KS-012049 eCQ 11-2 Newsletter

Quarterly Newsletter

Volume 11, Issue 2

Dementia Care Program Keeps Patients at Home and Lowers Medicare Costs

Acomprehensive, system-based demen- tia care program has been found to delay patients’ admissions to nursing homes while decreasing Medicare costs. Even after adjusting for program expenses, the collaborative program proved to be cost neutral, according to a report published in JAMA Internal Medicine. “The most striking finding was that patients enrolled in the program reduced their risk of entering a nursing home by about 40 percent,” says lead author Lee A. Jennings, MD. “We found the study to be very excit- ing, because it showed that an intensive intervention can delay nursing home entry without adding costs,” continues Jennings. “The intervention isn’t going to reverse dementia, but it allows us to provide high- quality care to help patients cope with the progression of this disease and stay in their homes for longer.” An independent, external evaluation of research conducted at the UCLA Al- zheimer’s and Dementia Care Program ana- lyzed program records linked to Medicare data on 1083 beneficiaries with dementia (mean age, 82.1 years) living at home who were enrolled in the program from 2012 through 2015 and followed for three years. Acomparison cohort consisted of 2166 non- participating dementia patients with similar characteristics living in the same area. 91% of referrals to the program were made by patients’ primary care physicians. Patient participants and their caregivers were given a 90-minute in-person assess- ment conducted by a nurse practitioner specializing in dementia, who then created a personalized dementia care plan that ad-

dressed the patient’s medical and mental health and the social needs of both persons. Working collaboratively with the pa- tients’ primary care physicians and special- ists, as well as with community dementia programs, the nurse practitioner imple- mented the care plan, making adjustments as needs changed over time. “Co-management of dementia care allows nurse practitioners to focus on comprehensive care of dementia while al- lowing the primary care physician to retain responsibility for the clinical treatment of dementia and other conditions,” write the authors. Similar collaborative models of care have been found to be valuable for patients with heart failure, they note. KEY FINDINGS • Patients in the dementia program were 40% less likely to be admitted to a long- termcare facility (hazard ratio, 0.60; 95% confidence interval, 0.59 to 0.61) than those in the comparison group. • Program participants saved Medicare $601 per quarter. When implementation costs were factored in, the program was cost-neutral, with an estimated net cost of -$284 per participant per quarter. Source: “HealthCareUtilization andCost Outcomes of a Comprehensive Dementia Care Program for Medicare Beneficiaries,” JAMA Internal Medicine; Epub ahead of print, December 21, 2018; DOI: 10.1001/jamainternmed.2018.5579. Jennings LA et al; Reynolds Department of Geriatric Medicine at the University of Oklahoma Health Sciences Center, Oklahoma City; NORC at the University of Chicago, Bethesda, Maryland; Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California, Los Angeles.

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CONTENTS

Page 1 Dementia Care Program Keeps Patients at Home and Lowers Medicare Costs Page 2 Emergency Department Intervention Aims to Engage Older Adults to Consider Serious Illness Conversations Page 3 Older Adults Reluctant to Discuss Long-Term Life Expectancy, But More Willing As Time Shortens Page 4 National Organization Launches Campaign to Extend Palliative Care to Seriously Ill Patients in All Settings

Emergency Department Intervention Aims to Engage Older Adults to Consider Serious Illness Conversations

Abrief, structured intervention aimed at empowering seriously ill older adults presenting to the emergency department (ED) to understand the importance of identifying their care goals and planning their future medical care was deemed acceptable by nearly three-quarters of participating patients, who found it to be appropriate, reasonable, and understandable. “Clinicians in the ED urgently need a practical intervention to engage older adults in serious illness conversations,” write the authors of a report published in the Journal of PalliativeMedicine. Their intervention is “tailored to allow busy emergency physicians to engage patients in addressing an important chronic care issue without conducting a time-consuming, sensitive conversation in the time-pressured ED environment.” Boston researchers adapted an established, brief negotiated interview (BNI) intervention designed for patients with alcohol dependence to fit the needs of seriously ill patients. The scripted interview guides clinicians in creating patient engagement and trust by showing respect for patient autonomy and compassion- ate curiosity. The interventionwas refined through a series of 16mock clinical encounters of ED clinicians (11 attending emergency physicians; three physician assistants; male, 71%) and seven members of the facility’s patient/family advisory council (mean age, 68 years; male, 43%) acting in the role of patients during the scenarios. EXAMPLES OF THE REFINED SCRIPT INCLUDE: • Focus on goals of care, specifically and respectfully. “Because you have (serious illness) and you are in the ED, I am worried that your disease may progress further. This is a really good time to think together about what kind of care is right for you if you get sicker. Can I help you talk to your doctor about what is important in your care when you get sicker?” • Address follow-up appointment following ED visit. “I’d like to talk about what’s ahead after leaving the ED and seeing your outpatient doctor to share what is important in your care if you get sicker.” The team then tested the resulting six-step intervention at an urban tertiary medical center’s ED by administering it in the fall of 2017 to 23 patients (mean age, 76 years; female, 65%; metastatic cancer, 43%) who had serious illness or whose treating ED clini- cian answered “No” to the Surprise Question (“Would you be sur- prised if this patient died in the next 12 months?”). Following the intervention, researchers conducted one-on-one interviews with the patient participants to assess the acceptability of the intervention. PATIENTS’ RESPONSE TO THE INTERVENTION • Most patient participants (73.9%) gave a positive assessment of the intervention, approving of the clinicians’ gentle and com- forting approach and reporting they experienced no negative emotions during the encounter.

