Message to the Field on the New IOM Report
On September 17th, the Institute of Medicine (IOM) released its new report on improving quality of care near the end of life. I had the privilege of serving on the report committee over the last two years, both as a writer and as a member of the consensus decision-making process on the recommendations provided.
The title of the report, Dying in America, is something of a misnomer. The report actually focuses extensively on people with serious and chronic illness of indeterminate prognoses, and why the current health care system has largely failed to meet their needs.
As a nation, we are fortunate to have a strong, primarily home-based, hospice infrastructure. Hospice is the gold standard of care quality for those who are at the end of life and predictably dying. Hospice care for people who are dying has been shown repeatedly to markedly improve quality of care during this most vulnerable and stressful phase of life. Thus, care during the last few months of life, if the patient is receiving hospice care, is not the main problem facing our healthcare system. Instead, the difficulties lie in the lack of options available for people who are either not hospice-eligible (due to uncertain or long prognosis or the continued need for disease treatment) or who are referred to hospice too late in the course of disease for hospice to truly influence the experience of both the person with serious illness and their family.
The IOM report calls for two fundamental and profound changes in organized medicine, which have the potential to greatly improve quality of care for our sickest patients.
The first is a call for universal education and training for all health professionals and clinicians (e.g., physicians, nurses, social workers and others) in the core principles and practices of palliative care. These practices include pain and symptom management; the safe and effective use of opioids; skilled communication with patients and their families to help them determine their goals; how the health care system can help them achieve those goals; and seamless, well-coordinated and well-communicated care, across multiple settings, over time.
The fact that a vast majority of today's clinicians have had no meaningful training in these essential skills is cause for serious concern. Without fundamental change in health professional training, no matter how payment and system designs may change, clinicians will be unable to adequately meet the needs of patients facing serious illness.
Since all meaningful change begins at the local level, and requires effective local leadership, the challenge before us now is to work within our own organizations and communities to change what is taught and how it is taught. CAPC looks forward to working with you to strategize ways to make an effective case for comprehensive interdisciplinary training in palliative care, both for those still in training and for those already in practice. A great example of our field's readiness to support the IOM's call for scalable training in essential communication skills comes from the VitalTalk team, namely Anthony Back, Robert Arnold, Kelly Edwards and James Tulsky (see vitalktalk.org and @vitaltalk). I encourage you to become a VitalTalk trainer, so you can bring this superb teaching experience back to your own colleagues and trainees, and ultimately to all the care settings where it is so urgently needed.
The second groundbreaking recommendation of the IOM report concerns coverage of both the social and medical needs of the most serious and complex patients. Approximately 40 percent of all medical spending is precipitated by unmet social support needs, including low literacy, language barriers, poor nutrition, unsafe housing, family violence, mental illness and—perhaps most important of all—the absence of support for exhausted and overwhelmed family caregivers.
Why don't we pay for these services? It is prohibited by law under the Medicare statute which covers only those services that are "medically necessary." Interestingly, as our payment system moves from a fee-for-service, pay-for-volume system to a global health care budget (where providers accept financial risk and become more focused on quality than quantity)—we are seeing medical-center operating dollars spent on social supports. This underscores the inextricable connection between healthcare reform and our ability to address social as well as medical needs.
As the palliative care field moves beyond hospitals to home-based care, long term care and other community settings, its success and sustainability will depend on the ability to integrate social and medical support services. One example of this kind of progress comes from my own hospital—the Mount Sinai Health System—which responded to the 30-day readmission penalties imposed by Medicare in the Affordable Care Act. Mount Sinai hired 80+ social workers to go out into the community to identify and address the social determinants of frequent emergency-room and hospital use. The problems they identified involved unsafe housing, lack of family support, high levels of family violence and trauma, poor literacy, language barriers, untreated mental illness and overwhelmed family caregivers. When these issues were addressed, 30-day readmissions plummeted. For details (see http://www.bloomberg.com/news/2013-09-25/obamacare-keeps-patients-at-home-slowing-hospital-use.html).
In 2015, CAPC will launch an extensive training series, featuring tools and technical assistance based on the best practices of various leaders and programs in our field, in order to help bring those community-based palliative care delivery models to scale in the United States. We will also offer clinical training on core palliative care skills and knowledge (such as safe and effective opioid prescribing and critical communication strategies) for front line doctors, nurses, and social workers.
To learn more about the IOM report, please join me for a webinar on Tuesday October 28 at 1:30PM EST. We will start with a web survey, in which I will ask for your ideas on leveraging the report and its recommendations—please come prepared with your suggestions. I will then discuss the report in depth, including how best to use it, as we advocate for positive change in our health systems and communities. For more information, please contact CAPC at 212-201-2670.
Diane E. Meier, MD