Download CARE - The Hastings Center

Getting from Roulette to Reliable:
High Value Care for the Last Part of Life
Aging America:
A Reform Agenda for Living Well and Dying Well
The Hasting Center Symposium, Washington, DC
May 20, 2008
Joanne Lynn, MD, MA, MS
[email protected]
(Speaking on my own, not for US government policy)
© Copyright 2003, Onion, Inc., All rights reserved.
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By permission of Johnny Hart and Creators Syndicate, Inc.
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How Americans Die: A Century of Change
1900
Age at death
Top Causes
46 years
2000
78 years
Infection
Cancer
Accident
Childbirth
Organ system failure
Stroke/Dementia
Disability
Not much
2-4 yrs ave. before death,
<6% die without related bills
Financing
Private,
Public, substantialin US - 83% in Medicare
~½ of women die in
modest
Medicaid
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Why target fatal chronic illness?
• It’s big – >1/3 of lifetime expenses, most “being ill”
• It’s bad – unreliable, often harmful
• It’s ugly – little political will for reform
– Unpleasant and complicated situations
– Inadequate data and methods
– Bad manners
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But – Some Promising Innovations
• Hospice
• PACE (Program of All-Inclusive Care for the Elderly)
• SNP (Special Needs Plans – capitated high-risk)
• Palliative care – now in most hospitals
• Elderly and Disabled Waivers
• CARE and Care Transitions, upcoming from CMS
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CARE:
Continuity Assessment Record & Evaluation
•
•
•
•
•
Beneficiary’s health situation
At critical times, such as transfers
On-line, real-time
Information to “downstream” clinicians
Quality and payment information to Medicare
In demonstration now, in QIO agenda by fall.
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Care Transitions in Communities
• Build on Dartmouth Data
• Target Seriously Ill Medicare Beneficiaries
• Assure Continuity and Reliability
• Support by Quality Improvement Organizations (QIOs)
• With ALL Clinical Service Providers
• And Community Leaders
How can we learn to improve quality
and also deliberately enhance efficiency?
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Lewis and Clark – leaving St Louis, May 1804
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Pushing for Reform
THE BUSINESS CASE:
THE AIM:
– Social consensus on how to live and die with serious illness
THE STRATEGIES:
– Engender political demand
– Engender the workforce
– Tailor services, payment, quality measures to populations10
The Business Case
• Pay well only for continuity care
• Make planning ahead standard
• Permit continuity over time and setting
• Change the information flow
– Require feedback “upstream”
– Give relevant information to patients/families
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The AIM
• Public stories – TV, famous people, other media
• Honest accounting of costs and benefits
• Include patient and caregiver voices –
payment, and quality
in coverage,
• Demonstrations – in substantial regions
• Compare small areas
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Caregivers – Politics and Needs
• Organize caregivers for political power
• Demand reasonable working conditions
• Demand a role in setting priorities
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Employee Work Force
• Change the skill mix for physicians
• Leadership positions for nurses, social workers
• Fair labor practices for aides
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Tailor Care to Populations…
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Short Decline, “Dying”
Cancer
Function
High
Low
death
Time
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Exacerbations and Sudden Dying
Function
High
Mostly Chronic Heart or Lung Failure
Low
death
Time
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Function
High
Dwindling Course
Frailty and dementia
death
Low
Time
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Tailor Care to Populations…
First – short course to dying
**Mesh hospice and conventional care
Second – exacerbations
**Move services to home, advance care planning
Third – dwindling course
**Family support, nursing homes, supportive care
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We have much to learn and little time
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Map of the US, 1802
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Map of the United States, 1826
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Maps of the US, 1802 and 1824
Maps from the Smithsonian Institution Collection
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Some Resources for Reform
Transitions - http://www.cfmc.org/value/co/index.htm
Patients and families
• Web – www.growthhouse.org
• Handbook for Mortals (Oxford U Press, 1999)
Policy
• Sick to Death and Not Going to Take it Anymore! Reforming Health Care for the Last Years of
Life (U California Press, 2004)
Quality Improvement
• Common Sense Guide to Improving Palliative Care (Oxford U Press., 2006)
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