Date of Implementation/Adoption: July 1, 2009
Project Status: X Ongoing One-time only
Did you submit this project before? Yes X No
Executive Summary: Describe the project in 15 lines or less using 12 point font. Summarize the problem, solution, and benefits of the project in a clear and direct manner
There are approximately 13,000 acute adult admissions at Olive View-UCLA Medical Center yearly with a significant number of young and middle-age patients (50% of adult admissions in 2008 are between ages of 30-59) who have little or no access to regular medical care. Patients often present with catastrophic and advanced illnesses. Malignancies and end stage renal disease make up 51% (546 patients) of the top ten discharges by DRG coding. The Palliative Care Service aimed to decrease the high number of ICU deaths by introducing goals of care discussions earlier in the disease trajectory and by offering families and patients alternative levels of care when curative options have been exhausted. Palliative Medicine is an essential component of our residency program. The biggest impacts are expediting symptom control and management, providing prompt psychosocial interventions where majority of the patients have complex economic and social issues of concern, providing smooth transition of care from the hospital, and incorporating participation of a Physical Therapist.
(1) ESTIMATED/ACTUAL ANNUAL COST AVOIDANCE
$240,221
(2) ESTIMATED/ACTUAL ANNUAL COST SAVINGS
$ (3) ESTIMATED/ACTUAL ANNUAL REVENUE $ (1)+(2)+(3) TOTAL ESTIMATED/ACTUAL BENEFIT $240,221 SERVICE ENHANCEMENT PROJECT ; SUBMITTING DEPARTMENT NAME AND COMPLETE ADDRESS (INCLUDE TELEPHONE AND FAX NUMBER)
ValleyCare Olive View-UCLA Medical Center 14445 Olive View Dr., Sylmar 91342
Carla Niño, Assistant Hospital Administrator IV 818-364-3579
818-364-3993
PROGRAM MANAGER’S NAME
Katherine Yu, MD
TELEPHONE NUMBER
PRODUCTIVITY MANAGER’S NAME AND SIGNATURE
Cheri Todoroff
DATE SIGNED
TELEPHONE NUMBER
213-240-8272
DEPARTMENT HEAD’S NAME AND SIGNATURE
John F. Schunhoff, Ph.D., Interim Director
DATE SIGNED TELEPHONE NUMBER 213-240-8108 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Fact Sheet – limited to 3 pages only: Describe the Challenge, Solution, and
Benefits of the project, written in plain language. Include a discussion of the
technology, links to the County Strategic Plan. The description should identify Performance Measures.
CHALLENGE (suggest ½ to one page)
There are approximately 13,000 acute adult admissions at Olive View-UCLA Medical Center yearly. A significant number of young and middle-age patients (50% of adult admissions in 2008 are between ages of 30-59) have little or no access to regular medical care. Patients often present with catastrophic and advanced illnesses. Malignancies and end stage renal disease make up 51% (546 patients) of the top ten discharges by DRG coding.
Unfortunately, many of our patients with advanced disease continue to receive intensive treatments in the last days of life, thus burdening our critical care units with high
utilization rate (1190 ICU days associated with 101 ICU deaths) and a high number of deaths (101 out of 198 adults deaths in 2008). More than a third (37%) of adult deaths in 2008 occurred in patients with malignant diseases and 16% of the deaths were attributable to end stage liver disease. During the last hospitalization for these patients, more than half are spent in the ICU (an average of 11 days). A preliminary chart review of patients who died within the last year demonstrated that discussions about goals of care occurred within days of death rather than earlier in the course of disease. Despite the availability of contracted hospices, there continues to be a low number of hospice referrals. Only 107 patients were referred to hospice out of 800 potentially eligible patients in 2008. By focusing on achievable outcomes, the palliative care
consultation service can significantly impact the quality of care transition and cost of the hospitalization by advocating more appropriate use of diagnostic tests, procedures and therapeutic measures. At Olive View-UCLA Medical Center, the current average cost of adult discharges of live versus deceased adult is $28,630 versus $124,669
SOLUTION (suggest ½ to one page)
The Palliative Care Service aimed to decrease the high number of ICU deaths by introducing goals of care discussions earlier in the disease trajectory and by offering families and patients alternative venues of care when curative options have been exhausted. The objectives of the palliative care service are to improve quality in end of life care for our patients and caregivers.
The team focused its attention on the coordination of care prior to discharge. We partnered with several community hospice agencies that evaluate our patients while in the hospital, helping to streamline the transition from hospital to home or skilled nursing facility and increase the awareness and consideration of the hospice option within our
inpatient culture. A primary goal is to increase the number of appropriate hospice referrals and to decrease the number of readmissions from the 2008 baseline of 2.4 hospitalizations per patient in the 6 months preceding death.
Based on patient demographics, a key step in improving cultural awareness and sensitivities is to ensure team members were proficient in Spanish. The team nurse coordinator and social worker, who share cultural heritage with a majority of our
patients, are both fluent in written and spoken Spanish. All social workers participating on our consultation team have attended additional courses in cultural competency as well as end-of-life care training and are equipped to train and provide in-service to other hospital staff on understanding the impact of cultural issues in health care especially end-of-life care. Our hospital provides excellent interpreter support through the video-based Health Care Interpreter Network (HCIN) whose staff is bicultural and
multinational in several of the most commonly spoken languages in our patient population.
