Palliative and End of Life Care in the Commonwealth by cuc21142


									Palliative and End of Life Care in the Commonwealth of Massachusetts –2009 
Quality and Cost Council Discussions on Current State, Challenges, and Opportunities 
The Commonwealth of Massachusetts palliative and end of life programs currently
include nationally recognized clinical and administrative leadership, examples of
effective advanced practice delivery models, strong professional associations, and
widely respected clinician education programs. Yet, palliative and end of life care in MA
continues to be seen as lagging when assessed by key stakeholders ranging from
consumers to policy leaders and from within and outside of the state. With vast
resources (human and financial) devoted to the care of residents during the last months
of life, it is especially important to ensure that these resources are being used wisely to
ensure that all patient and family needs are being optimally met.

A significant opportunity exists to take a leap in dramatically improving the outcomes
(clinical, financial, service, and satisfaction) and effectiveness of statewide programs.
The MA Legislature, Executive Office of Health and Human Services, Quality and Cost
Council, End of Life Commission believe we must take that leap now. (Appendix 1)

Current Structures, Processes, and Outcomes:
   • In 2007 52,690 people died for all reasons in the Commonwealth of MA with 40%
      of deaths occurring in patients under hospice care. This percent has been
      increasing each year and is consistent with national average rates (Mass Death,
      2007) (Hosp Fed, 2008) (NHPCO 2008)
   • There are a growing number of MA hospice and palliative care programs (62 in
      2009) and certified hospice and palliative care healthcare professionals (Hosp
      Fed, 2008)
   • When MA patients are under hospice care, there is a greater likelihood they will
      die at home (45%) than when not under hospice care (24%) (MA Death 2007,)
   • The MA population of hospice patients is becoming more diverse by diagnosis
      with cancer patients making up a significant but declining percent of cases (43%
      in 2007 and 46% in 2006) (Hosp Fed, 2008)
   • In adults in MA over the age of 50, there is a strong awareness of advance
      directives and proxy in MA. (97% and 95% respectively) (AARP EOL Survey,
   • The MA Quality of State Advance Directive Laws were seen as better than those
      of most states in the last national study conducted, earning a “B” (Last Acts,
   • The Pediatric Palliative Care Network of the Commonwealth is consistently
      referenced as innovative and responsive.
   • Specific MA hospices, palliative care programs, clinicians, researchers, and
      administrative staff continue to be recognized for the excellence of their effort.
   • Educational programs based in the state train a large number of palliative care
      professionals nationwide (HMS Center for Palliative Care)

Summary Prepared by J. Conway for the Expert Panel Commencement April 27, 2009       Page 1 
Palliative and End of Life Care in the Commonwealth of Massachusetts –2009 
Quality and Cost Council Discussions on Current State, Challenges, and Opportunities 

  • While patients express an interest in dying at home, the percent of deaths in
      home has stayed relatively stable for over ten years (23% in 2007 and 19% in
      1997). The percent of patients dying in skilled nursing facilities is increasing and
      in hospitals decreasing. (MA Death, 2007)
  • In MA, the average hospice length of stay (51 days in 2007) has declined and
      remained lower than the national ALOS (67.4 days in 2007). The median length
      of stay in MA stayed stable in recent years (25 days in 2007) and was higher
      than the national median (20.0 in 2007). 37% of MA hospice patients had a
      length of stay of 7 or fewer days. (Hosp. Fed, 2008), NHPCO, 2008)
  • For those end of life patients dying in the hospital, teaching hospitals have
      increased by 30% and community hospitals declined 11% in the period between
      1996 and 2006)
  • In a recent national survey, Massachusetts ranked below the national average in
      the number of medium and large hospitals with palliative care programs--MA
      reporting 50% and nationally 53%. (CAPC Survey).
  • There is significant variation in resource use (ICU, procedures, people) at the
      end of life in MA hospitals. MA consistently ranks among the highest in the
          a. Teaching hospitals tend to treat End of Life (EOL) patients with
              substantially more resources than community hospitals, even after
              adjusting for patient age and disease severity, but not accounting for
              patient preference. (DHCFP, 2007)
          b. In the care of Medicare patients in the last 6 months of life, Boston
              teaching hospitals cost 50% more than the national average. (Dartmouth
          c. Resource use in EOL care varies substantially, even across hospitals that
              share the same teaching status. (DHCFP, 2007)
          d. Massachusetts is one of the top ten states in percentage of patients
              seeing 10+ MDs during last six months of life (Dartmouth Atlas) (DHCFP,
          e. MA could save $2.3 billion in total end of life spending if it modeled its
              practiced care after that given in Minnesota made up from:
                   i. 355 million in home health
                  ii. 874 million in inpatient care
                 iii. 181 million in outpatient care
                 iv. 774 million in SNF/long-term care(Dartmouth Atlas)
  • Only 26% of MA AARP members over 50 have completed living wills or other
      written instructions concerning health care choices. (AARP, 2005)
  • Only 37% of MA AARP members over 50 have designated a health care proxy or
      durable power of attorney for health care. (AARP, 2005)
  • There are no DON or accreditation requirements for Hospices in the
      Commonwealth and survey / certification surveys infrequent.

