Palliative care boosts ACO results

In 2005, Dr. Robert Sawicki and his staff at OSF HealthCare, based in Peoria, Ill., decided they needed to do a better job of caring for terminally ill patients. This was nearly 10 years before the Institute of Medicine's Dying in America report detailed how patients needlessly suffer in their final days, months and years.

But as leaders at the Catholic-based system explored the issue, they discovered palliative care went far beyond helping patients who were close to death. “We very quickly realized you cannot do good end-of-life care if you wait until the end of life,” said Sawicki, OSF's senior vice president of supportive care who practices family medicine. “You have to start it way upstream.”

OSF launched a palliative-care program that year, and has since made it an integral part of its accountable care organization structure. The program started at a time when palliative care was in its relative infancy as a medical specialty and was often mistakenly equated with hospice care. As experts in the field like to say, all hospice is palliative, but not all palliative is hospice.

Palliative care is based on the needs and desires of patients, not their prognosis. Doctors, nurses, social workers and other caregivers work together to offer medicine and therapies to relieve pain and improve patients' quality of life. The process is just as appropriate for Alzheimer's disease patients with a decade to live as it is for cancer patients with only weeks to live.

When OSF began its Medicare Pioneer ACO in 2012, which it still operates, Sawicki said palliative care immediately became a bigger priority. ACOs are designed to improve healthcare quality while lowering costs. Studies have shown palliative care increases patient satisfaction, reduces adverse symptoms and has the potential to save money.

Palliative care is most effective for those who have the most serious, lingering health problems, said Dr. Diane Meier, director of the New York-based Center to Advance Palliative Care. Roughly 5% of patients account for more than half of U.S. healthcare costs, according to government estimates. The vast majority of those high-cost patients are not in their final year of life.

So OSF started identifying its high-risk patients and initiated advance care planning. Linda Fehr, a nurse and director of OSF's supportive-care division, said clinicians focus on patients with high-risk scores based on data from health insurers. They also ask patients who are admitted as inpatients if they have serious illnesses or uncontrolled chronic symptoms.

During the advance care planning process, clinicians, patients and family members meet and discuss issues that too often are taboo—their symptoms, spiritual health, what they most value and how they would like to die. Daily or weekly meetings provide routine updates. “This is everybody in the same room at the same time talking about the same patient,” Sawicki said. “It doesn't take that long, but it yields incredible insights you wouldn't ordinarily get.”

OSF has completed 18,000 advance care plans so far, Fehr said. Early results show OSF's direct costs to deliver care are $400 to $600 lower per day for patients who receive a palliative-care consultation compared with similar patients who do not.

The next step is moving more palliative care into less-expensive home settings, which leaders hope will prevent costly hospitalizations. Sawicki said OSF is conducting a home-visit pilot program for patients who were hospitalized and had a palliative-care consultation during that admission. Data are not yet complete, but there has been some anecdotal success.

For instance, one patient with a serious respiratory illness had been in and out of the emergency department at one of OSF's 11 hospitals roughly 20 times in a six-month period. While visiting the patient's home, caregivers found a cockroach infestation. The patient was allergic to the pests. The home was sprayed with insecticide and the patient has since made far fewer trips to the ED, Sawicki said.

Meier said OSF is “way ahead” of the rest of the U.S. in integrating palliative care into its delivery system. She sees the biggest opportunities for health systems and ACOs in extending palliative care into patients' homes. That's because social determinants such as poverty, food insecurity and poor housing directly affect palliative-care efforts.

But challenges remain in that area. For example, providers aren't paid to treat social factors. Medicare's payment policy is also very strict and narrowly tailored toward hospice care, Meier said.

Palliative care is key to the success of ACOs, Sawicki stressed. “You can do good population health without palliative care,” he said. “But it's going to take a lot more effort and a lot longer.”