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Service Delivery Innovation Profile

In-Home Palliative Care Allows More Patients to Die at Home, Leading to Higher Satisfaction and Lower Acute Care Utilization and Costs


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Summary

Kaiser Permanente developed a home-based model of palliative care that uses an interdisciplinary team of providers to manage symptoms and pain, provide emotional and spiritual support, and educate patients and family members on an ongoing basis about changes in the patient's condition. One randomized controlled trial and one comparison-group study showed that the program increases patient satisfaction, increases the portion of patients dying at home rather than in the hospital, and reduces emergency department visits, inpatient admissions, and costs.

Evidence Rating (What is this?)

Strong: The evidence consists of an RCT and one comparison group study that compare key outcomes measures, including the percentage of patients dying at home, health care utilization and costs, and patient satisfaction.
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Developing Organizations

Kaiser Permanente-TriCentral Service Area; Partners in Care Foundation
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Use By Other Organizations

  • HealthCare Partners, a managed care provider, adopted a modified version of this model of care to serve high-risk older adults.8

Date First Implemented

1998
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Patient Population

Vulnerable Populations > Terminally illend pp

Problem Addressed

Today's health care system often fails to provide patient-centered, cost-effective care to patients at the end of life.1 Instead, terminally ill patients tend to cycle through expensive acute care designed to prolong life, and then end up dying in pain in the hospital despite wishing to be at home surrounded by loved ones.
  • High costs of caring for dying patients: Almost one-third (30 percent) of the total Medicare budget is spent on beneficiaries in their last year of life; nearly 40 percent of this spending occurs in the last 30 days of life.2
  • Preferring (but unable) to die at home: Most terminally ill patients would prefer to die at home.1 Yet, only 25 percent do so, with 50 percent dying in the hospital. If an appropriate home care program were available, most of these patients would not require hospitalization, and hence, could be at home.3
  • Little access to high-quality, cost-effective palliative care: Palliative care services provide a number of benefits to chronically ill, end-of-life patients, including reduced pain, improved quality of life, and a reduction in emergency department (ED) visits, hospitalizations, and health care costs.4 Palliative care services, however, are seldom available. For example, a random sample of California hospitals found that only 17 percent had a palliative care consult service, while only 6 percent had an inpatient palliative care unit.5 The use of palliative care is even less common in outpatient settings.1

What They Did

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Description of the Innovative Activity

