BETTER DESIGNS FOR CARE – THE CASE OF PALLIATIVE CARE

Recently, Collabria Care hosted an annual symposium on palliative care that drew over 80 physicians, nurses, social workers and others to American Canyon to consider the advances in palliative care. This annual event is jointly sponsored by Partnership HealthPlan of California.

Each speaker over the two day symposium offered challenges for daily practice in palliative and end of life care. None was more challenging, dare I say, ground-breaking than the last presentation of the symposium by BJ Miller titled “Not Whether, But How: Exploring the Potential of Palliative Care”. Dr. Miller is a palliative care specialist at UCSF, and an internationally-renown thinker and speaker (see his TED talk at https://www.youtube.com/watch?v=apbSsILLh28 ) who brings design thinking to the reformation of palliative care.

His hour-long talk was part philosophy, part design, and wholly focused on the care that we give our patients who have serious illness and are moving towards the end of life. His prime challenge to us was how to move from a disease centered to a human centered approach to care. He reproached current medical systems who are locked into the increasing complexity and technologies of diagnosis and therapy, and miss the opportunity to address what really matters to patients that he identified as:

  • Not being a burden, esp financially to family and loved ones
  • Spiritual peace
  • Community and communion of loved ones
  • Respect for culture and traditions

He challenged us to move beyond the dualities that our health system has set up, and which impede human centered care. These include:

  • Acute vs chronic. Where is continuity and continuum of care in our system?
  • Intervening vs. supporting. Our system is geared towards doing, often because we can rather than because it is best for the patient. How does our health system support the needs of patients which are different than the needs of the providers?
  • Curing vs. healing. Does our health system truly understand what is meant by healing which is more than the elimination or control of disease?
  • Quality of health vs. quality of life. The focus of health systems is to restore physical health rather than achieve the patient-desired quality of life.
  • Less horrid vs. more wonderful. I love this paradigm where a health system moves beyond alleviating suffering (particularly physical) to a system that strives to bring delight and meaning to the people it serves. In other words, a system that brings wonder and creates an environment and state that is more wonderful. Contributing to the “horrid” mindset is our health systems proclivity to define illness, suffering, disability, aging, and dying as “abnormal” which need to be normalized.
  • Self vs other. Our health systems are constructed on the model of we, the care providers, doing to they, the patients in need, who are often categorized and compartmentalized by their disease state (we have pediatric floors, medical floors, surgical floors etc). How could we envision a system where we the dying are caring for others who are also dying. I am reminded of Gayle Stephens (one of the fathers of family medicine) who advocated person centered care defined as care of a person by a person.

Dr. Miller emphasized two other design keys. First is “proportionality”. We have a health system that can’t help itself, is so taken by the awesomeness of its capabilities that it “bestows” on patients often more than is desired, more than is needed, leading to more suffering rather than less.  Related to the first is the tyranny of choice. Too often “what can be done (choices) takes precedent over what is best for the patient (as negotiated in communion with the patient)”.

As with many other sectors of society, healthcare is enamored of words which are latinzied and too often not understand by the user or recipient. Dr. Miller challenged us to think beyond words, to the realm of experience and how health systems can design and use experience to care for patients.

Finally, and perhaps most radically, Dr. Miller challenged us to move beyond the healthcare paradigm that is wrapped into a time continuum of past into future. Palliative care buys into this paradigm through disease and outcome prognostication. His final (or at least what he left us to ponder) challenge was how to create a system where patient-provider and all their individual and amalgamated meanings converge in the real time of the present.

I walked away exhilarated and inspired that these design principles not only apply to the domain of palliative care but all of health care. There is hope that in the redesign of palliative care will be a blueprint for the rest of healthcare.

Scott Endsley MD, Associate Medical Director for Quality

DHCS Health Homes Initiative – What You Need to Know

The state of California will be implementing section 2703 of the Affordable Care Act in 2017.  Section 2703 defines the Health Homes Program (HHP) for Medicaid members in our state.  Most of us have heard the term, the Patient Centered Medical Home, and although Health Homes is new, the origins of the Health Homes Program goes back several decades.

