Palliative Care Models
Home-Based Palliative Care in a Shared Savings Environment: An Interview with Dr. Dana Lustbader
November 29, 2016 | By Dana Lustbader
In this post, CAPC interviews Dana Lustbader, MD, Chair of the Department of Palliative Care at ProHEALTH Care Associates in New Hyde Park, NY. Dr. Lustbader is a member of CAPC’s Home-Based Palliative Care Workgroup, an interdisciplinary committee of advisors producing technical assistance for home-based palliative care programs.
ProHEALTH Care Support is the home-based palliative care division of ProHEALTH Care, a large integrated multispecialty physician group with over 900 providers and 200 locations serving the New York metropolitan area. ProHEALTH Care Support is a specialty-trained team of doctors, nurses, and social workers that provides home-based palliative care to seriously ill patients. The team works with the patients’ other doctors to provide an extra layer of support to patients in their homes, with a focus on providing the right care at the right time. It is a nurse and social worker-driven “high touch” medical care model with strong physician involvement. A unique aspect of this program is the innovative use of telemedicine to provide virtual physician and social worker visits. The program also provides 24/7 telephonic coverage with strong partnerships to ProHEALTH Urgent Care Centers so patients are protected from unnecessary and avoidable emergency room visits and hospital admissions. The ProHEALTH Care Support program has three payment sources: fee-for-service, per member per month arrangements with health plans, and shared savings with health plans including a Medicare Shared Savings Program Accountable Care Organization (ACO).
ProHEALTH Care Support recently published outcomes data in the Journal of Palliative Medicine in an article titled “The Impact of a Home-Based Palliative Care Program in an Accountable Care Organization”. Key results for home-based palliative care patients in the Medicare Shared Savings ACO include:
- 34% reduction in hospital admissions in the final month of life
- 35% increase in hospice enrollment and 240% increase in hospice length of stay
- $12,000 reduction in cost per patient during the final three months of life
CAPC: How did your palliative care program get involved in ProHEALTH’s Medicare Shared Savings Program ACO?
DL: I had been doing inpatient critical care and inpatient palliative care in a large hospital-based health system for twenty years. I had this idea that home-based palliative care was something we should move towards. Two years ago, I called the CEO of ProHEALTH, and I happened to call him on the day he was sitting on an $11MM check from Medicare – ProHEALTH’s half of the $22MM savings that we received in the shared savings program. He thought palliative care would be a great way to help manage the highest-need, highest-spend patients within our ACO so that we could continue to receive shared savings payments while providing valuable palliative care services to people with advanced illness.
CAPC: So right out of the gates, you knew you were building the program in the context of the ACO and of shared savings.
DL: Yes, but that’s not actually how I started the program. We have about 900 doctors and initially I did what I had done in the hospital – open the doors wide open and say, “Send me all your seriously ill patients.” I started hiring up my staff, and we saw anyone who was a ProHEALTH patient with serious illness who had become too sick to come in to their doctor’s office for visits. After six months I realized that the way to continue to pay for, sustain, and grow the program was to find the financial sweet spot where it made sense for us to send nurses, social workers, and doctors to people’s homes – because we weren’t going to make up our program costs in the fee-for-service model. I knew we would go belly up in a year or two if we didn’t think more about ROI (Return On Investment) and sustainability.
I became laser focused on the ACO after that first six months, and I started to use some of the data we had from the Medicare claims to create an algorithm to find the sickest ACO members. We could proactively identify those members with advanced illness, frequent hospital admissions, emergency room visits, frailty (e.g. ordered a walker or hospital bed) and who had a high disease burden based on the Charlson comorbidity index. We focused our program on that population so that we could continue to pay for our services out of the shared savings dollars that we received.
CAPC: What performance measures are important for your ACO population?
DL: In the Medicare Shared Savings ACO itself, there are 32 general quality metrics that ProHEALTH has to meet – and we are one of the top performers in the country on meeting those metrics. They include things like cancer screening, diabetes care and flu shots, etc. More specific to palliative care, we track location of death (most of our patients would like to be at home) and documentation of advance directives and preferences. 87% of our patients are able to die comfortable at home, which is a sharp contrast to the 25% who die at home if they don’t have access to home-based palliative care. We also track hospital and ER visits in the final 30 days of life, and we track healthcare spend by month in the final months of life. We track hospice referral rate and hospice median LOS, and we now track patient and family satisfaction using a Net Promoter Score – “How likely are you to recommend the program from zero to ten?” We do a pain and symptom assessment and we track how often we document the assessment. We also want to understand the impact of our program on quality of life – right now we ask patients how they would rate their quality of life on a scale of one to ten and we ask that at each visit to be able to track over time.