Kaiser Permanente's in-home palliative care program, offered as a standard benefit to most members, includes an interdisciplinary team of providers who manage a patient's symptoms and pain, provide emotional and spiritual support, and offer ongoing education about changes in the patient's condition. Although the program emphasizes pain control and symptom management, patients do not have to forgo curative care, as they do in hospice programs. Key elements of the program include the following:
  • Program referrals and eligibility assessment: Any of a variety of caregivers can refer a patient to the program, including physicians, nurse practitioners, Kaiser Permanente liaison nurses (who visit seriously ill patients in a variety of settings), social workers, and hospital discharge planners; patients may also self-refer. Eligibility criteria include (but are not limited to) those patients with a primary diagnosis of cancer, congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD); life expectancy of 12 months or less; homebound status; and the presence of a primary caretaker in the home. A palliative care nurse conducts an initial screening of patients by telephone or in person to determine eligibility.
  • Palliative care team: The core palliative care team includes a physician; a nurse with experience in palliative care, pain management, and end-of-life issues; a social worker; and a chaplain. Other professionals, such as physical therapists, respiratory therapists, and home health aides, participate as needed.
  • Initial assessment: For those patients who are eligible for the program, the palliative care nurse completes an initial in-home assessment, as follows:
    • Basic assessment: The nurse reviews the program and obtains informed consent from the patient to participate. For those who agree, the nurse performs a medical history, medication review, physical assessment, and home safety assessment, and orders durable medical equipment as necessary.
    • Advance care planning: The nurse also discusses living wills and Do Not Resuscitate (DNR) orders with the patient.
    • Pain management: The patient receives pain medication as needed; pain management issues are also incorporated into every visit.
    • Eliciting patient/family desires: The nurse interviews the patient and family about their desires for end-of-life care. Typical desires include managing pain and other symptoms, achieving a sense of control, and alleviating the burden on family members. Cultural and spiritual preferences for care are discussed and always respected.
  • Ongoing care plan: Based on the initial assessment, the nurse develops a care plan, which is reviewed and revised with the palliative care team within 1 week of the patient's admission to the program. The plan incorporates an assessment of the patient's needs and treatment goals, and includes a schedule for home visits by team members, which typically consists of weekly nurse visits, periodic physician visits (usually once every 60 to 90 days), and as-needed visits from the social worker and chaplain.
  • Ongoing care and education: The patient is provided with care according to the schedule set in the plan, which can be adjusted as needed. During each visit, the visiting provider assesses pain management and symptom control. In addition, ongoing education is provided to the patient and family about changes in the patient's condition, including how to control symptoms and the desirability of making any necessary decisions (e.g., those related to DNR orders, curative care). The palliative care physician and the patient's primary physician are jointly responsible for the patient's care and coordinate needed medical treatment, including inpatient care.
  • Telephone support: A nurse call center provides 24-hour support to patients and families.
  • Biweekly team meetings: Team members hold biweekly meetings to discuss specific cases; each patient's care plan is reviewed and updated at least once every 60 days.
  • Discharge: Patients are discharged from the program if they transfer to hospice care (also a covered Kaiser Permanente benefit), no longer meet the palliative care admission criteria, no longer agree with palliative care goals, and/or stabilize or achieve control of symptoms.
  • Bereavement services: Bereavement services are available to the family after the death of any patient.

Context of the Innovation

The Kaiser Permanente TriCentral Service Area serves more than 600,000 members who live in the Los Angeles area; its palliative care and hospice programs are available to an additional 300,000 members who reside in neighboring communities. Kaiser Permanente Colorado has approximately 500 physicians and serves almost 500,000 members, while Kaiser Permanente Hawaii has 350 physicians and serves almost 250,000 members. Partners in Care Foundation (http://www.picf.org) in San Fernando, CA, is a research institute that focuses on testing and disseminating evidence-based models of care, including those that pertain to the elderly and those with chronic disease. The Kaiser Permanente TriCentral Service Area developed the in-home palliative care program as an alternative to its underutilized hospice program.

Did It Work?

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Results

One randomized controlled trial (RCT) and one study comparing in-home palliative care to usual care show that the program increases patient satisfaction, increases the portion of patients dying at home rather than in the hospital, and reduces ED visits, inpatient admissions, and costs. Specific results are as follows:

An RCT conducted at Kaiser Permanente Colorado and Kaiser Permanente Hawaii between 2002 and 2004 showed:1
  • Higher satisfaction: Approximately 80 and 93 percent of palliative care patients were very satisfied with their care 30 and 90 days after enrollment, respectively, well above the 74 and 81 percent figures within the usual care group.
  • More likely to die at home: 71 percent of palliative care patients died at home, in accordance with their wishes, compared with 51 percent of usual care patients.
  • Lower utilization and costs: Among palliative care patients, 22 percent visited the ED while 36 percent required hospitalization. Comparable figures for the usual care group were significantly higher—at 33 and 59 percent, respectively. The mean cost of care was $12,670 for the palliative care group, compared with $20,222 for the usual care group.
One comparative study at Kaiser Permanente TriCentral showed:6,7
  • More likely to die at home: Compared with the usual care group, patients receiving palliative care were much more likely to die at home (87 vs. 71 percent for cancer patients, 92 vs. 37 percent for COPD patients, and 87 vs. 47 percent for CHF patients) in accordance with their wishes.
  • Lower costs: As a result of reduced health care utilization, the average costs for palliative care patients were significantly lower than for those receiving usual care, including 35 percent lower for those with cancer, 67 percent lower for those with COPD, and 52 percent lower for those with CHF.

