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February 8, 2019

'Could this patient die in 6 months?' Why NYU Langone keeps asking this blunt, provocative question.

Daily Briefing

    By Deirdre Saulet, Practice Manager, Oncology Roundtable

    "Would you be surprised if this patient dies in the next 6 months?"

    Even in the language of physicians, who often must talk frankly about disease and death, that question may seem unusually blunt—even unsettling. But that's the question that NYU Langone recently added to its EHR admission process.

    Its goal? To identify patients who could benefit from palliative and other end-of-life services—many of whom Langone had previously not identified until it was too late.

    Under the new system, when a provider acknowledges that a patient could die within the next 6 months, they're directly linked to appropriate follow-up steps in the EHR, like encouraging advanced care planning and consults to social work, palliative care, or geriatrics specialists.

    Since Langone launched the new initiative in 2017, it has seen remarkable success—improving screening for patients with limited life expectancy by 34% and advance care plan documentation by 71%.

    That isn't the only new way that Langone and other health systems are trying to better serve patients at the end of life. Here are three other innovative approaches that are changing how U.S. hospitals approach end-of-life care.

    Resource: Patient question prompt list for end-of-life care

    1. Use data to objectively predict patients' mortality risk

    2. While asking physicians whether their patients could die soon can shine some light on mortality risk, it's an imperfect screening method—especially as doctors tend to err on the side of optimism when projecting patients' lifespans. To address that limitation, some health systems—including Langone—are using machine learning and other automated methods to predict short-term mortality.

      At the Denver Veterans Administration Medical Center, for example, researchers created prognostic criteria to identify patients with the highest mortality risk. The criteria rely on data that every patient could tell their provider or could easily be extracted from the patient's chart.

      Among a hospitalized veteran population, the tool demonstrated 79% sensitivity (rate of correct positive prediction) and 75% specificity (probability of correct negative prediction). To make this process even more sophisticated, researchers at Stanford are partnering with Google to leverage AI for predicting patients' risk of mortality for a number of different conditions.

    3. Train doctors to talk about end-of-life issues in a thoughtful, structured way

    4. It's not surprising that many physicians feel unprepared and uncomfortable talking about death with their patients, as many simply haven't been trained to have these tough conversations. For example, just 2% of the oncology board certification exam relates to end-of-life issues. 

      To guide providers through these conversations, Gundersen Health System created the "Respecting Choices Person-Centered Care Model," which has since been implemented at Langone and elsewhere. The curriculum includes modules to help team members learn how to start conversations about patient's wishes and manage communication in the advanced directive process.

      These conversations don't have to be initiated by physicians. For instance, UAB Medicine uses lay and clinical navigators to talk about end-of-life issues with patients. The navigators undergo robust training, including an internal certification course with the directors of palliative care, medicine, and nursing, as well as the Respecting Choices program. For patients who receive the services of a navigator, UAB documented an 18% decrease in costs of care for the last 90 days of life and a 13% increase in hospice use in the last two weeks of life.

    5. Make advance care planning standard for every single cancer patient

    6. In 2006, the Institute of Medicine issued a report recommending that every cancer patient receive a care management plan with 13 components, including an advance care plan. Since then, few—if any—organizations have been able to accomplish this hefty task. But the Oncology Care Model (OCM), which launched in 2016, reemphasized the importance by including IOM care plans as a requirement for participating practices.

      UAB Medicine, AtlantiCare, and the USA Mitchell Cancer Center are using treatment planning software called Carevive to meet this requirement. Using patient-reported and clinical data, the tool alerts them when patients do not have an advance care plan documented. Since using the tool, documentation of advance directives for breast cancer patients have increased from 19% to 81%.

      At Gundersen, medical assistants are responsible for identifying any patients without advance care plans and flagging them for oncologists. After highlighting the importance of advance care planning, oncologists introduce patients to a social worker, who walks patients through the process and saves the plan in the EHR. After implementing this process, Gundersen saw the percentage of cancer patients with documented advance care plans skyrocket to 60% from 15%.

    Next steps: Three more tactics to improve care and reduce costs at the end of life

    Improving care at the end of life is a prime opportunity for cancer programs to drive quality, decrease costs, and enhance the patient and family experience. To discover the three additional tactics we'd recommend to improve patient care and reduce cost at the end-of-life, check out our research report, Improving End-of-Life Care for Cancer Patients.

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