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AAMC Readiness for Reform
Innovations in Care Delivery Case Study
The AAMC launched the Readiness for Reform (R4R) initiative in 2010 to support
members as they implement key elements of health reform. R4R began with a
voluntary institution-wide survey to assess members’ level of preparedness for eight
key focus areas of health reform: education, research/comparative effectiveness,
payment reform, care delivery reform, community and patient engagement, access,
quality, and health information technology (HIT).
The AAMC now supports a number of projects aimed at identifying and sharing best
practices related to the R4R focus areas in member institutions. More information
on the R4R initiative can be found at: www.aamc.org/initiatives/r4r
This case study is one in a series that will highlight member success stories in the
eight R4R focus areas.
AAMC Readiness for Reform Case Study Project Team:
Joanne Conroy, M.D. Chief Health Care Officer AAMC
Michael Weitekamp, M.D.
Robert G. Petersdorf Scholar-in-Residence AAMC
Meaghan Quinn
Senior Program Specialist AAMC
Tom Enders Managing Director Manatt Health Solutions Molly Smith
Manager
Manatt Health Solutions Carl Mankowitz, M.D. Senior Advisor
Manatt Health Solutions
The following people from Mount Sinai Medical Center contributed to this case study:
Diane E. Meier, M.D., Professor Vice Chair for Public Policy Geriatrics and Palliative Medicine Director, Center to Advance Palliative Care
R. Sean Morrison, M.D., Professor
Director, Hertzberg Palliative Care Institute Geriatrics and Palliative Medicine
Director, National Palliative Care Research Center
Background
The changing expectations of consumers, payers, and the government are reshaping how health care is delivered. Payment reform as it develops is causing the introduction of new models of care delivery, which emphasize coordination of care, cross-continuum medical management, prevention, and population health. “Accountable care” will require the closer integration of tertiary, inpatient, primary, and subacute care supported by a unified medical management and health information technology infrastructure.
Many academic medical centers (AMCs) perceive their future success in terms of how well they incorporate these concepts into a more systematic approach to the management of complex care. Palliative care programs are a component essential to the management of complex illness: Improvements in quality and savings in health care expenditures are well documented in the peer-reviewed literature.
Palliative care is team based care that focuses on improving quality of life for patients with serious illness and their families. Palliative care teams provide an extra layer of support to primary doctors by relieving pain, symptoms, and stress of illness, facilitating complicated discussions around goals of care and treatment decisions, and addressing the needs of families and caregivers. Palliative care is provided at the same time as routine medical treatments – including curative therapies. Palliative care is different from hospice in that it is appropriate for any person with a serious illness, not just those that are dying. It is provided at every step of the continuum: in hospitals, office practices and cancer centers, in nursing homes, in hospice, and at home.
Mount Sinai’s Results with Palliative Care
The Mount Sinai Medical Center in New York City—including its hospital and its medical school— is one of the country’s leading research-intensive medical schools, with more than 500 medical students and 3,400 faculty members. Its Hertzberg Palliative Care Institute was selected for this case study, because it is one of the leading palliative care programs nationally. Started in the late ’90s and endowed by the Hertzberg family, it is a fully mature program, with strength in all three academic missions: teaching, research, and patient care. It has been a leading source of documenting success in improving quality and reducing the cost of care. Peer-reviewed journal articles from this program in the early- to mid-2000s were among the first to document the economic value of palliative care.
At Mount Sinai itself, the program saves the hospital between $5 million and $7 million per year, net of program costs. The program reduces intensive care unit (ICU) costs, reduces pharmacy costs, reduces ancillary service costs, and shortens ICU stays (important in a tertiary institution where ICU beds are in demand and a lack of beds can cause surgical cases to be lost or delayed).
Morrison and other investigators from Mount Sinai, the University of Rochester, and Bronx Lebanon Hospital recently published a paper1 describing reduced hospital costs for Medicaid patients facing
1 Morrison, et. al. Palliative care consultation teams cut hospital costs for Medicaid beneficiaries. Health Affairs (2011); 30(3):454-463.