Evidence Rating (What is this?)

Strong: The evidence consists of an RCT and one comparison group study that compare key outcomes measures, including the percentage of patients dying at home, health care utilization and costs, and patient satisfaction.

How They Did It

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Planning and Development Process

The key elements of the planning and development process as outlined by the TriCentral Palliative Care Program Toolkit included the following:
  • Conducting a needs assessment: TriCentral leaders interviewed key health care staff, analyzed service utilization data, and performed an assessment of available community services for critically ill adults.
  • Establishing leadership: TriCentral formed a team of institutional leaders who were interested in improving end-of-life care, including a physician, nurse manager, and hospice providers.
  • Developing a business plan: The team created a business plan for the palliative care program that covered key program elements, marketing plans, and projected finances. This plan was used to convince senior administration of the value of the program, and to secure funding from the Garfield Memorial Fund, an internal Kaiser Permanente funding source.
  • Designing program details: The team developed policies and procedures related to all aspects of the program, including a mission statement, organizational structure, staff roles and responsibilities, eligibility criteria, referral processes, care planning processes, services to be offered, discharge procedures, and a plan for quality assurance and program evaluation.
  • Expanding the program: The program began in Kaiser Permanente's TriCentral Service Area (around Los Angeles) and was later expanded to Kaiser Permanente Colorado, Kaiser Permanente Hawaii, and other Kaiser regions.

Resources Used and Skills Needed

  • Staffing: Staff members include the core team of a physician, nurse, social worker, and chaplain. Other professionals, such as physical therapists, respiratory therapists, and home health aides, can be included as needed. The number of full-time equivalent (FTE) staff needed depends on the average daily census of patients in the program. To serve 30 patients on an ongoing basis, the program would require 0.4 FTE physicians, 2.2 FTE registered nurses, 1.2 FTE social workers, and 0.2 FTE chaplains.
  • Costs: The primary costs consist of salary and benefits for members of the palliative care team.
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Funding Sources

Kaiser Permanente Garfield Memorial Fund
The Kaiser Permanente Garfield Memorial Fund funded the research. The TriCentral Palliative Care Program Toolkit was developed with a Soros Faculty Scholarship Award granted by the Open Society Institute's Project on Death in America. Additional funding for direct patient care is provided Kaiser Permanente via premiums.
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Tools and Other Resources

The Kaiser Permanente TriCentral Palliative Care Program Toolkit is available at http://www.growthhouse.org/palliative/.

Adoption Considerations

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Getting Started with This Innovation

  • Identify a program champion: A champion, ideally a physician with palliative care experience, can help design a patient-centered program and educate referral sources about the value of palliative care.
  • Set clear, appropriate eligibility criteria: Setting clear eligibility criteria helps to ensure referrals of appropriate patients; criteria should be somewhat limiting so that the program is not initially overwhelmed with patients.
  • Emphasize program benefits in marketing: Patients, families, and even many caregivers do not understand palliative care services and may be reluctant to try them. Referrals can be encouraged by emphasizing the patient-centered nature of the service, the ability to continue with curative care options, the focus on pain management, and the difference between hospice and palliative care.

Sustaining This Innovation

  • Support in-home physician visits: Physician visits are the most likely to generate cost savings, because they often prevent the need for inpatient and ED care.

Use By Other Organizations

  • HealthCare Partners, a managed care provider, adopted a modified version of this model of care to serve high-risk older adults.8

Additional Considerations

  • Because this model shifts care from the hospital to the home, creating a net reduction in costs, it will be most beneficial financially for health plans or integrated systems that receive a fixed revenue stream to provide services to a defined population. For these organizations, costs will decline without a corresponding drop in revenues. Other provider organizations, however, might find it more difficult to make a business case for this type of program. For example, hospitals and health systems without a fixed revenue stream might experience declining revenues due to fewer ED visits and inpatient admissions. In addition, these organizations, along with independent hospice and home care agencies, may have difficulty in securing reimbursement for in-home palliative care services from Medicare or commercial insurers.

