Time & Motion Study of Community Based Palliative Care

We have a new paper (open access) in the Journal of Palliative Medicine, providing a Time and Motion study overview of the care delivery model at the heart of our CMMI HCIA-2 innovation award with Four Seasons Hospice in Western, North Carolina (Janet Bull, who is also President of the American Academy of Hospice and Palliative Medicine and I are the co-PIs of the project).

This figure provides an overview of the palliative care model that we are providing across setting (~5,000 patients will enrolled by the end of Summer, 2017, and we just received Medicare claims records for the first 2+ years of the project, so should have preliminary cost findings in the Fall).

TimeandMotion.6.6.17jpm.2016

 

Death with Dignity Forum, March 17

I am participating Thursday, March 17 in a public forum discussing pending “Death with Dignity” legislation in the North Carolina General Assembly (Thursday, March 17, 4-7pm, Friday Center in Chapel Hill; free but registration required).

I don’t consider myself an expert on the topic of Assisted Death* (where the patient must administer a lethal dose of prescribed medications; that is the topic of the forum Thursday, and is the basis of the Oregon law) or Euthanasia (where a physician administers a lethal dose of medication; illegal in all U.S. states, but legal in some European countries), but do focus most of my research attention of hospice, palliative care and how we care for persons with disability. I am a member of the “Death with Dignity” panel to discuss how we care for the dying generally in the U.S.

I am ambivalent about Assisted Death legislation–meaning I have conflicted views and can see the issue from both the pro and con positions. I suspect most other panelists have quite strong views, either for or against. This got me to thinking about the most convincing case I have read about the pro and con positions as someone who remains ambivalent.

There is not a singular “pro” piece I can point to, but instead it is the fear of a future unremitting suffering for myself and my family (this worries me most–that I will burden my children) merged with my current position in life that leads me to see the “pro” point of view. By current position in life, I mean that I am a person with prestigious job and career status, power, good economic means and someone who is generally used to things going roughly speaking how I wish them to go. And if they aren’t going as I wish, I have a general sense that I can do something to change the course of events. The “pro” position of maintaining my options is quite intuitive to me.

This from Katherine Sleeman, a Palliative Care physician in England from the Cicely Saunders Institute, University College London is the most convincing, succinct argument against Assisted Dying laws that I have read. I won’t summarize it–it is short, so go and read it. The piece is effective and convincing in arguing against Assisted Dying legislation to me because it doesn’t treat the issue as a simple one, and also because it notes how much work there is to do to improve our systems of caring for sick and infirm citizens regardless of how this issue is decided.

In that sense, the issue of Assisted Dying is far from the most important end-of-life topic of our day, and the noise around this debate crowds out the most important issue as I see it–developing coherent systems of providing the care that most of us will need before we die. The basic policy milieu available to the dying and their families will effect far more persons than any Assisted Dying law ever would. Let’s not forget that.

 

*A fight of the language of how to even talk about this is possible, but not so useful. I think Assisted Death is the most descriptive term. The law being proposed is called “Death with Dignity” which is a more positive framing, and opponents will sometimes call this anything from killing to murder, which is obviously a less positive framing. My two cents.

CMMI proposal on Community Based Palliative Care

Blogging was non-existent this week because I was working on a huge CMMI grant that was due yesterday. We (myself + Amy Abernethy at Duke and our long time partners Four Seasons Hospice and Palliative Care, lead by Janet Bull) are proposing to expand the Four Seasons Community-Based Palliative Care (CPC) model that is running in 4 Western, North Carolina counties to 14 counties, and to evaluate the impact (N=10,000 patients/3 years) on patient outcomes and cost.

From this evidence base, we will develop a new financing approach for CPC in the Medicare program (we plan to develop both a transitional fee for service approach designed to make CPC a break even propostion (it is now a $ loser), as well as a fully bundled/capitated payment approach that would reduce overall Medicare costs and allow for shared savings, as the long run goal). The ability to work with such great colleagues on issues of consequence is very exciting.