Evolution & Maturation of the Practice of Hospice and Palliative Medicine

Charles F. von Gunten, MD, PhDCharles F. von Gunten, MD, PhD

May 16, 2013

Vice President, Medical AffairsHospice & Palliative Care

Value Equation

Value

Quality

Cost=

‘Excellent’ Quality of Care

Teno et al JAMA 2004;291:88-93

per

cen

t

Outcomes in Last Place of Care

Teno et al JAMA 2004;291:88-93

n = 1578

per

cen

t

Cost

• Significant Savings with Hospice Care as compared with no hospice care.

– 1-7 days; $2,650

– 8-14 days: $5,040

– 15-30 days: $6,340

– 53-105 days: $2,561

Kelley AS et al Health Affairs 2013;552:561.

Inescapable conclusion

• Referral for hospice care is expected outcome when death is expected.

• Quality measure

• End of ‘choice’ for hospice care

• Analogy of hand-washing

90% of Americans die of Diseases of ‘chronic illness’

• Heart Failure

• Cancer

• Emphysema / COPD

• Stroke

• Dementia

• Diabetes mellitus

England vs USEngland vs USConvergent EvolutionConvergent Evolution

• Inpatient UnitInpatient Unit• Home care teamsHome care teams• Consultation Consultation

ServicesServicesHospitalHospitalAmbulatoryAmbulatory

• Formal training & Formal training & recognitionrecognition

• Health System Health System StandardsStandards

• Home Care TeamsHome Care Teams• Inpatient UnitsInpatient Units• Consultation Consultation

ServicesServicesHospitalHospitalAmbulatoryAmbulatory

• Formal training & Formal training & recognitionrecognition

• Health System Health System StandardsStandards

Conventional Care

PresentationPresentationPresentationPresentation DeathDeathDeathDeath

Anti-disease TherapyAnti-disease TherapyAnti-disease TherapyAnti-disease Therapy

BereavementBereavementCareCare

BereavementBereavementCareCare

6m6m6m6m

Hospice Hospice CareCare

Hospice Hospice CareCare

Conventional Care

PresentationPresentationPresentationPresentation DeathDeathDeathDeath

Anti-disease TherapyAnti-disease TherapyAnti-disease TherapyAnti-disease Therapy

BereavementBereavementCareCare

BereavementBereavementCareCare

6m6m6m6m

Palliative Palliative CareCare

Palliative Palliative CareCare

Palliative Care

Palliative Care

Therapies to modify disease

Hospice Medicar

e Benefit

Presentation Therapies to

relieve suffering and/or improve quality of life

Bereavement Care

6m Death

Palliative Care

Std + Palliative Care = 3 Prolonged life 3 months

2010

Benefits of Early Palliative Cancer Care

Survival• Longer

• Better

• Understanding prognosis

• Goals of care

Less IV chemo in last 60 days

Quality of Life• Improved mood

ASCO Recommends… Concurrent palliative care

for seriously ill cancer patients– from the beginning

2012

Clinical Palliative Care

ConsultationConsultationServicesServices

ConsultationConsultationServicesServices

InpatientInpatientCareCare

InpatientInpatientCareCare

HospiceHospiceHospiceHospice

Ambulatory Ambulatory & Home Health& Home Health

Ambulatory Ambulatory & Home Health& Home Health

SNFSNFSNFSNF

Not-for-profit, faith-based health systemWest Ohio Conference of United Methodist Church

18,000 staff

2,800 physicians

3,000 volunteers

10 hospitals(member and managed)

+30+ sites

+124,000+ effective occupancy cases (inpatient admissions and observation stays)

+393,000 ED visits

+1.8 million outpatient visits (excluding Emergency Department)

+$2.4B in net revenue

OhioHealth

© OhioHealth Inc. April 2013. All rights reserved. CONFIDENTIAL.

OhioHealth LocationsCoverage

• 40 county market area serving 3.5M people

© OhioHealth Inc. April 2013. All rights reserved. CONFIDENTIAL.

1919

Barriers

• Hospices

• Palliative Care Clinicians

• Religious (Magical) Thinking

• Consumerism

• Current Reward System

2020

Take Home Messages

• Palliative Medicine delivers on the value equation: improved quality; reduced cost.

• Hospice care is an expected part of comprehensive care

– No more talk of ‘choice’

• Specialist Palliative care teams bring innovations into rest of health care.

– Generalist care changes