Name of Project: CHOICES (Comprehensive Home-based Options for Informed Consent about End-stage Services)
Institution: Sutter Visiting Nurse Association and Hospice, Santa Rosa, CA
PI: Brad Stuart, MD and Carol N. D’Onofrio, DrPH
Abstract (as described by Project staff)
CHOICES provides 1) care coordination; 2) patient/family education; 3) advance care planning; and 4) home-based medical, psychosocial and end-of-life care to Medicare HMO patients. The program aims to increase quality of care and quality of life for patients who are ineligible for home care or hospice, while maintaining revenue neutrality or cost savings.
Brief Synopsis of Program Characteristics, Successes and Challenges
CHOICES is designed to provide care to Medicare HMO patients who traditionally fall outside of the care available from home health or hospice. Home health care services, by regulation, are limited to patients with acute skilled nursing needs. Hospice is limited to patients with a six-months prognosis who have agreed to forego further curative treatment. Many chronically ill patients who are approximately within two years of death are not eligible for either home health or hospice. And, many patients with advanced illness benefit from a combination of acute care and palliative care…these are the patients that CHOICES is designed to serve.
At the core of this model is a philosophy of offering patients a full range of care options and then providing the necessary management to assure preferences are met. This is accomplished by a home-based care management system, provided by a team consisting of a geriatric nurse practitioner, RN, and social worker. The team describes the heart of the project as working with patients and families on defining their wishes, a process that proved far more difficult than initially imagined. Staff relate that it has taken several years to fully appreciate that advance care planning is a process (not a piece of paper) that can only successfully occur when attention is paid to building relationships and developing trust, particularly when working with patients who don’t yet define themselves as terminal.
The project brochure (a beautifully designed three-fold) conveys the philosophy that CHOICES is not a program for the dying; rather it is about moving palliative care “upstream.” The service package is described as follows: “In partnership with patients, families, physicians, and other primary care providers, the CHOICES team provides in-home assessments, planning and informed consent, choices about treatments, and home-based case management,” supplemented by a range of services including acute medical intervention, life-sustaining treatments, pain and symptom control, medication monitoring, and end-of-life care if needed.
The CHOICES project is being piloted through a rather complex network of organizations. It is a service of Sutter VNA and Hospice (formerly VNA and Hospice of Northern California) offered to capitated Medicare enrollees whose health care is managed by North American Medical Management (NAMM), a nationwide business specializing in co-ventures with leading physicians and hospitals to deliver medical services in managed care markets. The physicians responsible for the care of NAMM enrollees in the project service area are organized in 6 PODS (Physician Organized Delivery Systems). The CHOICES demonstration project concentrated on 2 of these PODS, selected because of their medical directors’ interest in palliative care; other PODS were used as controls. Project staff paid great attention to educating the physicians in the participating PODS about the project itself and about the eligibility criteria and clinical triggers used to identify at-risk patients appropriate for CHOICES. Staff feels that peer leadership among physicians has been a critical element of the project’s success.
Project research staff is collecting cost data using NAMM’s information systems. While there have been numerous difficulties obtaining the data, preliminary results indicate that the cost of care for patients in the intervention has decreased. The project has been challenged by the inherent difficulties in accounting for costs associated with end-of-life care and staff has expressed gratitude for the creation of the NPO’s Cost Accounting Workgroup, seeing it as a forum to work collaboratively with others trying to crack this complex nut.
Exportable Products/Tools
During the project, staff has created:
Policy Issues
Dr. Stuart talks about the importance of aligning incentives in such a way that it makes financial sense to provide high quality care in accordance with patient preferences.
Communications
The nature of this project lends itself to a variety of dissemination topics, including:
The team’s social worker feels the project has gained considerable insights into the process of advance care planning and he is interested in writing an article on the topic. Additionally, the project should be discussed in nursing, social work, hospice and home health, and managed care circles.
Internal Sustainability
When project staff was asked what it would take to sustain what they have learned, they replied:
Generalizing the Model
In Dr. Stuarts’ view, CHOICES is ready to be rolled out in the Sutter system; we should explore Sutter’s inclination to do this during the conference call. Rolling the project out into such a large system would potentially bring care coordination for advanced illness to a large number of chronically ill patients in the Bay Area. Additionally, a solid base for CHOICES has been established that should allow expansion to additional PODS in the NAMM system. The project should look beyond the Sutter system in exporting its work, based on Dr. Stuart’s belief that the CHOICES model can be replicated wherever there is a managed care capitated system.
When project staff was asked what it would take to generalize what they have learned, they replied:
Words of Wisdom from the Project
When project staff was asked what advice they would give to others considering a similar project, they replied: