Finding The Sweet Spot Where Geriatrics, Palliative Care, and System Integration Intersect

This is my last regular “what works” column for this health policy forum, although I may still chime in now and then. So I thought it would be fitting to report on a health care system that’s blending two of the topics I’ve often written about and care about – palliative care and integrated health care systems.

When I hear people talk about integrated health systems, or ACOs, or medical homes, or bundling or any of those innovations, I don’t hear a lot of explicit talk about palliative care, or end-of-life care. That’s partly because of the political environment, the reluctance to get delivery system reform tied up in death panels redux. But it’s also a reflection of cultural forces. We don’t do a good job of addressing the hard stuff. “Die well here,” probably isn’t such a good highway billboard for a local health system. I don’t think we are even ready for “We respect your wishes,” or “We’ll keep you out of our hospital.” Yet dealing with the hard stuff – the very sick, the complex, the dying – is the essence of quality health care in an aging society.

Which brings me to Summa Health system and Steven “Skip” Radwany, M.D., the medical director of its palliative care and hospice service. Not because Summa is the only health care system addressing these issues, or that they have unique solutions. But because the health care system, which serves Akron, Ohio and several nearby counties, seems to be finding the sweet spot where geriatrics, palliative care, and system integration intersect. And because they are training younger doctors and nurses to build out from these achievements. They are also making an effort to share with other health systems what they have learned about creating a continuum of care. (Also because when I met Radwany, after I gave a talk to some hospice and palliative care docs meeting in D.C. this fall, he was just so darn fired up about what Summa is doing, it just invited a column.)

I’ve never visited Summa (although I’ve talked to a few people there before, written a bit about them elsewhere a few years ago). I don’t know every detail of its history. They didn’t sit down 20 years ago – when they began seriously introducing a lot of forward-looking geriatrics programs –  and plot out exactly how they would interweave palliative care with “regular” care, or its role in inpatient assessment, geriatric rehab, or home care. They certainly couldn’t have anticipated the changing incentives being fostered by the health reform law. Nor when they began their palliative care service did they fully foresee how the palliative care “continuum” would expand as they began to introduce palliative care earlier in the disease trajectory, while the patient is still receiving treatment aimed at curing or at least slowing down the illness. But from what I can see at a distance, the culture of Summa, its approach to patient care, allows all these elements to grow hand in hand.

In my follow up conversation with Radwany, through our emails, and through some documents and PowerPoints he sent me, I got a picture of a health system that wants to create seamless transitions,  reduce the length of stay and hospital readmissions, address fragmentation and duplication, stress medication reconciliation, help people stay in their homes, support family caregivers, find community partners (even if Summa doesn’t own them), and advocate, facilitate and respect advanced care planning. It’s hard to assess at a distance how far they have traveled toward these goals, but they are accumulating data (and grants and publications) that suggests progress.

A vision statement paper he shared with me summed it up like this:

Summa’s Senior and Post Acute Care Service “has long been a pioneer in establishing a nationally acclaimed model for accountable care delivery, education and research in geriatrics, palliative and end-of-life care; and chronic care management in a community teaching hospital setting. Its services are distinguished by community collaboration, interdisciplinary teams management models, integration between acute and long-term care institutional and community sites (alternative programs or services), and the involvement of patient, family and other caregivers in managing chronic illness. These attributes, now part of the national health care reform agenda, have been and will continue to be the philosophical foundation and actual practice of Summa’s Senior and Post Acute Care Services.

While geriatrics and palliative care has been a key area of coordination, the palliative care team has also expanded its involvement in cancer care, both in terms of earlier intervention and less common settings.  “We’re not just in the hospital, we’re not even just in the clinic,” Radwany said. “We’re in physician offices, infusion centers, radiation oncology.” Not so long ago, if a palliative care team member attended a tumor board, they got a “what are you doing here” kind of response, he said. Now the response is, “What do you think about this case? What can you do?”

The palliative care consulting teams now works in five of Summa’s six hospitals, and will start in the sixth next year. Five also have inpatient hospice beds and there are also two palliative care inpatient units, both of which have flexible hospice beds. What is even more unusual is how early the team gets involved, how well integrated they have become in Summa’s geriatric programs, in the hospital, in the special geriatric rehab centers, in long-term care settings and with patients at home. “You get the full spectrum of options, wherever they are in their illness trajectory,” Radwany said.

“Overall by building this model within a large community teaching hospital and then an [integrated delivery system] IDS, we demonstrate that anybody should be able to do this with sufficient vision and commitment,” he told me. “By focusing on the neediest and most complex 10 percent of patients and families, we grew organically and succeeded within a fee for service environment, and without major external grant support (except for research) but are well positioned for a prospective payment system. “

When high-risk patients are admitted to the hospital, a form of triage begins right away. The aim is not only to line up the right approach for the inpatient stay, but to start planning appropriate discharge from the outset. (Sometimes the assessment begins even before they are admitted, in the emergency department, but that’s not yet routine.) Palliative care can get involved from the get-go. The hospital also has well developed care transition programs – including protocols for transitions from one setting to another, such as nursing home to hospital to avoid errors and miscommunication. The system has a “Bridge to Home system,” (which shares some traits with  the  Mary Naylor program at Penn that I wrote about last June, although it’s not identical ) . “Bridges” helps patients and families for the first month after a hospitalization. Palliative care and hospice can play a role for around 15 percent of these patients. Summa has a physician house call program too, and patients can smoothly transition to home hospice when necessary.

“We’re integrated across the continuum,” he told me. At Summa, they like to say that geriatrics developed “in” and spread “out” into community settings, while palliative care with its roots in community hospice, developed “out” and came “in” to the hospital. Now, they share space – not just their office space but in a larger sense. “We didn’t start together,” Radwany said. “But we grew together. “

As I mentioned, this is my last regular column for the Altarum Health Policy Forum. I’ve decided that at this point in the health reform story, it would be an interesting time to plunge back into daily journalism. I’ve also been busy creating a health policy resource project with the Association of Health Care Journalists. I haven’t succumbed to Facebook, but finally joined Twitter. You can keep track of my work by following me @JoanneKenen.


Contributing Writer Joanne Kenen writes monthly news features for the Health Policy Forum discussing health policy innovation and “what works” in our health care system, as well as the politics of health policy and reform. As a leading nonprofit health care research and consulting institute dedicated to improving human health, Altarum encourages open discussion and debate about the many challenges in health care today. All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Altarum is a nonprofit, nonpartisan organization. No posting should be considered an endorsement by Altarum of individual candidates, political parties, opinions, or policy positions.

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