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serious or life-threating illnesses. The authors examined data between 2004 and 2007 for Medicaid beneficiaries at four New York hospitals. On average, patients who received palliative care incurred $6,900 less in hospital costs during a given admission than a matched group of patients who received usual care. Savings for patients discharged alive were $4,098; for patients who died in hospital, the savings were $7,563. Palliative care patients spent less time in intensive care, were less likely to die in intensive care units, and were more likely to receive hospice referrals than the matched usual-care patients. The authors estimate that the reductions in Medicaid hospital spending in New York State could range from $84 million (if 2 percent of patients received palliative care) to $252 million annually, (if 6 percent of patients, received palliative care), if every hospital with at least 150 beds had an operational palliative care team.
Morrison et al published a paper2 in 2008 documenting savings from palliative care in eight
hospitals with established palliative care programs. This was a propensity score matched case-control study of nearly 6,000 patients—about half of whom died in hospital and half of whom were discharged alive. The patients discharged alive had an adjusted net savings of $1,696 in direct costs per admission and $279 per day, including significant reductions in laboratory and intensive care costs compared to the controls. The patients who died had an adjusted net savings of $4,908 per admission and $374 in direct costs per day.
Program Overview
Clinical. The Hertzberg Palliative Care Institute has a strong clinical presence within the hospital, as well as a well-developed community network. The program has two inpatient consultation teams, an outpatient consultation clinic, and most recently a dedicated inpatient palliative care unit. Staffing includes six faculty members, five fellows, a full-time nurse practitioner on the inpatient unit, two full-time nurse practitioners on the inpatient consultation teams; two nurse practitioners in the ambulatory consultation clinic, one registered nurse, two social workers, and a chaplain. The Palliative Care Institute has working relationships with hospice providers throughout the five boroughs of New York City. It also has a close working relationship with a Mount Sinai-sponsored Visiting Doctors program that conducts home visits, and relations with major home health agencies in all boroughs of New York. It has developed strong linkages with related disciplines, including geriatrics, general medicine, hospital medicine, anesthesia, cardiology, oncology, pulmonary medicine, neurology, and pediatrics. The clinical service is organized on a consultation model and has earned the respect of clinical colleagues throughout the hospital. The palliative care program is about to institute a screening tool that will evaluate all patients to determine if palliative care is appropriate.
Education. The program runs a post-graduate fellowship training program in palliative medicine that provides training for five palliative medicine fellows each year. Additionally, residents and fellows from critical care/pulmonary medicine, general internal medicine, anesthesia –pain
management, geriatrics, radiation oncology, and oncology rotate through the program. A required third-year medical student rotation was added recently. Rotations are optional for residents.
2 Morrison, et.al. Cost savings associated with U.S. hospital palliative care consultation programs. Arch Int Med September 8, 2008; 168(16):1783-1790.
The program has collaborative research studies with a number of related disciplines. Research, education, and care are mutually reinforcing. The program’s ability to get grants makes it a good friend to have for other specialties. In addition, the program provides mini-fellowships for the Visiting Doctors described above, and for physicians working in affiliated nursing homes.
Research. The program has secured more than $50 million of extramural funding since 1999. Dr. Diane Meier and Dr. Sean Morrison, the leaders of the program, have between them authored or co-authored more than 250 papers, among them the first published documentation of the savings associated with palliative care.
Factors for Success
Entrepreneurial program leadership. Meier and Morrison typify the highly motivated and
entrepreneurial leadership that is required to start new and different programs in a tradition-bound academic medical center. They are both superb clinicians—Meier provided leadership in developing the clinical program, and Morrison the research program.
Meier and Morrison were motivated by personal observation of patients treated inappropriately. In 1996, they described3 the history of a 73-year-old patient with terminal cancer who spent his
last 47 days in hospital, tied to his bed for 29 days and undergoing countless fruitless tests and procedures. Recognizing that a palliative care program could not be started with funding through clinical consultation revenues, they sought and received a United Hospital Fund grant for initial start-up in the late ’90s. Since then, the program has been assiduous in developing a diversified portfolio of philanthropic support from foundations, grateful patients and their families, and other supporters.