• A majority of participants expressed positive attitudes toward advance care planning.Whether or not they felt ready to engage in care planning, most said they comprehended its importance. • Most participants expressed appreciation for being given an impetus to think about and discuss their future care and for receiving suggested questions they could ask their primary physicians. It was “like a wakeup call,” reported one patient, “to sit down with my doctor to discuss these issues.” Prior research has shown that between 56% and 99% of older adults have not completed an advance directive when presenting to the ED, note the authors. Not having previously considered and documented their preferences for future medical care puts these patients at risk of receiving care that does not alignwith their goals. “The BNI intervention uses clinicians’ empathetic, reflective listening to elicit behavior change by helping patients appreciate the discrepancy between their goals and current behavior (e.g., having no advance directive) and ultimately resolve this ambiva- lence,” write the authors. Although emergency physicians are aware that encounters with older, seriously ill patients provide an opportunity to discuss care wishes, barriers intrinsic to the ED setting “make it very difficult to conduct effective, in-depth conversations,” note the authors. BARRIERS TO ED CARE PLANNING INCLUDE • The time-pressed ED environment • The acuity of many patients’ medical needs • Lack of training in serious illness communication in this setting “Our carefully developed, structured intervention represents a promising tool that respects the time demands of the setting... and the imperative to activate patients to seek conversation with their primary outpatient clinician,” write the authors. “Our study is the first to adapt the BNI concept in the context of serious ill- ness conversations.” The authors suggest that further study of the feasibility and efficacy of the intervention is needed, along with testing of pos- sible modifications, e.g., for patients with dementia or for when caregivers wish to be included, and they plan to present follow-up outcome data from their future studies. The full ED intervention script is available online as supple- mentary material to the report. Source: “Empower Seriously Ill Older Adults to Formulate Their Goals for Medical Care in the Emergency Department,” Journal of Palliative Medicine; Epub ahead of print, November 12, 2018; DOI: 1089/jpm.2018.0360. Ouchi K, Block SD, et al; Department of Emergency Medicine, Brigham andWomen’s Hospital; Department of Emergency Medicine, Harvard Medical School; Serious Illness Care Program, Ariadne Labs; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute; Department of Emergency Medicine, Boston University School of Medicine; Division of Palliative Medicine, Department of Medicine, and Department of Psychiatry, Brigham and Women’s Hospital; all in Boston.

Volume 11, Issue 2

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Older Adults Reluctant to Discuss Long-Term Life Expectancy, But More Willing As Time Shortens

for easing into a conversation about the patient’s own situation and preferences, she points out. Preferences for life expectancy discus- sions did not differ by participant sociode- mographic or medical characteristics, note the authors. “Rather, the preferences for discussing life expectancy were associ- ated with past experiences and whether one believed that life expectancy can be predicted.” Participants, both those who did and did not want a discussion, were about evenly divided on how they would want a five- year life expectancy presented, with 51.1% favoring a quantitative description (“about a 50/50 chance to live another five years”) over the more qualitative description (“in the range of a few years”). Based on their findings, the authors suggest several approaches physicians can use to assess whether and when patients are ready for life expectancy discussions. PHYSICIANS CAN: • Explore the patient’s past experiences with serious illness and life expectancy discussions and his/her beliefs about physician predictions. • Because a patient’s attitude and prefer- ences may change over time, assess preferences at multiple time points. • Approach the conversation when life expectancy is closer to two years, which more patients may find acceptable. • Incorporate life expectancies to inform and guide care recommendations, re- gardless of whether the patient wishes to discuss estimated survival time him/ herself. Source: “Older Adults’ Preferences for Discussing Long-Term Life Expectancy: Results from a National Survey,” Annals of Family Medicine; November 2018; 16(6):530–537. Schoenborn NL, Janssen EM, Boyd C, Bridges JFP, Wolff AC, Xue KL, Pollack CE; The Johns Hopkins School of Medicine and School of Public Health, Baltimore; ICON Plc, Gaithersburg, Maryland; Department of Biomedical Informatics, Ohio State University, Columbus.

