Text

The WellMed Bridges palliative care program

Elizabeth Glazier, MD, MPH, Chief of Palliative Care

WellMed

Text

Seeing relationships between clinicians and patients as crucial to wellness, and with a vision for improving health care delivery for seniors, Dr. George Rapier III founded WellMed in 1990. 

Using the WellMed Care model, which adopts the philosophies of the Accountable Care Organization (ACO), WellMed, a part of OptumCare®, continuously strives to improve quality and lower costs. 

With a strong focus on primary and preventive care while using advanced informatics, WellMed produces high-quality outcomes, i.e., healthier patients. 

They have recently been recognized by The Joint Commission, the nation’s oldest and largest health care standard-setting and accrediting body, as an accredited Primary Care Medical Home and have been awarded the Gold Seal of Approval for Ambulatory Care.

Patients with life-limiting illnesses face difficult choices. As a patient’s condition becomes more complex and grave, even leaving home to meet with clinicians can be burdensome. 

Yet, if options to try and cure the disease are available, many patients wish to pursue every opportunity for recovery. 

Those moving along the spectrum of serious illness can find themselves struggling with symptoms of disease and adverse effects of treatment. In that situation, the question becomes ‘who will step in to manage quality of life for these patients?’

The field of palliative medicine pertains to the care of these individuals. With 20 patients enrolled, WellMed began the Bridges palliative care program in San Antonio in 2013. 

The program delivers patient-centered care in the home with a multidisciplinary team trained in palliative medicine. 

Caring for the sickest of patients as they move through and exhaust curative treatment, but before they either qualify for or elect to enter hospice care, Bridges improves quality of life and reduces utilization burden on the health care system.

Text

What is palliative care?

Though the palliative care specialty plays a large role in end-of-life, it is unique from hospice care. The purpose of palliative care is to relieve pain and other symptoms related to serious illness, whether or not the patient is terminal. 

Importantly, patients can receive palliative and curative care at the same time. Palliative care, therefore, is unlike hospice, that latter requiring that patients have a terminal diagnosis and no longer be seeking curative care.

Under Bridges palliative care, umbrella patients are seen in settings from home and clinics to skilled nursing facilities and hospitals, shoulder to shoulder with specialists like oncologists and cardiologists. 

A high-tech, high-touch approach brings procedures commonly thought to belong in hospitals to people. Examples include electrocardiograms, echocardiograms, joint injections and intravenous infusions.  

Text

A network of specialty care clinicians accessible through telemedicine, keeps patients in place and comfortable.The main focus of the Bridges program is to reduce suffering and improve quality of life. 

Delivering care in the home is a real benefit to homebound patients. Coordination between Bridges’ team of clinicians: specialists in primary care, palliative care, case management, nursing and administration are a major factor in meeting the unique needs and goals of their patients.

Improving end-of-life

The well-known SUPPORT trial, conducted in 1998, showed that 82 percent of patients expressed the desire to die at home. In the US, only one third of patients fulfill this desire.1

The majority of people enter hospice only a few days before death, too late in their trajectory to reap much benefit from the services. Most are in nursing homes or hospitals, and progress too far to have the chance to return home.

Compounding the tragedy of unfulfilled wishes, the expense of hospital and nursing home care in the last year of life is tremendous. End of life care represents 28 percent of total US health care costs.2

One in four Medicare dollars is spent on services for the five percent of beneficiaries in the last year of life.

The most significant predictor of having wishes to die at home fulfilled and avoiding the high cost and discomfort of hospitalization is use of hospice. 

Unfortunately, over one-third of patients in hospice care begin their time with hospice less than one week before death.4 This is not sufficient time to realize major benefits.

The Bridges program has been successful at enrolling patients in hospice care and doing so earlier on. In 2017, 73 percent of palliative care patients were in hospice at the time of death; better than the national average of 50 percent. 

Bridges patients also had a much longer average time on hospice: the national median length of stay was 18.2 days,5 while Bridges’ patients had a median length of stay of 36.2 days.

Also of note was that 82 percent of Bridges’ patients died at home with hospice or palliative support. Nearly the reverse is true for national statistics, with 81 percent dying in a hospital or nursing home.

Bridges’ goals

With the Bridges program, WellMed is working to better the experience of their most complex patients in the most challenging moments of their lives. 

By coordinating care and addressing end-of-life issues with trained specialists, in time, patients are more likely to have their values respected and wishes honored. 

Transitions in care are made smoother by team collaboration. Unnecessary hospitalizations can be avoided through close contact with clinicians and access to care in the home. Pain and suffering is reduced by closely attending to symptom management. 

Before Bridges, life for the many seriously ill patients included gaps in care, difficult transitions, and pain and suffering. WellMed palliative care has grown from 20 patients in San Antonio in 2013 to nearly 4,000 across Texas and Florida in 2017. 

The program has created a place for the diverse needs of people at the end of their lives. Through better coordination and communication, patient wishes are being honored and values are being upheld. 

Families and caregivers have greater support. Bridges is an opportunity to have better quality of life, making each lasting day a better experience.

Text

This publication is informational and for educational purposes for practitioners only. The views and opinions expressed herein are those of the authors and do not necessarily represent the views of OptumCare. The views and opinions expressed may change without notice. 

References:

  1. Teno JM, Gozalo PL, Bynum JPW, et al. Change in End-of-Life Care for Medicare BeneficiariesSite of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009. JAMA. 2013;309(5):470–477. doi:10.1001/jama.2012.207624
  2. Riley, G. F., & Lubitz, J. D. (2010). Long‐term trends in Medicare payments in the last year of life. Health services research, 45(2), 565-576.
  3. Ibid
  4. Spencer Scott, P. 10 Facts You Need to Know About Hospice. AARP Bulletin. doi:https://www.aarp.org/caregiving/basics/info-2017/hospice-need-to-know.html
  5. Medpac. (2016). Report to the Congress: Medicare Payment Policy(March ed., pp. 299-323). Washington, DC: Medpac. doi:http://www.medpac.gov/docs/default-source/reports/chapter-11-hospice-services-march-2016-report-.pdf