Palliative care must be an academic endeavor in an academic medical center. Meier and Morrison recognized from the outset that the program would have to conduct serious, extramurally funded
3 Morrison RS, Meier DE, and Cassel CK. When too much is too little. N Engl J Med (1996); 335:1755-1759.
Factors for Success
Entrepreneurial Program Leadership Committed Academic Endeavor Interdisciplinary Staff & Linkage to
Other Disciplines
Philanthropic
Support Community Network CommunicationsEffective
Balanced revenue streams from patient billings, extramural research funding, hospital support, and philanthropic support
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research, would have to educate fellow attendings, residents, and medical students, and would have to provide consistent high-quality care.
Clinical: The clinical program was rapidly built. In the first year, 500 patients were seen in consultation. By the third year, 1,000, and now about 1,800 patients are seen in consultation annually, representing about 1.5 percent of all admissions. The leadership of the program believes about 5 percent to 7.5 percent of all patients should receive palliative care consultation.
Education: The Palliative Care fellowship was developed through an NCI R25 education cancer grant. The fellowship was conceived as an integrated oncology or geriatrics and palliative medicine training program. It is now philanthropically funded and trains five palliative care fellows per year. Consultative work and rotations were initially based on relationships, but the exposure of geriatrics and oncology fellows led to their educating colleagues in their division about palliative care. Because it was an NIH grant, it had academic legitimacy and prestige.
Research: From the outset, the program conducted systematic evaluations of every patient seen, and developed a dynamic database. The early grant support built in a program evaluation component that became integral to the success of the program. Treatments and patient
satisfaction were recorded. These data and conclusions were presented to fellow faculty members —both to establish the need for the program and to demonstrate the academic rigor with which care was approached.
The emphasis on the research is on translation into practice. Dr. Meier leads the Center to Advance Palliative Care, CAPC (www.capc.org ), the program’s translational arm; and Dr. Morrison leads the National Palliative Care Research Center, NPCRC (www.npcrc.org), the program’s research arm. Overall, the Palliative Care Program, with more than $50 million in extramural grant funding since 1999, is seen at Mount Sinai by colleagues as a serious academic enterprise. A number of important publications resulted from the data that were collected, and these in turn have helped the program gain credibility both within the institution and nationally: Meier and Morrison have authored or coauthored more than 200 papers in the last decade.
A critical mass of interdisciplinary staff share the work of program development and patient care. As Meier stated: “We are a uniquely generative team with complementary skills— between us, we were able to cover a lot more bases and domains of advancing palliative care— both here and nationally.” The initial team of four faculty members was needed to share the day-to-day clinical consultation load as well as to do the necessary internal and external development work. The approach to expanding the clinical staff was creative: Faculty from related specialties, particularly in oncology, neurology, anesthesia, pulmonary medicine, and intensive care, were recruited to be palliative care service attendings for defined periods within the year. Not only did these physicians bring their own specialty skills to bear, but they also acquired palliative care skills that they took back to their home divisions. This approach both disseminated palliative care skills in related specialty divisions and also created demand for palliative care consultations. The value of the program was further demonstrated with the establishment of the Palliative Medicine fellowship—a collaboration between the oncology and geriatrics divisions based on an NCI grant.
Philanthropic support was secured early—both from foundations and from grateful patient donors. According to Meier, palliative care is a poster child for a systematic philanthropy strategy. Small and large foundations were recruited over a 20-year period. The philanthropic support created a constituency that led to additional support. In securing foundation support, Meier and Morrison tailored their proposals to the foundation’s interests. For example, in addition to the initial United Hospital Fund of New York grant that helped launch the clinical service, the program received subsequent additional funding to sustain itself.
