This past week, I gave you a brief glimpse of the 2015 GIH Annual Conference in Austin, Texas.
Here are two more vignettes from the conference, held in March. Its theme was Pathways to Health.
Director of the Center to Advance Palliative Care at the Icahn School of Medicine at Mount Sinai and a past MacArthur Fellow (2008), Diane Meier was another plenary speaker. She commented to the audience of mostly foundation staffers that her body of work and career in palliative care is due to the support of private-sector philanthropy, including more than twenty foundations.
Following are just some of the points she made in a stimulating and persuasive speech.
Meier noted that health spending in the United States is very highly concentrated among the highest-risk, sickest patients. (Of course, the sickest people are the costliest to the health care system.) The question is, though, are we spending money in a way that improves the quality of care?
She pointed out that palliative care is not limited to the dying. It addresses pain and other symptoms and supports overworked family caregivers. Palliative care is for people at any age—for example, it could be used for someone age twenty-four with curable leukemia, she noted.
Meier mentioned an illustrative example of overuse of the emergency department (ED) by a man, age eighty-eight, who was in pain from severe spinal arthritis. He was in too much pain to get up from a chair.
His elderly wife could not move him, and when she tried to reach his physician, she got a voicemail message saying, “If this is a medical emergency, hang up now, and call 911.” So, she did exactly as the doctor’s office instructed and called 911. The ambulance took the husband to the hospital ED. He was admitted to the hospital, where he unfortunately developed a hospital-acquired infection (urinary tract infection) and delirium.
Subsequently, he started receiving palliative care at Meier’s direction. She and her palliative care team managed his pain with a “tiny dose” of morphine and over-the-counter medications to prevent constipation. The Mount Sinai Visiting Doctors Program (which makes house calls) helped make the couple’s home safe, visits from their church allowed the wife to take a break from caregiving, and things started improving.
I was pleased to see that Meier cited research by Alex Smith of the University of California, San Francisco, and coauthors that was published in the June 2012 issue of Health Affairs. The article noted that 75 percent of Medicare beneficiaries are in an ED at least once during the last six months of life.
Meier explained that exhausted, overwhelmed caregivers have little alternative but to call 911 when no other recourse is available. This leads to high-cost care in the hospital.
Home-based and community-based services are high-value, in her view. For example, she mentioned research by Kali Thomas and Vince Mor of Brown University that was published in the October 2013 issue of Health Affairs. The article projects a cost savings when older people with low care needs receive home-delivered meals, such as Meals on Wheels, because adequate nutrition results in better health and can help people avoid being admitted to a nursing home.
Citing research published in the New England Journal of Medicine, Meier told the audience that palliative care can even improve the length of a patient’s life. Meier, herself a physician, commented that many doctors do not understand this.
Meier mentioned five key predictors of success for a program trying to keep high-risk, high-cost patients safely in their homes and communities:
- Target people at highest risk for medical crises, symptom distress, and family caregiver burden
- Ask patients what matters to them most and organize care plans to achieve those goals
- Assess and address the needs and concerns of family caregivers
- Ensure that staff who deliver home-based care to this patient population are knowledgeable and skilled in pain and symptom management, because symptom distress is the main driver of 911 calls, ED visits, and hospitalizations
- Provide 24/7 phone access to a clinician connected to the patient’s electronic health record, because patients and families need advice and help whenever the need arises—not just during office hours.
Meier also mentioned that she would like to see every clinician trained in the basic knowledge and skills of palliative care. By training all clinicians, access to palliative care can be reliably assured across all care settings and beyond hospitals—to homes, cancer centers, doctors’ offices, and nursing homes, for example.
She noted that the Institute of Medicine has agreed—in eight reports—that access to high-quality palliative care is an important national priority.
Foundations collectively have put in a minimum of $300 million to palliative care efforts since the mid-1980s, Meier said. Both national and regional foundations have stepped forward. The result is a growing and thriving field in the United States that is working to match care delivery to the most important needs of our sickest and most complex patients and their families.
“New in the Journal: Funders’ Support for Palliative and End-of-Life Care,” by Lee-Lee Prina, Health Affairs GrantWatch Blog, February 12.
CARE: A documentary about cracks in the elder care system
GIH hosted a film night, and I chose to view a “rough cut” of the powerful documentary CARE, which was followed by a discussion with the director and foundation staffers. This film “chronicles the struggles of home health aides, elders, and their families, exposing the deep flaws in the US elder care system,” according to GIH. “The film paints a picture of an impending care crisis. . . .”
The film also illustrates how the system is failing both families burdened by the cost of care and direct-care workers struggling to get by on low wages. Direct-care workers are getting paid $10 an hour in New York City, one of the panelists said.
The film, directed by Deirdre Fishel, is in the post-production stage, and the team hopes to release it in fall 2015. She mentioned to me on April 9 that additional funding is still needed for production costs and will be sought through a Kickstarter campaign. Those wanting to know the status of the film should “like” it on Facebook, Fishel said: https://www.facebook.com/caredocumentary.
So far, the Ford Foundation, the John D. and Catherine T. MacArthur Foundation, the Independence Foundation, the Discount Foundation, and Chicken & Egg Pictures have funded production of the film, Fishel told me. The Fledgling Fund has funded a two-year outreach and engagement campaign.
Ai-Jen Poo, codirector of Caring Across Generations (which receives funding from Atlantic Philanthropies and others), director of the National Domestic Workers Alliance, and a 2014 MacArthur Fellow, was an adviser to the film and on the GIH panel facilitating the discussion. Fishel, Laine Romero-Alston of the Ford Foundation, and Chris Langston of the John A. Hartford Foundation were also on the panel.