At the Veterans Affairs (VA) medical center in Los Angeles, California, global budgeting for medical services has helped to illuminate palliative care’s potential to increase both the quality and the efficiency of health care delivery—even within a system struggling against financial uncertainty. The VA, which in recent years has pursued a national agenda of improving end-of-life care, often provides a clearer setting to demonstrate the benefits of palliative care than does fee-for-service health care. Each VA medical center is an integrated health system, with an overall or “global” budget under which it assumes financial risk and responsibility for the health care needs of enrolled veterans—and thus for the prevention of unwanted and costly treatments and hospitalizations at the end of life.
The Pathways of Caring demonstration project at the VA’s Greater Los Angeles (GLA) Healthcare System has posted impressive results in improving quality of care while reducing hospitalizations and overall costs of care for veterans with advanced lung cancer, congestive heart failure and chronic obstructive pulmonary disease while dramatically increasing the proportion of those patients enrolled in hospice and achieving high rates of completed advanced directives and documented goals of care.
Based on the program’s demonstrated efficiency of health care utilization, the medical center’s administration has opted to continue the project beyond the duration of its Promoting Excellence grant, supplemented by a new Inter-Professional Palliative Care Fellowship Program awarded to the program starting in academic year 2002–03. The planned institutional expansion of the Pathways program (renamed the Veterans Integrated Palliative Program or VIP) to poor-prognosis patients regardless of diagnosis has been delayed by organizational instability.
Such instability has included three changes in CEO in the past four years, hiring freezes and “reductions in force” actions, reorganizations, budgetary cuts and the loss of key departmental physician champions of palliative care. While the delay underscores the fact that even successful palliative programs are at the mercy of organizational problems within their parent systems, GLA VA’s leadership remains committed to continuing and, ultimately, expanding VIP.
Introducing Palliative Care at the Earliest Opportunity
Clinician-researchers at GLA knew that barriers to improving quality of life for patients with advanced, incurable illnesses included late identification of dying patients, inadequate management of symptoms and discontinuities of care. The Pathways team aimed to address those barriers by implementing a generalized palliative care model with disease condition-specific elements. The program centered around a nurse case manager who educated enrolled patients and families regarding decision-making and symptom self-management, provided continuity and coordination of care, and served as the “hub” of an interdisciplinary palliative care support team that helped to manage patients’ psycho-social and spiritual needs. Team members, in addition to the nurse, included a psychologist, chaplain, dietician, pharmacist, physician and advanced care planning expert.
“A key component of the program design was our decision to introduce palliative care at the first possible opportunity after a poor prognosis is given— offering frank discussion of illness and advanced care planning farther upstream,” says the project’s principal investigator and medical consultant, Dr. Kenneth Rosenfeld. Key to achieving that goal was early identification of eligible patients through active case-finding in clinics, tumor board meetings and other locations with information on newly diagnosed patients. This proactive approach proved far more effective than relying on primary care physicians for referrals.
In another setting, the program’s assertiveness in recruiting patients and then encouraging them to consider their own treatment goals and preferences might have been viewed as intrusive and an infringement on physicians’ professional prerogatives, Rosenfeld notes. The Pathways project was able to pursue such an assertive approach, he adds, because the historical lack of continuity of care within the GLA VA system left a vacuum for palliative care to fill. A 1996 chart audit of patients diagnosed with incurable lung cancer confirmed the extent of discontinuity faced by GLA patients and providers. None of those patients ever had a return visit to their primary care physician following diagnosis, and a quarter of them were completely lost to follow-up.
“We recognized this as an opportunity, but also a mandate to try to bridge those gaps and reconnect doctors to patients, based on our understanding of this system and how it works.” Still, Rosenfeld notes, there was ongoing tension with primary care providers and some resistance to the program’s emphasis on facilitating open discussions about prognosis and goals of care. Enrolled patients and their families almost universally reported that these honest discussions were among the most beneficial services offered by Pathways.