Early funding also resulted from carefully tailored research proposals tied closely to clinical care. In the late ’90s, George Soros provided three years of faculty scholarships and funds to invite speakers and hold seminars. These speakers and seminars were critical to creating an understanding and acceptance of palliative care early in the life of the program. A group of foundations4 provided
funding to create and sustain the Center to Advance Palliative Care. It now provides support to help other institutions start palliative care programs and provides advocacy and education for palliative care nationally. Philanthropic support also helped to create the NPCRC. This companion national organization to CAPC was established in 2006 to develop and promote research in palliative care nationally.
In developing individual philanthropy, Meier believes that “real people” understand the need for palliative care much better than health care professionals. That understanding has motivated a number of individual philanthropists, mostly grateful patients and their families. One such family endowed the Palliative Care Center with a $5 million gift in the late ’90s, with additional gifts thereafter. Meier takes the time to steward the major donors and involve them closely in the work of the palliative care program so they feel involvement and ownership. In 2008, Meier was awarded a MacArthur Foundation award. The prestige of that award has attracted additional donors to the Palliative Care Center.
The palliative care program communicated with and mobilized all stakeholders at the outset using a variety of creative approaches and continues a consistent communication program. Executive support was secured early from both the medical school (the dean at that time, Dr. Arthur Rubinstein) and the hospital (Dr. Jack Rowe, the CEO at that time). A business and quality of care case was made from the systematic gathering of data from patient consultations. Faculty from related disciplines rotated through on a regular basis, thus becoming trained in the techniques of palliative care and at the same time becoming ambassadors to those disciplines where the majority of patients were. Gaps and deficiencies in care were documented in a
systematic way and presented in multiple forums. A patient registry was developed and continually updated. High-level seminars in palliative care were held for faculty. Outside experts were brought to Mount Sinai. Faculty who were known to be friends were targeted in other departments. Attendance was by invitation, creating an aura of desirability and exclusivity. After a few months, many faculty beyond those who had been invited to the program were asking to be admitted to the seminar series and were asking for consultations for their patients. Seminars continue today.
4 The Robert Wood Johnson Foundation, the Atlantic Philanthropies, the Brookdale Foundation, the Open Society Institute (supported by George Soros), and the Hartford Foundation
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The collaboration with oncology in the development of the palliative care fellowship was a critical step to putting the education component of the program on a firm footing.
5 Berger, A. Establishing a palliative care program in a research center: evolution of a model. Cancer Invest (2003); 21(2):313-320.
NIH Clinical Center Palliative Care Program
The NIH Clinical Center developed a palliative care program in the early 2000s under the leadership of Dr. Ann Berger.5 The key success factors for this program were strikingly similarto the key success factors at Mount Sinai. Berger started with a performance improvement project that involved departments interested in establishing a palliative care program: nursing, anesthesia, rehabilitation, social work, pharmacy, the NCI, the National Institute of Dental and Cranio-Facial Research, and the National Institute of Allergy and Infectious Disease. Berger benchmarked emerging palliative care programs to develop models and conducted research to provide customer feedback to clinicians and patient representatives via surveys. Key findings were the need for increased continuity of care across settings; the need to address patient symptoms that may be secondary to protocol requirements; and a review of the literature that indicated an undertreatment of pain in hospital settings. Three expert clinicians were invited to attend a review of the identified issues; this meeting solidified the need for the new program to be interdisciplinary and consultative in format, and broaden its scope to include not only pain management but pain management and palliative care.
Berger provided the clinical leadership for the program. Executive leadership provided public support for the program by attending rounds with Berger and her colleagues to introduce the new service to the different research teams. A consultative format was determined to be the best approach to facilitate the program’s growth. Integration of the pain and palliative care service into the functioning of the research team was critical to the success of the program. Teaching others was also seen to be critical to success. Daily rounds with the protocol team, daily follow-up visits, and documentation in a consultation format eventually won strong support from the clinical research teams. Now routinely, nurses on the units are the caregivers who typically call Berger first about a patient—a result of her constant presence in rounding on patients. Current staffing includes three physicians, two advanced nurse practitioners, and numerous rotators from other services.