Consultative services with the interdisciplinary team commenced in October 2009 to coincide with the establishment of an inpatient Oncology Unit at our hospital. The palliative care team continuously tracked both the financial and clinical impact of the program. The evaluation process included prospective data collection on core
measures based on the consensus guidelines on Palliative Care Consultation Service Metrics of 2008 recommended by the Center to Advance Palliative Care.
Olive View Medical Center is committed to the success of the palliative care program, taking steps to ensure its sustainability. A key component of our program was the development of a nurse led care coordination program that identified patients on the inpatient wards and in the critical care units who would benefit from palliative care services. The nurse coordinator assisted in transitioning care from the acute inpatient setting to hospice and other long term care venues when appropriate. The nurse coordinator was responsible for data collection pertaining to patient care including clinical outcomes and utilization patterns. This service enhanced the sustainability of the program by documenting from inception, the consultations service impact on quality of patient care, medical staff satisfaction, and cost avoidance of futile medical
intervention.
BENEFITS (suggest 1 to 2 pages)
We calculated approximately 650 potential consults in the first year based on 5% of all discharges. We anticipated between 200-250 consults in the first year of program inception and yearly consultations of 300-350 from the second year onward.
As with many public palliative care programs cost avoidance is an expected outcome of a well run service. Palliative Medicine is an essential component of our residency
program. A commitment was secured of the residency director in the establishment of a palliative care curriculum, integrating the palliative experience as a clinical elective rotation. The dedicated support of the residency director lent itself to the success and sustainability of the program as training multifaceted providers was an important goal of the UCLA Olive View Internal Medicine Program and palliative care is an integral part of a well-rounded residency education.
The palliative program biggest impacts are expediting symptom control and management, providing prompt psychosocial interventions where majority of the patients have complex economic and social issues of concern, providing smooth transition of care from the hospital, and incorporating assessment skills of a Physical Therapist for safe care transition. Providers predominately consult palliative care for assistance for goals of care discussions and psych-social support, rating the goals of care clarification at 92.7% most beneficial. Seeking input on the level of satisfaction with the ease of referring patients, response times to consult requests, and
communicating recommendations, providers responded with an 88.5% excellent rating. They rate the helpfulness of the palliative care service at 85.7% very helpful benefit of the program. One hundred percent of providers responded that the Palliative Care Program has contributed positively to the overall care of the patient. Almost 98% responded being highly satisfied with the experience and 100% would consult the service in the future.
Since service inception, ten POLST forms were completed prior to discharge and twice as many were provided the information and form for consideration before completion at the time of transfer or discharge. The rest have either completed the form by primary team or had advanced directives incorporating similar items as the POLST.
Patient Consults Code Status Clarification Placement in Hospice POLST Completion 10-09 to 12-09 56 15 26 1-10 to 4-10 77 32 26 10
Cost Prior to Consult $439,976
Cost After Consult $199,755
Avoided Cost $240,221
Total Patients 45
Avoided Cost Per Patient $5,338
The cost avoidance shown is only for the first 3 months of the program. We have now served over 168 patients since inception, based on the avoided cost per patient
Cost Avoidance, Cost Savings, and Revenue Generated (Estimated Benefit): Use this form and provide details on the estimated/actual benefits. As a suggestion, work with your fiscal staff.
Cost Avoidance: Anticipated costs that are eliminated or not incurred as a result of program outcomes. Cost Savings: A reduction or lessening of expenditures as a result of program outcomes.
Revenue: Increases in existing revenue streams or new revenue sources to the County as a result of program outcomes.
(1) ESTIMATED/ACTUAL ANNUAL COST AVOIDANCE
$240,221
(2) ESTIMATED/ACTUAL ANNUAL COST SAVINGS
$ (3) ESTIMATED/ACTUAL ANNUAL REVENUE $ (1)+(2)+(3) TOTAL ESTIMATED/ACTUAL BENEFIT $240,221 SERVICE ENHANCEMENT PROJECT ;
Cost Prior to Consult $439,976
Cost After Consult $199,755
FOR COLLABORATING DEPARTMENTS ONLY
(for single department submissions, do not include this page)
DEPARTMENT NO.2NAME AND COMPLETE ADDRESS
Productivity Manager’s Name and Signature
Department Head’s Name and Signature
DEPARTMENT NO.3NAME AND COMPLETE ADDRESS
Productivity Manager’s Name and Signature
Department Head’s Name and Signature
DEPARTMENT NO.4NAME AND COMPLETE ADDRESS
Productivity Manager’s Name and Signature
Department Head’s Name and Signature
DEPARTMENT NO.5NAME AND COMPLETE ADDRESS
Productivity Manager’s Name and Signature
Department Head’s Name and Signature
DEPARTMENT NO.6NAME AND COMPLETE ADDRESS
Productivity Manager’s Name and Signature
Department Head’s Name and Signature