The “Medical Home” was first defined by the American Academy of Pediatrics in 1967. The Standard of Child Health Care envisioned “one central source of a child’s pediatric records to resolve duplication and gaps in service that occur as a result of lack of communication and coordination.”  A few years later, the AAP issued a policy statement, “The Medical Home” (Pediatrics 1992;90:774), that proposed the pediatric practice as an Accessible, Continuous, Comprehensive, Family-centered, Coordinated and Compassionate place for the care of infants, children and adolescents to provide:

  • Preventive care and immunizations
  • Health screening and assessments of growth and development
  • Patient and parental counseling about health and psychosocial issues
  • Care over an extended period of time to enhance continuity
  • Interaction with school and community agencies so that health needs are met
  • Centralized records and enhanced communication

In 2002, the AAP added Culturally Effective to the definition and recommended that the care be “delivered or directed by well-trained physicians who provide primary care and help to manage and facilitate essentially all aspects of pediatric care.”

The key concepts of the medical home as envisioned by the AAP are preventive care, screening, counselling, continuity over time, interaction with the community and enhanced communication.  Two years later, the American Academy of Family Physicians, in the Future of Family Medicine project continued the evolution of the health home when they proposed the “Personal Medical Home” to provide continuous healing relationships, care customized to patient needs and values, the free flow of information, cooperation among clinicians and safe, timely, effective and equitable patient centered care.

The Patient Centered Medical Home (2006) was a joint statement by the AAP, AAFP, ACP and the AOA that added whole person orientation, coordinated care, quality and safety to the medical home. The Department of Health Services and the CMS Federal Work Group became involved and added coordination of medical and social services across the lifespan in 2008. Then, in 2009, in recognition that patients primarily receiving behavioral health care are often disconnected from medical care, SAMHSA added the integration of community based behavioral health care and medical care into the medical home definition.

All of these refinements came together with the Affordable Care Act in 2010.  Section 2703 of the ACA created the Medicaid Health Home program to coordinate the full range of physical and behavioral health services, community support services and long term supportive care with enhanced coordination of medical and behavioral health in a whole person philosophy of care.  The guiding principles and goals for the health homes program are to:

  • Improve care coordination
  • Strengthen community care linkages
  • Offer team based care including community health workers
  • Improve health outcomes for members with high risk chronic diseases
  • Integrate physical and behavioral health issues
  • Integrate palliative care into primary care delivery
  • Recognize and respond to trauma informed care needs
  • Improve medical care to homeless members
  • Improve integration and treatment of patients with substance abuse disorder

PHC will be implementing the HHP program for our members in 2017.  PHC has been providing intensive care management in many of our FQHCs through an Intensive Out-Patient Care Management (IOPCM) program since 2012.  All of these IOPCM sites will transition to the health home concept next year.  Health Home sites will work to provide a multi-disciplinary approach for our members with increased use of health navigators and improved connections with community based resources to enhance the care of our most challenging health plan members

Trauma Informed Care – What You Can Do In Your Practice

PHC has had intensive care management programs in many of our FQHCs since 2012.  These care management programs will be evolving into our health homes programs in 2017.  Health Homes is an evolution of the patient centered medical home with an increased focus on substance abuse, integration of mental and behavioral health with medical care and a more intense effort to work with homeless members.

One of the new components in patient assessments will be a look at how trauma has affected the lives of our patients.  How serious is this problem?  Here are a few statistics:

  • Over half of women (55 to 99%) in substance abuse treatment report trauma
  • Nearly all women in the public mental health system (85 to 95%) have had trauma
  • Nearly all homeless veterans suffer PTSD
  • Trauma exposed youth have arrest rates 8 times that of same age peers
  • The economic costs of untreated trauma-related alcohol and drug abuse are estimated to have been $161 billion in 2000.

