Maine Cancer Consortium – Palliative Care Steven L. D’Amato BSP, BCOP Executive Director, Maine Center for Cancer Medicine S Introduction S Present system objectives and goals for an advanced palliative care program S Discuss quality outcomes and measures that can be derived from an integrated system Palliative Care S Definition S Palliative care is both a philosophy of care and an organized, highly structured system for delivering care to persons with lifethreatening or debilitating illness. S Palliative care is patient and family-centered care that focuses upon effective management of pain and other distressing symptoms, while incorporating psychosocial and spiritual care according to patient/family needs, values, beliefs, and culture(s). Palliative Care S Goal S The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of disease and the need for other therapies. S Palliative care can be delivered concurrently with lifeprolonging care or as the main focus of care. Palliative Care Standards (1/2) S Institutions should develop a process that ensures all patients have access to palliative care services from the initial visit. S All cancer patients should be screened for palliative care needs at their initial visit, at appropriate intervals, and as clinically indicated S Patients and families should be informed that palliative care is an integral part of their comprehensive cancer care. Palliative Care Standards (2/2) S Educational programs should be provided to all healthcare professionals and trainees so that they can develop effective palliative care knowledge, skills, and attitudes. S Skilled, palliative care specialists and interdisciplinary, palliative care teams should be readily available to provide consultative or direct care to patients/families who request or require their expertise. S Clinical health outcomes measurement should include palliative care domains. S Quality of palliative care should be monitored by institutional quality improvement programs. NCCN Guidelines Version 2.2011 Palliative Care Palliative Care Evidence S There have been two recent studies published, one by Bezjak and another by Temel, that demonstrate that individuals diagnosed with Stage IV lung cancer treated with chemotherapy and an organized program of palliative care and symptom control achieved longer survivals than those treated with chemotherapy alone and no intervention from a palliative care consultant. Bezjak A et al. J Clin Oncology 2006;24:3831-7. Temel JS et al. NEJM 2010;363:733-82. Palliative Care Reduces Expenditures Mean direct costs per day for palliative care patients who were discharged alive (A) or died (B) before and after palliative care consultation Morrison, R. S. et al. Arch Intern Med 2008;168:1783-1790. Copyright restrictions may apply. Palliative Oncology S More than 1.5 million people diagnosed with cancer in 2010 S 0.5 million died of the disease S Patients are referred too late to derive the benefits from comprehensive palliative care S Administration of chemotherapy late in the course of cancer care, including the last days of life is becoming more common An Organized Palliative Care Program Will Be A Critical Component to the Development of an Oncology Centered Patient Medical Home S Optimize patient outcomes in terms of prolonging survival and patient QOL S Optimize patient outcomes in terms of preparing them in appropriate time frame for the eventual failure of modern oncolytics to control their disease S Optimize informed delivery of oncolytics to patients based upon true measurements of treatment successes S Partner with the patients to make ethical decisions regarding the use of medical technology/pharmaceuticals as disease progresses The Five Questions S Who do you want to make health care decisions for you when you can not make them? S What kind of medical treatment do you want or not want? S How comfortable do you want to be? S How do you want people to treat you? S What do you want your loved ones to know? The Big Six 1. Staging 2. Intent of therapy 3. Adverse event grade 4. Disease status 5. Patient status 6. Line of therapy Palliative Care at MMC S Inpatient program – consulted for management of pain and other symptoms, emotional distress, end of life consultation regarding DNR and choices, site of hospice services (e.g. home vs Gosnell House) S Outpatient program – intended to partner with physicians and other clinicians to co-manage patients with terminal illness in an outpatient setting MMC Outpatient Palliative Care Clinic has Challenges with Broad Integration into the Management of the Oncology Patient in the Outpatient Setting S Meets 1 day per week (may be changing) S Introduces a new “team” of care providers to a patient that already closely identifies with their primary medical oncologist S Possible confusion regarding who is managing what problem S Who does the patient call after hours when there is a problem with medication S Management of the shear volume of terminally ill patients MCCM is in the Process of Developing an Outpatient Palliative Care Program (1/2) S A dedicated physician has been hired with the following responsibilities: S Teach all physicians, RNs, and midlevel providers about effective palliative care and keep the entire practice updated on the newest developments in this field S Maintain and update all QOPI indicators on palliative care at all sites S Coordinate outpatient care with each hospital’s inpatient palliative care program MCCM is in the Process of Developing an Outpatient Palliative Care Program (2/2) S A dedicated physician has been hired with the following responsibilities: S Provide palliative care consultations to MCCM patients S Work in conjunction with the patient’s MCCM team to execute and optimize the plan of care S Develop tools in OncoEMR (Altos) to effectively measure outcomes of palliative care intervention Vision of an Integrated Palliative Care Program S MCCM/MMCCI integration of palliative care efforts S Education of providers S Develop tools for clinicians, patients, and families S Develop a systems-based approach to care S Measure quality indicators S Improve primary care knowledge, skills, and practice behavior S Palliative care documentation and integration of electronic systems S Coordination with hospice programs Eight Domains of Palliative Care (NCP and NQF) 1. Structure and processes of care 2. Physical aspects of care 3. Psychosocial and psychiatric aspects of care 4. Social aspects of care 5. Spiritual, religious, and existential aspects of care 6. Cultural aspects of care 7. Care of the imminently dying patient 8. Ethical and legal aspects of care Palliative Care Efforts and Alignment with NCCP Goals S MMCCI commits to continue its palliative care initiatives aimed at increased integration into the cancer program, including referrals to hospice. S Through these efforts we aim to improve one or more categories on the NCCCP Palliative Care Matrix Assessment Tool by at least one Level during year 3 of funding. QOPI 2012 S MCCM/NCCCP QOPI Certification for 2012 S Interim spring 2012 report S QOPI Certification Overall Quality Score Required: 72.62% S MCCM QOPI Score: 85.33% S Minimum Adjuvant Measure Score needed: 80% S MCCM Adjuvant Measure Score: 93.88% QOPI EOL Measures (1/2) S Pain assessment S Pain Intensity S Plan of care for moderate/severe pain S Pain addressed appropriately S Dyspnea assessed QOPI EOL Measures (2/2) S Dyspnea addressed and addressed appropriately S Hospice enrollment (7 different measures) S Hospice enrollment or palliative care referral services S Chemotherapy administered within the last 2 weeks of life Integration Leads to Better Care S Five areas where integration is critical to optimize management S Symptom management S Transitioning from disease-focused care to palliative care S Discussing goals of care and advance care planning S Community care S Psychosocial support for patients and families Summary S Palliative care is a critical component of overall cancer care S Education and development of system wide resources is necessary for an effective program S Implementation of a comprehensive palliative care program will result in better patient outcomes, improved quality of life, and reduce healthcare expenditures.