and 87.7%would not want the physician to discuss life expectancywith their fam- ily and/or friends. • Among those willing to discuss life expectancy, 94.8% were amenable to introduction of the topic by the physi- cian, as long as they had the option to decline. • The reason most often given for want- ing a discussion was that it would help patients plan their lives (72.3%). • 55.8% of participants were willing to have the discussion only if life expec- tancy were less than two years. “We found that the longer the hypotheti- cal patient was expected to live, the smaller the proportion of participants who wanted to discuss life expectancy,” write the au- thors. “A sizable minority (16.5%) did not wish to have this discussion, even when it was one month.” At the other extreme, 11%of participants were fine with discuss- ing life expectancy even as far distant as 20 years. • Higher education level (odds ratio [OR] for college degree and above, 2.18; 95% confidence interval [CI], 1.25 to 3.80; P = 0.004 across categories) • Belief that physicians can accurately predict life expectancy (OR, 3.06; 95% CI, 1.93 to 4.86; P < 0.001) • Past experience with a life-threatening illness (OR, 1.50; 95% CI, 1.07 to 2.09; P = 0.02) • Having previously discussed life expec- tancy of a loved one (OR, 3.98; 95%CI, 2.82 to 5.62; P < 0.001) “My patients often talk about being a caregiver for another family member or tell me if there’s been a recent death in their family,” says lead author and geriatrician Nancy L. Schoenborn, MD, MHS, of Johns Hopkins University School of Medicine. This type of personal patient information can provide clinicians with a starting point FACTORS ASSOCIATED WITH WANTING A LIFE EXPECTANCY DISCUSSION INCLUDED:

Most older adults in a national survey said they would prefer not to discuss life expectancy when asked to imagine them- selves as a hypothetical patient with serious illnesses who was not imminently dying and had an unspecified length of time to live.As the projected time until death grew shorter, however, participants’willingness for discussions increased. “This study is, to our knowledge, the first to assess older adults’ preferences for discussing life expectancy outside of the context of cancer or end of life in a large national sample,” write the authors of a report published in Annals of Family Medicine. “This is also the first study, to our knowledge, to quantify the preferred timing for discussing life expectancy.” Although many clinical guidelines rec- ommend incorporating ten-year life expec- tancy into care decisions for older patients, “best practices are not well established for communicating long-term life expectancy in a primary care setting when patients may have less than ten years to live but are not at the end of life or do not have a single, life-limiting illness such as cancer,” the authors note. They sought information regarding patient preferences that might help clinicians consider how to approach such a discussion. Investigators analyzed responses of 878 participants (mean age, 73.4 years; female, 55.1%) recruited in 2016 from a nationally representative, online survey panel of U.S. adults aged 65 years or older. Participants were presented with a hypothetical sce- nario of a patient with serious health con- ditions and limitations in daily activities, and asked to consider their communication preferences about life expectancy if they were that patient. KEY FINDINGS • 59.4% of participants did not want any discussion of how long they might live if they were the patient in the scenario. • Of these, 59.9% did not think the physi- cian should even offer such a discussion,

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Volume 11, Issue 2

© 2019 by Quality of Life Publishing Co. May not be reproduced without permission of the publisher. 877-513-0099

National Organization Launches Campaign to Extend Palliative Care to Seriously Ill Patients in All Settings

enables the trust necessary for shared decision making,” says Meier. She notes that although most pal- liative care skills have not been part of medical and nursing education, seriously ill patients still expect their clinicians to: • Understand what matters most to them • Explain what to expect as their illness progresses • Explain the benefits and risks of dif- ferent treatment options • Support decisions consistent with realistic and achievable goals • Manage their symptoms throughout the course of their illness For more information on the project, visit www.capc.org. CAPC also offers a patient resources site, Get Palliative Care: https://getpalliativecare.org.

A five-year national effort to ensure high-quality palliative care and expand access to its delivery into all care settings for patients living with serious illness has been launched by the Center to Ad- vance Palliative Care (CAPC), which has been promoting and supporting the development of palliative care programs within the healthcare system since 1999. “People living with a serious illness such as cancer, CHF, COPD, Parkin- son’s, and more, experience all the associated burdens of illness, including worry, pain, and other symptoms, and caregiver distress,” says CAPC direc- tor Diane E. Meier, MD. “Despite the rapid growth of palliative care, which is specialized medical care focused on relief of the symptoms and stress of serious illness, most people who need palliative care don’t get it.” The stated aims of the campaign,

entitled Project Tipping Point, are: • To increase access to quality pal- liative care services across the full continuum of care in all settings: in the hospital, at home, in office prac- tices, and in long-term care facilities • To enhance knowledge and skill — among all specialties and disciplines — in complex pain and symptom management and in physician/pa- tient/family communication The campaign also includes the launch of the Tipping Point Challenge, in which member organizations and individuals can participate in courses to improve the quality of care delivered to patients with serious illness and en- hance palliative care skills among other healthcare professionals. “The long-term relationship between doctor and patient is the essential ele- ment for high-quality health care, as it

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