We developed these metrics ourselves because we are becoming experts in the space – we develop them, we test them, we tweak them. We are piloting a serious illness conversation script written directly into the EHR to help frame patient conversations, and we’ve written it to include questions such as, “What are you worried about most?” and “What is most important to you as your disease progresses?” We have a lot of flexibility to pilot and test new things and to course correct very quickly within our ACO because we have access to such rich cost and utilization data. It’s a wonderful environment and laboratory in which to study what is working in our home-based palliative care program and what isn’t.
CAPC: Can you explain for readers exactly how and when you get paid in relation to your services for ACO members?
DL: In our shared savings programs – including the Medicare Shared Savings ACO and programs with other health plans –we get paid after the fact if we’ve achieved savings or met certain targets. With the health plans those targets are the MLR [The Medical Loss Ratio is the ratio of health plan spending on medical care to total health plan premium income – under the ACA, health plans must achieve an MLR of at least 80-85% or the plan is required to provide a rebate of the difference to its members], or utilization metrics like hospitalizations or ER visits per thousand members per year, or it might be satisfaction or another quality metric. If we meet those quality and cost targets we get a bonus payment at the end of the year. The Medicare shared savings payment comes in even later because of the way the shared savings bonus is calculated – we will get our 2015 check sometime this week (November 2016).
CAPC: How do you meet payroll given this delayed flow of funds?
DL: It’s an investment by the organization based on a belief in the value of our palliative care program – but we also track every quarter whether or not we’re on target for the shared savings metrics with all of our health plan partners. The ACO provides us with our benchmarks so we understand how likely we are to hit our goals. That allows us to focus on where we may fall short.
Financing home-based palliative care services – particularly in partnership with a health plan – takes creativity. I met with a health plan recently and they noticed that 18 of their Medicare Advantage patients (who had not previously been served by our program) were not coded with quadriplegia or frailty or cachexia as they had been in the past. Since they are seriously ill and homebound, our palliative care team can actually visit those patients to help the health plan with coding accuracy and completeness, and more importantly take advantage of the opportunity to assess for palliative care needs and provide those services. This is an example of how we can be creative with health plan partners to meet their needs, and in turn get paid a case rate to provide much needed home based palliative care services to people who would otherwise not have access to palliative care.
CAPC: Does ProHEALTH only participate in shared savings, or do you also accept risk?
DL: In the next year or so we will be standing up a risk-bearing entity in the Northeast. That’s important, because it is another incentive for ProHEALTH to invest in home-based palliative care regardless of whether we get a shared savings payment or not: as an organization we need to learn how to manage risk. As we enter into a world of value-based payment and full risk we want to have the capabilities to not just do specialty palliative care but also case management and population health for a broader population. ProHEALTH sees home-based palliative care as a strategic investment for the organization. It’s not just about the P&L of the department, but also about where we as an organization are going in the future.
CAPC: So in that sense, is it fair to say that your home-based palliative care program is leading the charge and sharing its lessons with the rest of the organization?
DL: Yes – we are leading the charge and that can be good and bad. We are viewed as the “experts at sick people” so there are other initiatives that we are sometimes pulled into that can be distracting. However, our primary focus and what we do best is home-based palliative care. We’ve gotten that down to a model that is very cost-effective, very attentive to clinical quality, and very patient- and family-centered. We do that through a nurse (RN)-based home visiting model, with social work support and high levels of physician oversight for these complex patients.
For example, we were asked to go in and ‘rescue’ people out of sub-acute rehab for the hospital. Although the potential return on investment could be huge, that commitment could also have drained our program’s resources. We found that we can do a lot better by preventing the avoidable hospital admission in the first place – and that’s an even greater ROI. We can be in people’s homes, we can treat the UTI much sooner or on a Saturday so that the patient doesn’t get septic in the first place and they don’t get admitted to the hospital and go to rehab. We decided to move much further upstream because it is our program’s core competency, and because it has a higher likelihood of working.
CAPC: What advice would you give to a health care professional who is planning a new home-based palliative care program?
DL: One of the most important things is to stay laser-focused on building a high quality palliative care program, which requires a full interdisciplinary team and close and regular oversight of the medical and social needs of this high-risk group. You are not in a position to bargain or negotiate unless you have a rigorous program under your belt. That means having seen a few hundred patients already, and having a little bit of data to show for it – even if it’s descriptive data.
ProHEALTH’s cost and quality data can be read in their a publication in the Journal of Palliative Medicine here.
For practical program startup information, business planning support, and profiles of ProHEALTH and the other nine programs in CAPC’s Home-Based Palliative Care Workgroup, order the Guide to Home-Based Palliative Care Program Design. Members, take CAPC’s online continuing education courses in community palliative care program design, and download tools from the CAPC Home-Based Toolkit. Download CAPC’s glossary of payment terms here.
This is the third post in CAPC’s home-based palliative care blog series. In case you missed #1 and #2, we’ve linked them below.
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