Berger emphasizes a holistic approach that includes psychosocial tools to manage body, mind, and spirit. She emphasizes, like Meier and Morrison, that palliative care must be divorced from prognosis—palliative care is valuable for those patients being treated with curative modalities. She sees the palliative care physician as the one on the team who can clarify the overall goals for the patient. Berger is one of the authors of the fourth edition of a leading text, Palliative Care and Supportive Oncology.
Build a strong network of service across the continuum of care. Palliative care in centers with robust programs has become a routine part of the care of patients with complex illness, regardless of whether they are close to the end of life. Therefore, an effective palliative care program must provide services across the continuum of care. All the leading palliative care programs in the country, including Mount Sinai, have developed a strong network of care providers, including subacute care, home care, hospice care, and community physicians.
In addition, palliative care physicians must make themselves available in subacute and home
settings. At Mount Sinai, the palliative care program has a relationship with a group of Mount Sinai physicians with palliative care skills who make home visits. These physicians improve their palliative care skills by attending on the palliative care inpatient consultative service. Drs. Meier and Morrison and their colleagues continue to do home visits. They train physicians who provide care in subacute settings (nursing homes, hospice) in palliative care techniques through annual courses and mini-fellowships. Discharged patients are routinely followed in the palliative care clinic.
The program operates on balanced revenue streams from patient billings, extramural research funding, hospital support, and philanthropic support. The hospital provides about 40 percent of total funding; professional billing for clinical services provides 20 percent; extramural research grants provide 25 percent; and philanthropy provides 15 percent. Clinical billing supports 75 percent of physician salaries and 80 percent of nurse practitioner salaries. Compared to other leading palliative care programs, more of the revenue to support the program is derived from extramural funding. Financial results have been documented in peer-reviewed journals, which has helped to build continuing support from the executive leadership of Mount Sinai.
Lessons Learned
How palliative care is presented depends on the audience. For professional colleagues, the message initially was that palliative care is a consultation service; that is, “We don’t take over your patient.” Today the message is: “Use palliative care as a specialized consultative service—you can save time.” For families and patients the message is: “Improve the quality of your care.” For hospital executives, the message is: “Palliative care can improve quality and patient satisfaction and reduce costs.”
Palliative care in an academic center needs to be aligned with the academic mission of the center. While not every academic center can develop a broadly based palliative care research program, at a minimum the program must involve fellows, residents, and medical students in a meaningful way.
Develop a strong business case; meet with the hospital CFO to make the case. There is now plenty of evidence in the literature about cost savings from palliative care.
Understand the strategic interplay among the missions and among the funding streams. A robust clinical service leads to a strong foundation for education and research; success in the missions facilitates garnering philanthropic support, which in turn leads to greater capabilities.
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Resources
A number of national organizations are working to advance the recognition and the practice of palliative care medicine.
The Center to Advance Palliative Care (CAPC), formerly a national program office of the Robert Wood Johnson Foundation, now funded by a consortium of private-sector foundations,7 provides
support for institutions wishing to start palliative care programs and provides advocacy on behalf of palliative care. Its director is Dr. Diane Meier. CAPC provides resources and technical assistance for building a hospital-based palliative care program: making the case, designing and financing
6 Meyer, H. Changing the conversation in California about care near the end of life. Health Affairs (2011); 30(3):390-393. 7 The Archstone Foundation, Atlantic Philanthropies, the Brookdale Foundation, the Donaghue Foundation, the John A. Hartford
Foundation, the Mill Park Foundation, the Olive Branch Fund, the Partnership for Palliative Care, the Robert Wood Johnson Foundation, and the Y.C. Ho/Helen and Michael Chiang Foundation.
