“We’re in this odd situation in the U.S., where everybody agrees advanced care planning is super important, and nobody does it.” 

At the recent NAACOS meeting, that was how Nathan Moore, M.D., medical director of BJC HealthCare’s accountable care organization, led off his presentation about how BJC has increased advanced care planning and the impact it has had on the use of palliative care. 

St. Louis-based BJC HealthCare is a large integrated health system with 14 hospitals. Moore further explained the conundrum about the lack of progress on advanced care planning. He said reading the literature, two themes repeatedly emerge. One is that it's hard to figure out which patients need this intervention and when. Second, how do you engage providers to have these difficult, time-consuming conversations? “Primary care says you should talk to your oncologist. Oncologist says you should talk to your cardiologist,” he said, “Patient gets admitted, and the hospital says, ‘I just met you, you should talk to your primary care doctor.’ Nobody wants to be the bad guy.”

Some health systems’ approach is that advanced care planning should be like blood pressure — just do it for every patient, every visit. “That is not realistic, nor has it been shown to be helpful,” Moore said. “Instead, you have to figure out where along the care continuum you want to do the intervention. Is it outpatient, primary care, specialty care? Is it inpatient? Is it ICU? Is it post-discharge? Then you have to figure out which tranche of risk patients you are trying to target — who to target and when, and then who is providing the intervention.”

Providers and patients are both looking for excuses not to have this conversation, Moore stressed. “In our system, our mantra is make this as painless as possible.” He recommends focusing efforts on implementation and usability.

It also depends on what resources you have available in your health system. “But the real impact when it comes to ACOs and cost of care doesn't come from the conversation itself. It helps, but it's what you do after that,” Moore said. There's palliative care in an outpatient setting or telemedicine, and home-based palliative care.

He mentioned a publication about an ACO’s home-based palliative care reducing total cost of care substantially. In that case the palliative care was helpful, but what really moved the needle with their spending was that when those patients called their general triage line with dyspnea or nausea or fatigue, they didn't go down the typical protocols that everybody else in their triage line did. If they were already enrolled in home-based palliative care, they went down an alternative triage pathway so they weren't just reflexively sent to the emergency room. “You really have to change your downstream workflows with these patients to reduce utilization that we know isn't really going to help the patient,” Moore said. 

Another option involves hospital-at-home programs. Moore said he spoke with leaders of an ACO in Iowa a few years ago. They would identify their frail elderly that were likely to need admission in the next 12 months, and get everything set up for hospital at home for when the time came. Part of that process was thinking through how hospice is a likely outcome for a lot of these patients, so instead of being reactive, they were proactive and had those resources available. 

Then there is hospice. “I think all of us would agree hospice is the preferred pathway before dying for most patients, and the more you get the better — at least two weeks, and ideally closer to three to six months,” Moore said. 

Once you've decided on a program, what can you measure for success? You can track documentation in the EHR, hospice utilization and billing codes. 
“Our vendor automatically reports for our patients who die — did they get no hospice, hospice for less than two weeks, or hospice for more than two weeks,” Moore said. “There’s a substantial difference in total cost of care near the end of life. That's a fairly easy data point for ACO board members and hospital leadership to understand. I am happy to report that our ACO, for the first time ever, has finally hit national average for hospice use.”

Creating an algorithm

BJC HealthCare set out to help prioritize which patients to have these conversations with. “We looked at some of the available algorithms out there, and nothing seemed to meet our needs, including the native one in our EMR,” Moore said, “so we ended up working with our informatics colleagues to build a machine learning algorithm that takes basically every structured piece of data out of our EMR and claims to predict risk of dying. For example, for any patient admitted to any of our hospitals, on the day after admission, we're predicting their risk of dying in the next 30 days, and then we are looking for those high-risk patients.”

Then they look to see if anyone ever had a goals-of-care or advanced care planning conversation with them. “If not, we are reaching out to their attending providers, saying, ‘Would you like to have a goals of care discussion with them, or should we do it for you?’ So it's an opt-out rather than an opt-in,” he explained. 

They built a training session for providers that's a four-hour small-group meeting with standardized patients. “What I found is that everybody thinks they do a good job at this until they're sitting with a well-trained, standardized patient, and they're stumbling through the conversation in front of their colleagues,” he said. “That’s when we see the lightbulb go on that they can do better. I just did the training again myself earlier this week, and I am still learning things.” 

BJC put significant effort into creating something that busy hospitalists and other clinicians would actually use. “We started this for hospital floor patients and then moved forward into the ICU, then backwards into primary care. We're going live with home health later this quarter, and then we'll be expanding to outpatient specialty care,” Moore said. “Our goal is to have an integrated system that covers the whole continuum of care and follows these patients along every step.”

Moore described several positive outcomes: “With our inpatient mortality index, observed to expected, we've gone from about the 35th percentile nationally as a system to about the 75th percentile, and in conjunction documented advanced care planning for our hospitalized patients has gone from a really pathetic one in 500 to a much better one in 10. Some of that had to do with standardization of documentation, but we also saw substantial downstream impacts — increases in our home hospice census, our inpatient hospice, our hospice house,” he said. 

“We were worried hospital docs would just say, ‘you guys do it for us all the time,' and our small but mighty palliative care team would get overwhelmed quickly,” Moore said. But that hasn't happened. More than two-thirds of the time the hospitalists say they're going to have the conversation themselves with these patients. And palliative care utilization has gone up on the inpatient side. 

BJC’s ICU and primary care data is more preliminary. “We haven't published this yet, but in the ICU, we've seen an overall reduction in length of stay of about 30% with a 70% increase in hospice conversions and a 68% increase in organ donation rates,” Moore said.

He noted that the head of palliative care and hospice likes to say he doesn't get to save a lot of lives in his line of work, so the organ donations were a really unexpected benefit that does require a lot more resources. "You're providing a lot of hand-holding support to the patients and families in particular. And that's entirely about gaining the trust of the critical care docs and showing them that you can be helpful.”

BJC has gone from multiple ICUs where palliative care was not even allowed to walk through the doors to now multiple places where they find them indispensable and part of the care team.

Turning to primary care, BJC also has found that the post-hospital transition-of-care visit is an opportunity where both the patient and provider are more open to these conversations. “So we target the providers at the time of the transition-of-care visit, and that has gone pretty well. Traditionally, our primary care providers did very, very little advanced care planning or goals-of-care discussions at all, or hospice referrals. We've seen about a 3,000% increase in advanced care planning in the outpatient space since we started from a baseline of nothing.”

The BJC leaders are excited about home health as well. “We think there's an opportunity there to make a big impact, too, especially knowing that a lot of those patients will end up back in the hospital,” Moore said. 

In closing, he encouraged health systems thinking about doing something in this space to just get started. “It doesn't have to be a comprehensive system,” he said. “When you start, just pick somewhere you think you can make an impact. I like to say that it's not low-hanging fruit. Here the fruit is on the ground and rotting, so it's not hard to make an impact. What really matters is what resources you have in your system and where you think the culture of providers is going to be accepting of this. Once you start somewhere and show that it can be done and has a positive impact, that's when you can expand to other parts of your system.”