Date: 07/27/2009
Final
Life Quality Insitute
HOSPICE AND PALLIATIVE CARE
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11:12 AM -- Life Quality Institute
The committee reconvened. Dr. Daniel Johnson, Regional Chief, Department of Palliative Care, Kaiser Permanente, began his presentation on palliative care (see Attachment E). He discussed how people have different definitions and expectations of end-of-life care. He described Kaiser Permanente, which is an integrated health plan that provides insurance and delivers health care services. He said that Kaiser Permanente serves about 500,000 members in Colorado and employs approximately 700 physicians.
11:16 AM
Dr. Johnson discussed three control trials concerning palliative care that touched on aspects such as family satisfaction, pain management, and hope. The studies showed that palliative care did not affect mortality, but did improve quality of life. The control trial on inpatient palliative care showed that palliative care reduced utilization and costs. The home-based palliative care study also showed increased satisfaction and increased likelihood that the patient would die at home. The study on advanced illness care coordination showed that four to six visits by a palliative care social worker provided more support for patients and families, addressed spiritual affairs, and decreased utilization and costs.
Dr. Johnson explained that Kaiser Permanente began its palliative care center in 2005. Dr. Johnson said that hospice is the gold standard for palliative care. He discussed the other types of palliative care for people who may not be ready or eligible for hospice.
11:23 AM
Dr. Johnson discussed the number of patients participating in various palliative care programs and described the lessons of Kaiser's experience with palliative care. He said that families aren't always after the most advanced or expensive treatments, but rather that they want improved quality of live and to be able to stay in their home. He described Kaiser's investment in the palliative program and community relations and partnerships. Dr. Johnson talked about how Kaiser's lessons can be applied to other systems.
Senator Newell asked about data from the control group in the randomized control trials. Dr. Johnson described the methodology of the control trial.
Representative Roberts asked how Kaiser accomplished shifting the physician mindset concerning palliative care. Dr. Johnson said that as director of the Life Quality Institute, he does education and outreach. He said that Kaiser works to identify advocates of palliative care that can promote the model. He said that families are also valuable advocates if they have a good experience, and families can influence doctors' behavior and views toward palliative care.
11:30 AM
Representative Riesberg asked about communication with the Colorado Hospice and Palliative Care Association. Dr. Johnson described Kaiser's partnership with the association.. Representative Roberts asked about the pharmaceutical component of palliative care and the large number of medicines that are often involved, and possibilities for cost savings and improved quality of life. Dr. Johnson said that many people with advanced illness do require a large number of drugs. He stated that palliative care physicians must understand a patient's goals before altering a patient's medication, i.e., whether the patient is seeking curative care or care for pain management. He mentioned that palliative care and hospice care can reduce need for some medication and reduce costs. Representative Roberts asked how Kaiser promotes advance directives and if patients are accepting of them. Dr. Johnson said that he believes that advanced directives are important, but are limited tool that do not always do what they are intended to do. He described Kaiser's public training on advanced directives. He noted that only about 20 percent of the public creates advanced directives. He said many individuals do not know what they want and want their families to do the best they can. Dr. Johnson said that a 90 percent goal for completing advanced directives is not feasible. He said the goal should be for skilled and compassionate caregivers to guide families and patients through the process.
11:38 AM
Senator Williams asked if palliative care is included in all Kaiser policies. Dr. Johnson said that usually it is, but sometime home-based palliative care is not included. Senator Williams asked about CPR directives and other advanced directives. Dr. Johnsons said that patients often discuss what they want and it can be put in the patient's electronic medical record. However, he said patient wishes on advanced directives and orders are a moving target and the physicians need to continually ask patients their wishes to revise their orders. Dr. Johnson said that the goal of annual updates on patients' wishes regarding advanced directives is important, but difficult.
11:41 AM
Representative Roberts asked about data concerning prescription drug costs. She also asked about national health care reform and the role of hospice and palliative care in the reform effort. Dr. Johnson described some of the outreach efforts to put hospice and palliative care into federal discussions regarding health care reform. He stated that hospice care and its possible cost savings are getting a lot of attention. He mentioned the Veterans' Administration as another integrated care model that provides hospice.
Representative Roberts asked about local efforts to implement hospice and palliative care. Dr. Johnson discussed how local situations and barriers can influence a national initiative to implement a program like Kaiser's.
Senator Newell asked what can be done legislatively. Dr. Johnson discussed recommendations and discussed serving patients who are eligible for both Medicare and Medicaid. He also discussed how physicians are not reimbursed for consultations concerning end-of-life care. He said that it is important to show that having the consultations can increase length of stay in hospice and lead to other improvements. He said that community-based palliative care needs to be certified so that quality services are there. Dr. Roberts said there is a need for accreditation of programs. He also discuss loan forgiveness and other incentives for getting people into the field of hospice and palliative care.
11:52 AM
Senator Tochtrop asked if physicians need continuing education regarding hospice and palliative care. Dr. Johnson said it depends on the institution. Representative Tyler asked about the community, team-based model and if it can go beyond palliative care. Dr. Johnson said team care is a good model and that there needs to be the right training to ensure that the teams work well and meet the needs of the patients. Representative Tyler asked if a team approach would work in treating chronic disease and in other areas. Dr. Johnson said that there needs to be training around the specific area of care.
Representative Soper asked about board certification for palliative care. Dr. Johnson discussed the board requirements and deadlines. Rep. Soper asked if general practitioners or other specialists must answer questions regarding end-of-life care on their board recertifications. Dr. Johnson said specialists who do not work in palliative care probably do not have to answer such questions. He described why it is necessary to improve knowledge of end-of-life care among all doctors. Senator Williams asked about social work certification and palliative care requirements. Dr. Johnsons said that there are no palliative care certification requirements for social workers and chaplains.
12:00 PM
Representative Roberts asked about the role of advanced practice nurses, especially in rural areas. Dr. Johnson said that advance practice nurses are important in the palliative care model. He said that advance practice nurses can do great things, especially with physician back-up.
Dr. Johnson concluded his remarks by discussing education and increasing awareness concerning end-of-life care. The committee recessed.