Sutter Health Community Based Palliative Care
An example of a strong community-based palliative care program that focuses on delivering palliative care to patients who are not in an acute-care setting can be seen at Sutter Health, a system with 24 hospitals in northern California.6 The Advanced Illness Management (AIM)program was launched in two Sutter hospitals and in three large medical groups in the Sacramento/Sierra region. AIM is described as “an integrated system of care for patients with late-stage chronic illnesses that provides home-based transitional and palliative care and counsels patients and families with the goal of increasing hospice use and decreasing the use of unwanted acute care.” This program focuses on patients with severe chronic disease who may die in a year, including patients who may benefit from palliative care but who have not chosen hospice or who may not yet be eligible. The rationale for such a program in the Readiness for Reform context is that a program based in the community can significantly reduce hospitalizations. According to program leader Brad Stuart, it is easier to enroll patients in AIM than to get them to choose hospice: “It’s perceived as providing a lot of help rather than making people admit that they are dying.” AIM staff members approach patients in hospital and provide support for their return home. A similar process is used at the three medical groups for ambulatory patients. AIM, unlike hospice, does not require patients to give up curative care. The program enables a gradual transition from aggressive medical treatment to more comfort-oriented care, at the patient’s and family’s pace and discretion.
The Sutter program described above documented that among 185 patients who enrolled in AIM and lived at least 30 days, 68 percent had fewer hospitalizations. Patients who lived 90 days had 63 percent few hospitalizations. Average savings per patient were $2,000 per month. Of the terminally ill Medicare patients in the program, 47 percent were discharged to hospice, compared to 20 percent who were not enrolled.
a program, and measuring quality and impact. It provides support and technical assistance for developing the necessary network across the continuum of care, including hospice-hospital partnerships, long-term care, and community-based palliative care. It provides mentoring and operating training to nascent programs. It has established eight palliative care leadership centers that provide mentoring, including Akron Children’s Hospital; Children’s Hospitals and Clinics of Minnesota; Fairview Health System in Minnesota; Mount Carmel Health System, Columbus, Ohio; Palliative Care Center of the Bluegrass, Lexington Ky.; the University of Alabama at Birmingham; the University of California, San Francisco; and Virginia Commonwealth University (VCU) Massey Cancer Center, Richmond, Va.
The NPCRC is a companion organization to CAPC that focuses on stimulating and funding research in palliative care. Its director is Dr. Sean Morrison. NPCRC is funded by several foundations.8
For academic medical centers starting a palliative care program or for centers with a primarily clinically oriented palliative care program, this center represents a resource to establish a research component to their program. The missions of the NPCRC are to establish priorities for palliative care research, develop a new generation of researchers in palliative care, and coordinate and support studies focused on improving care for patients and their families living with serious illness. Its areas of interest for funding include pain and symptom management; communication between adults and children living with serious illness, their families and their health care providers; and models of health care delivery.
The Coalition to Transform Advanced Care (C-TAC) (www.advancedcarecoalition.org) is a new organization started in 2011 by Bill Novelli, the former CEO of AARP, whose goal is to advance generally the treatment of complex and life-threatening disease, through advocacy and the development of systemwide models. It has a broad set of stakeholders, including patient and consumer advocacy groups, health professionals, faith-based organizations, and health care payers. Several large health systems are represented: Sutter, Gunderson Lutheran, Allina, and Ascension. The AAMC is represented on its board. Its work includes policy and advocacy at the federal and state legislative and executive branches; public education and engagement, developing clinical models of best practice, and professional education. It uses the term “advanced care,” because it believes that the term “palliative care” is not well understood by the public.
8 The Emily Davie and Joseph S. Kornfeld Foundation, the Brookdale Foundation, the Y.C. Ho/Helen and Michael Chiang Foundation, the Mill Park Foundation, the Olive Branch Fund, Atlantic Philanthropies, the Open Society Institute, the Betty and Norman Levy Foundation, the American Express Foundation, the U.S. Cancer Pain Relief Task Force, the Lord Foundation, the Hearst Foundations, LiveStrong, American Cancer Society, the American Academy of Hospice and Palliative Medicine, the Hospital and Palliative Care Nurses Association, and the National Institute on Aging.