More Information

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Contact the Innovator

Richard D. Brumley, MD
3401 W. Sunflower Ave, Suite 225
Santa Ana, CA 92704
phone (949) 633-4608
fax (949( 499-5158
E-mail: richard.d.brumley@gmail.com

Susan Enguidanos, MPH, PhD

Hanson Family Assistant Professor of Gerontology
University of Southern California
Davis School of Gerontology
3715 McClintock Ave, Gero 228B
Los Angeles, CA 90089-0191
(213) 740-9822
E-mail: sengui@aol.com

June Simmons, CEO

Partners in Care Foundation
732 Mott Street, Suite 105
San Fernando, CA 91340
(818) 837-3775 ext. 101
E-mail: jsimmons@picf.org

Sandy Atkins, V.P. Institute for Change
Partners in Care Foundation
732 Mott Street, Suite 105
San Fernando, CA 91340
(818) 837-3775 ext. 111
E-mail: satkins@picf.org

Innovator Disclosures

Dr. Brumley, Dr. Enguidanos, Ms. Simmons, and Ms. Atkins have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Brumley R, Enguidanos S, Jamison P, et al. Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. J Am Geriatr Soc. 2007;55(7):993-1000. [PubMed]

Davis EM, Jamison P, Brumley R, et al. Barriers and facilitators to replicating an evidence-based palliative care model. Home Health Care Serv Q. 2006;25(1-2):149-65. [PubMed]

Enguidanos SM, Cherin D, Brumley R, et al. Home-based palliative care study: site of death and cost of medical care for patients with congestive heart failure, chronic obstructive pulmonary disease, and cancer. J Soc Work End Life Palliat Care. 2005;1(3):37-56. [PubMed]

Brumley RD, Enguidanos S, Cherin DA. Effectiveness of a home-based palliative care program for end-of-life. J Palliat Med. 2003;6(5):715-25. [PubMed]

Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012 Dec;15(12):1356-61. [PubMed]

Footnotes

1 Brumley R, Enguidanos S, Jamison P, et al. Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. J Am Geriatr Soc. 2007;55(7):993-1000. [PubMed]
2 Lubitz JD, Riley GF. Trends in Medicare payments in the last year of life. N Engl J Med. 1993;328(15):1092-6. [PubMed]
3 Ryan P, Kobb R, Hilsen P. Making the right connection: matching patients to technology. Telemed J E Health. 2003 Spring;9(1):81-8. [PubMed]
4 Morrison RS. Palliative care outcomes research: the next steps. J Palliat Med. 2005;8(1):13-16. [PubMed] Also available at: http://www.liebertonline.com/doi/abs/10.1089/jpm.2005.8.13
5 Pantilat SZ, Billings JA. Prevalence and structure of palliative care services in California hospitals. Arch Intern Med. 2003;163(9):1084-88. [PubMed]
6 Brumley RD, Enguidanos S, Cherin DA. Effectiveness of a home-based palliative care program for end-of-life. J Palliat Med. 2003;6(5):715-25. [PubMed]
7 Enguidanos SM, Cherin D, Brumley R, et al. Home-based palliative care study: site of death and cost of medical care for patients with congestive heart failure, chronic obstructive pulmonary disease, and cancer. J Soc Work End Life Palliat Care. 2005;1(3):37-56. [PubMed]
8 Levine S, Steinman BA, Attaway K, et al. Home care program for patients at high risk of hospitalization. Am J Manag Care. 2012 Aug 1;18(8):e269-76. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: March 02, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 03, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 13, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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