Clinical-Care Improvement Programs (Vol.2)
End of Life Care Initiative
Community Care consultant Jonathan Fischer, MD, is hoping to meet with networks about End of Life services and resources across the state. Specifically, Dr. Fischer would like to meet with individual networks to provide the groundwork for the formation of various CCNC pilots in End of Life Care, and he is willing to attend upcoming network management, chronic care management, or network provider meetings in CCNC networks.
Under Dr. Fischer's project, Community Care is seeking to investigate possible pilot programs in End of Life, including initiatives that:
- Increase access to palliative and hospice care by an interdisciplinary team of skilled palliative care professionals, including, for example, physicians, nurses, social workers, pharmacists, spiritual care counselors, and others who collaborate with primary healthcare professionals.
- Enable patients to make informed decisions about their care by educating themselves on the process of their disease, prognosis, and the benefits of potential interventions.
- Develop health care and community collaborations to promote advanced care planning and completion of advance directives for all individuals.
- Make advance directives and surrogacy designations available across care settings.
Dr. Fischer, a Family Physician with the Carrboro Community Health Center, part of Piedmont Health Services, says, 'While advances in medical treatment have changed most causes of death into chronic conditions, our care systems have not adapted to serve those patients nearing the end of life.' He added, 'The availability and quality of health care for those nearing the end of life is largely thought to be unreliable and lacking.'
Patients with chronic illness are living longer, and patients living with long-term disabilities are more common. By 'reconceptualizing dying and end of life care,' Dr. Fischer believes practices can better utilize advanced directives and palliative care services for those with chronic disease. He also recognizes that one barrier to enhanced care is Medicare's restrictive hospice benefit. He is looking to interview leaders in local CCNC networks to discuss these and other issues relating to End of Life Care.
Chronic disease, while potentially challenging for a patient, their families and care providers, presents an interval of opportunity to introduce an end of life focus, he says. Effective treatment and support strategies include advance care planning, symptom relief, and attention to spiritual and family matters, and these strategies can emerge from a patient-centered approach to chronic disease management.
Dr. Fischer cites several national examples of collaboratives that improve the quality of End of Life Care, including those sponsored by the Institute for Healthcare Improvement and the Center to Improve Care of the Dying. Innovations have included the creation of new services, as well as the integration and strengthening of existing services. In one noteworthy example, the Franciscan Health System in Tacoma, Washington, asked physicians to identify high-risk patients and then gave those patients 'prehospice services' through palliative care, pastoral care and volunteers. Patients receiving earlier intervention used fewer hospital days, more died outside the hospital, their satisfaction with care was higher, and they used hospice care for more days before death than did a matched set of patients without special supportive services.
To make such improvements of care financially viable, the challenge remains to identify interventions that reduce the use of truly avoidable and unnecessary services such as repeated hospitalizations, while simultaneously enhancing the overall quality and access to care.
In meeting with networks, Dr. Fischer is seeking to learn more about community frustrations with the lack of resources or other barriers to quality End of Life Care. Please contact him to discuss these important issues further. Contact Jonathan Fischer, MD, at fischerj@piedmonthealth.org, or by phone at (919) 942-8741.
Networks Provide Transitional Care from Hospital to Home
Community Care networks are leading concerted efforts to provide Transitional Care that is improving outcomes for patients transitioning from the hospital after an acute illness. Two networks are highlighted below.
Community Care Plan of Eastern Carolina has been piloting a concentrated transitional care effort since last December. Following the lessons learned from the Chronic Care pilot in Bertie two years ago, Linda Jenkins, one of four project coordinators for the 27-county network, said network leaders believe their greatest chance for significant cost savings can come from focusing on hospital care and the transition of patients to their homes. With a focus on education, the network has case managers in five of the 18 hospitals in the network, which is the state's second-largest Community Care network. Those case managers review medications and eliminate redundancies, as well as review charts with the primary care provider. 'The hospital discharge is the best chance to change habits,' Jenkins said, and case managers look for those 'teachable moments' to improve patient compliance and patient self-care. Having real-time access to hospital data has proven critical to success with transitions to the home setting for these case managers and their patients.
In another large network, the seven-county Sandhills Community Care Network has six case managers who are hospital liaisons, visiting patients while they are hospitalized and having remote access to hospital data for those patients who are transitioning to home following a hospital stay. The network has seven hospitals in its region, ranging from FirstHealth Moore Regional with more than 300 beds to smaller 20-25 bed hospitals in rural counties. Tammie McLean, RN, Network Director, thinks this established hospital-to-home link makes them 'strategically more ready for the 646 waiver' to manage the care of the dual eligible patients in their network. Three of their counties - Hoke, Moore and Montgomery - are part of the initial 26 counties included in the 646 waiver. Hospital leadership has proven important to their success, as they have been willing to share data and support the network's efforts. Once the patient is released from the hospital, the case manager works to reconcile the various data, especially the medication list, and send it on to the primary care provider. The real obstacles have come from how to share data since hospitals do not want patient data printed in order to ensure privacy. McLean and her case managers have set up multiple computer screens so that case managers can accurately copy data from one screen (from the hospital data source) onto the network provider's database. Lisa Chase, the network's Chronic Care project coordinator, says this multiple screen approach has saved not only paper, but also improved accuracy, by allowing case managers to have multiple screens up at the same time.
Transitional Care also can be a key in cutting pharmacy costs in Medicaid. Case managers can make sure patients are on medications on Medicaid's Prescription Advantage List whenever possible.
State Employees Health Plan
Community Care has met with State Health Plan (SHP) leadership to identify potential opportunities for working together. SHP is interested in re-engineering their support services to be able to better support patients and physicians in a coordinated fashion and within the community. Since most of the physicians are also part of Community Care, they are interested in engaging the CCNC infrastructure in this effort. They seemed open to exploring a pilot project or in having NCCCN bid on the RFP either alone or in partnership with other groups. They provided some data on the plan and its members.
On October 14th, SHP issued the RFP for Population Health Management Services that would support the PCMH model of healthcare delivery and the Collaborative Care model for members with chronic disease. In addition to providing the standard array of disease and case management services through telephonic interactions, the contractor will provide support for primary care providers, provider groups or networks to assume or direct disease and case management activities for Plan Members locally. Bids were due December 15th, 2009. Community Care has participated with three bidders.
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