Wednesday, March 5, 2014

“Honoring Choices” in PACE programs

This is the way it went: a group of familiar faces, some family, some professional care providers, gathered around the man's bedside and talked about his preferences. Aspiration pneumonia or not, he didn't want the feeding tube, and was sick of going to the hospital, so for the next episode of pneumonia, could he please just be treated at home? Notes were made, the decision was repeated aloud to get everyone on the same page, and the preference became the plan. The decision became the default.

This is news because we know the usual defaults in health care run more like this: Panicked relative: "He's getting so sick - shouldn't he be in the hospital?" By-the-book emergency department physician, "Well, I can't send her home like this, can I?" Social worker in hospital, "With so many patient needs, you really ought to consider a nursing home."

Community Life, a Pittsburgh-area provider of comprehensive geriatric care under the Medicaid PACE model (Program for All-encompassing Care for the Elderly), is changing the default settings for their clients by "Honoring Choices."

“Honoring Choices” is the title of a Community Life quality improvement program that addressed a vexing problem that they encountered over and over again. The program’s success was recognized by The Fine Foundation, Jewish Healthcare Foundation and the Pittsburgh Regional Health Initiative with a bronze award at the recent Fine Award for Teamwork Excellence in Care at the End-of-Life.

Community Life provides a type of integrated care of which most patients can only dream, serving as PCP, insurer, pharmacy, physical and occupational therapy, home care provider and adult day care rolled into one. The integration even extends to the interdisciplinary team meetings, where the patient is at the table and essentially running the meeting. With this level of integration and patient-centeredness, high levels of satisfaction and consistency between patients' stated wishes and actual care delivered should be routine, right?

Unfortunately, the actual data didn't bear this out; pain management satisfaction scores, overall satisfaction and rates of patients dying in inpatient acute care were all falling short of stated goals. People who had made clear choices like the man in the first paragraph were ending up in the exact situation they had hoped to avoid. The last was a particular concern; if there is one wish that has been consistent across every end-of-life survey going back to the SUPPORT study in the 1990s, it is that people do not want to die in the hospital. Integrated care is supposed to help fix that problem - so what went wrong?

“Honoring Choices” was about Community Life trying to get to the bottom of this problem and set it right. What they discovered was that the loop of communication wasn't closing - the patients may have stated their wishes, and the Community Life physicians may have heard them and recorded them, but when a patient got sick after hours or a family member became acutely concerned about their health, they went to the emergency room. Once there, a series of physicians (emergency, "moonlighter" admitting patients to the hospital, hospitalist attending and occasionally even an intensivist) who were not around the table when that compact was made were making decisions, without benefit of knowing the "plan." The acute episode wasn't usually discussed by Community Life staff until the next morning, by which time the wheels were often turning in the hospital - often without anyone communicating with the Community Life physician about it first. At discharge, the instructions given to the patient and family often didn't make it into the hands of Community Life staff - setting up the patient to "bounce back" (to the hospital, not to their previous state of vigor).

“Honoring Choices” prioritized using alternative care settings - home care, nursing facility, hospice - wherever appropriate ‒ instead of the hospital. To quote Community Life medical director Emily Jaffe, "Good care and judicious use of resources are not mutually exclusive." Doing so meant codifying closed-loop communication into the way Community Life delivers care to every patient: immediate notification of Community Life MDs when one of their patients is admitted to the hospital; daily, direct doctor-to-doctor communication between Community Life and the hospital physician; daily conference calls between hospital staff and Community Life staff for the purposes of setting daily goals and goals for discharge; continual reassessment of the best location to provide care for that patient, including early Palliative Care and timely hospice referrals where appropriate; ordering of meds, DME and home care 24 hours before discharge; Community Life follow up within 24 hours after discharge; and integration of advance care planning, review of POLST documents and other related conversations as an express agenda item in the post-acute follow-up visit. The conversation in the opening paragraph grows out of this kind of follow-up meeting, which asks the question, "Well, that was awful - how do we keep that from happening again?"

This is a 21st century problem. Community Life addressed it using a 19th century instrument - the telephone - and an intervention as old as homo sapiens - conversation. Lots of it. Coupled with systematic, pro-active management, Community Life has managed to get their inpatient death rates down, hospice utilization up, and both overall satisfaction and specific satisfaction with pain management up compared with pre-intervention data.

by: Dr. Jonathan Weinkle, Squirrel Hill Health Center and a Jewish Healthcare Foundation (JHF) consultant,

Note: “Honoring Choices” is just one example of what this year’s Fine awards set out to demonstrate: namely, that if quality healthcare is marked by teamwork, attention to detail, and striving to deliver care that works to every patient, that quality should follow patients throughout their lives including during the days, weeks and months that make up the “last chapter” of their life story. Every other aspect of care – orthopedics, bariatrics, long-term care, and prevention – is today focused on helping patients live their best life, their way. This year’s awards are focused on those who are helping people live their final days the best they can, on their own terms.

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