eric Widera said...

Here is mine:

I am an Assistant Clinical Professor in the Division of Geriatrics at the University of California San Francisco, the Director of the Hospice & Palliative Care Service in San Francisco, the Associate Program Director for the Geriatrics Fellowship at UCSF, and the VA site director for the UCSF Hospice and Palliative Medicine Fellowship. The focus of my career is on improving the care of elderly patients with severe chronic and/or terminal conditions. To this end I am very interested in commenting on three of the questions posed by this call for comments.
Our current health care system suffers from many ills, one of the key aspects, especially for patients living with chronic diseases, is that our treatments do not often meet the hopes and goals that patients have. The rather new field of Palliative care hopes to rectify this by aligning the treatments we give to patients with their goals and values. This principle is central to making care centered on the patient instead of on technological advances. Important concepts within palliative care include improving how we manage the physical, psychological, social and spiritual suffering of patients. Of note, recent studies have demonstrated that palliative care and hospice care (for those in last 6 months of life) not only to improve quality of life and satisfaction with care, but also to significantly prolong life.

How can we include palliative care into the design of Accountable Care Organizations (ACOs)? Here are some comments on three main questions posed in this call for public comments:

1. How should we assess beneficiary and caregiver experience of care as part of our assessment of ACO performance?

We need to require the assessment of patient and family goals of care. There are currently well developed models in doing so including the use of the POLST form and other advance care planning documents. We need to be able to determine the patient-family recall of discussions about care goals, and degree to which care actually received is concordant with goals. We need to require access to quality palliative care and Medicare-certified hospices as a condition of participation in an ACO. We also need to assess penetration of and receipt of palliative care among high need high cost patient populations across diagnostic categories.

2. The Affordable Care Act requires us to develop patient-centeredness criteria for assessment of ACOs participating in the Medicare Shared Savings Program. What aspects of patient-centeredness are particularly important for us to consider and how should we evaluate them?

The core principles of "patient-centered care" are also those of palliative care. It is vital that informed and achievable patient and family goals for care are elicited, documented in an accessible and retrievable manner, and actually followed in the care plan.

3. In order for an ACO to share in savings under the Medicare Shared Savings Program, it must meet a quality performance standard determined by the Secretary. What quality measures should the Secretary use to determine performance in the Shared Savings Program?

Quality measures must include measures of whether current treatments meet patient's goals for their care. These include documentation of advance care planning; occurrence and timing of palliative care services among appropriate patient subgroups; occurrence and timing of hospice services among appropriate patient subgroups; symptom burden; patient confidence that someone on the team knows them and can be reached after hours; degree to which patients families believe they know what to expect and are prepared to handle their illness; degree to which family needs are assessed and addressed among appropriate patient subgroups .
ACOs must be prepared to care for high need/high cost patients. Palliative care can help.

I hope these recommendations will ensure high quality palliative care will be an integral part of the ACO developement plan.

Eric Widera said...

Turns out there is not a lot of room. I made a short version (see below) and also attached a document that include the full version.

"I am a physician at the University of California San Francisco. My focus is on improving the care of elderly patients with severe chronic and/or terminal conditions. To this end I am very interested in commenting on three of the questions:
1. How should we assess beneficiary and caregiver experience of care as part of our assessment of ACO performance?
We need to require the assessment of patient and family goals of care. There are currently well developed models in doing so including the use of the POLST form and other advance care planning documents. We need to be able to determine the patient-family recall of discussions about care goals, and degree to which care actually received is concordant with goals. We need to require access to quality palliative care and Medicare-certified hospices as a condition of participation in an ACO. We also need to assess penetration of and receipt of palliative care among high need high cost patient populations across diagnostic categories.

2. What aspects of patient-centeredness are particularly important for us to consider and how should we evaluate them?
It is vital that informed and achievable patient and family goals for care are elicited, documented in an accessible and retrievable manner, and actually followed in the care plan.

3. What quality measures should the Secretary use to determine performance in the Shared Savings Program?
Quality measures must include measures of whether current treatments meet patient's goals for their care. These include documentation of advance care planning; occurrence and timing of palliative care services among appropriate patient subgroups; occurrence and timing of hospice services among appropriate patient subgroups; symptom burden; patient confidence that someone on the team knows them and can be reached after hours; degree to which patients families believe they know what to expect and are prepared to handle their illness; degree to which family needs are assessed"

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