The Substance Abuse and Mental Health Services Administration (SAMHSA) concept of the trauma informed approach defines a trauma informed system of care:

  • Realize the widespread impact of trauma and understand paths to recovery
  • Recognize the signs and symptoms of trauma
  • Respond by integrating policies and procedures in your practices
  • Resist re-traumatizing patients

The goal is recognizing the effects of trauma on our patients is to provide an emotionally and physically safe environment for our patients.

How can you know if trauma is playing in a role in your patient’s behavior or choices?  You might start by asking about his or her childhood or how things are going at home.  Once you get a feel for whether trauma has affected your patient you may be able to be more direct in your questioning. The Life Events Checklist has 17 specific traumatic events, but you can consider a shorter list that we will be implementing into our PHC health risk assessments.

Have you been involved in or exposed to:

  • A natural disaster such as a flood, fire or earthquake?
  • Combat or a warzone?
  • Physical or emotional abuse?
  • Sexual abuse or assault?
  • Sudden violent death or unexpected death in someone close to you?
  • Any serious harm, injury or death caused by you?

Trauma is treatable. There are many evidence-based models and practices to help heal our patients and improve the behavioral manifestations of trauma.  A history of trauma is often hidden or denied and we don’t often ask about trauma in our patients with problematic behaviors.

How will this play out in your practices?  The next time someone acts out in your practice, consider asking “Can you tell me what happened to you?” instead of “What’s wrong with you?” You may be surprised at the answer.

TRAMADOL – A TIGER IN SHEEP’S CLOTHING

Tramadol is a not a benign, NSAID analogue. It is a dual action narcotic acting on both the serotonin and norephinephrine reuptake system, and through its metabolite (M1) acts on the opioid mu receptor. Both actions contribute to the analgesic properties of Tramadol. Initially considered to be 10 times less potent than other opioids such as morphine, evidence is changing.  Tramadol was first introduced in 1977 in Germany in I.V. form which has been found in studies to have low efficacy for pain. However, studies conducted by Johns Hopkins University in the 1990’s, at the time that Ortho McNeil was seeking FDA approval for its oral form called Ultram, indicated that high dose Tramadol acted very similarly to other opioids such as oxycodone. Like these other opioids, it is associated with dependence. Upon abrupt cessation, Tramadol users experience mild withdrawal symptoms. Ignoring this evidence, the FDA did not schedule Tramadol as in 1994, considering that it possessed the same risk as Viagra or Lipitor. After growing evidence of its contribution to opioid overdose morbidity and mortality, in August 2016, the FDA did reschedule it as a schedule IV drug.

Tramadol use has skyrocketed. In 2008, 25 million prescriptions were filled. Four years later (2012), over 40 million prescriptions were being filled. In 2011, Tramadol was associated with 20,000 Emergency Department visits for opioid overdose, often in combination with other opioids. For instance, in Florida in 2011, there were 379 overdoses that involved Tramadol. Tramadol is used for non-medical purposes just like the other opioids. Reviewing statistics for 2011, the DEA estimates that Tramadol was being used recreationally by over 2.6 million individuals, many of whom have substance use disorder linked to the other opioids.

tramadol

Tramadol’s effectiveness is limited. A meta-analysis indicated no significant effect on pain relief in low back pain and only modest effect in osteoarthritis. The World Health Organization considers this latter use as the only evidence-based use of Tramadol.

The FDA has issued a drug warning for Tramadol, advising not to use Tramadol in patients who are addiction prone or are a suicidal risk. FDA notes that Tramadol has serious addictive effects with other opioids and alcohol in respiratory depression.

Because of its inhibitory effects on serotonin reuptake, Tramadol has also been associated with serotonin syndrome.

Key take home lessons:

  1. Tramadol is not benign, and has been associated with abuse and overdose
  2. Tramadol has very few indications, the most notable is for treatment of osteoarthritis pain
  3. If you need to use Tramadol, avoid using with other opioid drugs.