Summary Prepared by J. Conway for the Expert Panel Commencement April 27, 2009      Page 2 
Palliative and End of Life Care in the Commonwealth of Massachusetts –2009 
Quality and Cost Council Discussions on Current State, Challenges, and Opportunities 
   •   Historically the focus on end of life care in MA has been at the hospital and must
       be balanced across all elements of the care system and specifically ambulatory
       care and wellness.
   •   A recent MA study of the Comfort Care / DNR Order Verification suggests that
       when the order and system is used, it facilitates effective honoring of patient
       wishes. Regrettably, it is not used often. (DPH, 2007)
   •   The MA End of Life Commission has not been funded in its work since fiscal year
   •   There is a perceived significant shortage of workforce in all areas of palliative
       care in MA. Data does not exist to support understanding either the current state
       or the future need.

   • System redesign in association with Health Reform, EOHHS, the QCC and
     others provides an opportunity to align incentives in support of effective palliative
     and end of life care. Specifically, opportunities including establishing protocols
     and pathways in line with the use of health information technology.
   • There is a strong consumer movement in MA being led by EOHHS, Health Care
     for All, the Partnership for Healthcare Excellence and others interested in
     dramatically increasing consumer use of living wills and proxies.
   • The expert panel charged in Chapter 305 and currently meeting will deliver its
     recommendations by October 31, 2009, with the aim of catalyzing processes that
     will achieve the improvements we so urgently need.
   • The emphasis on care across the continuum by EOHHS, the QCC, the MA Care
     Transitions Task Force, and others allows for the integration of palliative and end
     of life care throughout the continuum.
   • The state funded pilot of medical orders for life sustaining treatment (MOLST) in
     the Worcester community has significant potential to support effective
     management of orders across the continuum.
   • The National Quality Forum, and its National Priorities Partnership, had identified
     palliative and end of life care as one of 6 national priorities. Opportunities exist to
     align the MA efforts with those at the national level.
   • There is a growing evidence of research, heavily driven by MA researchers, on
     changing mental models of consumer/cancer patient interest in care planning at
     the end of life: 80% are interested in talking about care at the end of life.
   • The Patient Care Assessment Committee of the BRM has expressed an interest
     in imbedding training in palliative care as part of their annual expectations of
     patient care staff.
   • Standardization and reduction of variation in palliative and end of life care can
     dramatically improve care at the end of life, improve satisfaction and return
     significant financial resources to the health system and individuals

Summary Prepared by J. Conway for the Expert Panel Commencement April 27, 2009       Page 3 
Palliative and End of Life Care in the Commonwealth of Massachusetts –2009 
Quality and Cost Council Discussions on Current State, Challenges, and Opportunities 

Attachment A

Quality and Cost Council Goals
Develop processes and measures to improve adherence to patients’ wishes in
providing care at the end of life. Ensure that health care providers ask about and
follow patients’ wishes with respect to invasive treatments, do not resuscitate
orders, hospice and palliative care, and other treatments at the end of life.
1. The Commonwealth of Massachusetts Executive Office of Health and Human
    Services (EOHHS) should implement a statewide public health educational
    campaign by September, 2008.
2. Hospitals, nursing homes, physicians and other providers should implement, by
    2010, a process for communicating patients’ wishes for care at the end of life, similar
    to the Physician Order for Life Sustaining Treatment (POLST) processes currently in
    use in Oregon, Washington, New York, West Virginia, and other states.
3. Hospitals, extended care facilities, and home health care organizations should, by
    March, 2009, offer formal hospice and palliative care programs to their terminally ill
    patients, and should ensure that these programs meet the needs of patients with
    different cultural expectations at the end of life.
4. The Board of Registration in Medicine should require hospitals to submit a plan for
    ensuring that all clinical professionals who care for patients at the end of life are
    educated in the delivery of culturally sensitive care.
5. Payers should adopt policies and standards to support and improve the process of
    care at the end of life.
6. Progress on establishing performance measurement benchmarks, in accordance
    with FY08 Council recommendations

Expert Panel Charge, Chapter 305, September 2008
SECTION 41. Notwithstanding any general or special law to the contrary, the executive
   office of health and human services, in consultation with the health care quality and
   cost council, commission on end-of-life care established by section 480 of chapter
   159 of the Acts of 2000, and the Betsy Lehman Center for Patient Safety and the
   Reduction of Medical Errors, shall convene an expert panel on end-of-life care for
   patients with serious chronic illnesses. The panel shall investigate and study health
   care delivery for these patients and the variations in delivery of such care among
   health care providers in the commonwealth. For the purposes of this investigation
   and study, “health care providers” shall mean facilities and health care professionals
   licensed to provide acute inpatient hospital care, outpatient services, skilled nursing,
   rehabilitation and long-term hospital care, home health care and hospice
   services. The panel shall identify best practices for end-of-life care, including those
   that minimize disparities in care delivery and variations in practice or spending
   among geographic regions and hospitals, and shall present recommendations for
   any legislative, regulatory, or other policy changes necessary to implement its

Summary Prepared by J. Conway for the Expert Panel Commencement April 27, 2009       Page 4 

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