Ultimately, Rosenfeld explains, the program tried to orchestrate the provision of two markedly different approaches to care: disease-modifying treatment for advanced, life-limiting conditions and palliative care focused on improving comfort and quality of life. Providing what at times seemed like contradictory approaches side-by-side proved to be a complex balancing act. For the Pathways team, it required carefully negotiating the nuances of concurrent life-prolonging and palliative care.
Cost Per Patient in the Final Month of Life
“Areas of tension between the palliative model and standard care need to be discussed openly and productively. You can’t pretend that they don’t exist,” he relates. “But it was important to us that patients had an understanding of their prognosis. We are not willing to sacrifice fundamental principles of palliative care just to make the program more acceptable to physicians—for example, allowing patients to receive chemotherapy thinking it would cure them, when it won’t.”
In addition to early case identification, care coordination, communication and holistic symptom management, other key components of the Pathways program include:
Patients Who Spent Last Days at Home
Patients Who Died in Hospital
Positive Outcomes From Pathways
Preliminary data on 54 participants who died while enrolled in the Pathways of Caring program, compared with a retrospectively matched control group of patients who did not receive the palliative intervention, show dramatic differences. Forty-three percent of Pathways patients were able to die at home, compared to just 7 percent of matched control patients. Forty-five percent of Pathways patients died in a hospital or long-term care facility, compared to 68 percent of controls.
The Pathways program averaged 3.5 hospital days per patient during the final month of life, compared with 8.2 days for the control group. More striking still, the group of patients who died while served by Pathways spent an average of just 0.4 days in an intensive care unit during the last month of life, compared with 4.5 days for those in the group not served. Intervention patients also spent far less time on mechanical ventilators, 0.1 days per patient in the final month versus 3.5 days in the control group.
Expressed in financial terms, the program’s ability to better manage its patients with life-threatening illnesses in more appropriate and cost-effective settings breaks down as presented in the chart below, with overall savings of 45 percent on the cost of care in the final month of life. Rosenfeld and colleagues are now seeking additional grant funding to expand the project as a randomized controlled trial with more extensive and rigorous data-gathering capacity.
Patient resistance to lengthy and cumbersome quality-of-life assessment tools has limited the project’s ability to gather clinical efficacy data. However, available evidence indicates improvements in the proportion of cases with documented goals of care (69 percent) and completed advance directives (72 percent). Medical records also revealed that 55 percent of Pathways patients indicated that they favored some limitations in life-sustaining treatments.
Number of Days Spent in Hospital
Easing the Transition to Hospice
“The transition to hospice care can be a tough issue,” Rosenfeld notes. The Pathways of Caring project addressed this challenge first by establishing a collaborating relationship with Trinity Home Health and Hospice, a Medicare-certified community hospice program based in nearby Torrance. The hospice assigned a liaison nurse to attend Pathways team meetings and work closely with the project’s case managers and agreed to a more flexible approach to care planning. The VA system permitted hospice-enrolled patients to continue receiving chemotherapy and other disease-modifying treatments, if that is what they wanted, without having to confront the “terrible choice.” Patients enjoyed greater flexibility of care goals and more innovative side-by-side care planning than is customary in hospice care.
The flexibility and coordination between the VA and Trinity Home Health and Hospice proved effective. Fully 50 percent of Pathways patients who died were enrolled in hospice care before their deaths, compared with only 4 percent for the control group, with a median length of stay in hospice care of 29 days. That figure is higher than current national averages and, Rosenfeld believes, may be “about right” for this patient population.
Overall, the Pathways project identified “incredible unmet needs” within the GLA VA health system. “What we found in doing this project confirmed our understanding of what was missing from the status quo.” At times the Pathways program was oversubscribed and had to turn patients away. Although the project’s evaluative data may be hard to generalize to other settings, he notes, “We showed that within this care system and its structure, using this particular way of doing business, we could be successful.”
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