Care Transitions in Akron, OH

Poor people “over the age of 60 who are living with one of 9 life-limiting conditions” are being subjected to an ongoing experiment in care transitions in the Akron, Ohio, region.

Medicaring.org gave the project a very favorable review just a few months ago.  The study is called the “PEACE Trial (Promoting Effective Advanced Care for Elders), a project involving Summa Health, the Area Agency on Aging (AAA), University of Akron, Kent State University, and the Northeastern Ohio Universities of College of Medicine and Pharmacy.

It’s all very scientific.  As Medicaring.org explains:

The randomized controlled pilot study features a geri-palliative care case management intervention for Ohio consumers who are participants in the state’s long-term care Medicaid waiver program, PASSPORT.  Frequently, these elders have not documented their advance care preferences, and so arrive in the hospital, where family members are left to make critical decisions for which they are unprepared.

In other words, a social worker or nurse from the Area Agency on Aging will follow the patient home, and later to the physician’s office, to coach the patient on how to take medications and, more importantly, to coach the patient on “appropriate” care and end-of-life decisions:

The PEACE Trial [focuses] on health coaching and patient activation for self management, while promoting advance care planning discussions with primary care providers.

. . . Care managers make two home visits, for example, centered on symptom assessment and advance care planning. They review findings with an interdisciplinary team, which makes appropriate recommendations for the patient and the primary care provider. The care manager next accompanies the consumer to one visit with the primary care provider to discuss advance care goals. Following this, the care manager and the palliative care nurse supervisor make an additional home visit to begin to implement the care plan.

Because Summa has a history of running the PEACE Trial and other case management projects, Medicare and Medicaid (CMS) announced last November that Akron would be awarded funding as a test site for the Center for Innovation’s CCTP project (see Care Transitions in Akron in this AOA presentation, beginning at slide 41.)

PEACE Trial is funded by the National Palliative Care Research Center (NPCRC) in New York City.  NPCRC was established in 2005 with a $3 million grant from the Kornfeld Foundation to Sean Morrison, MD.  Dr. Morrison was known to be sympathetic to physician-assisted suicide; several years earlier he had co-authored with Timothy Quill an article in New England Journal of Medicine that surveyed how physicians can and do assist suicides.  The Kornfeld Foundation had funded a similar NEJM article in 1989.  Kornfeld’s objective was clear.  As they stated in their Form 990 for the IRS, their mission was to support “the right of the individual to choose the time and manner of his or her death, without undue interference by doctors, hospitals, courts, churches, families or society.”

Let’s be clear:  the PEACE Trial is not about physician-assisted suicide.  It is not about barbiturate overdosing or gas inhaling in the manner of Timothy Quill or Jack Kevorkian.  The PEACE Trial is all about  coaching people on making end-of-life decisions.

Co-investigator for the PEACE Trial is Steven “Skip” Radwany. MD.  Dr. Radwany is a professor of medicine at Northeastern Ohio Universities Colleges of Medicine and Pharmacy, and medical director for Summa Health System’s Palliative Care and Hospice Services.

Dr. Radwany gained credentials with the death with dignity crowd in 2003 when he called for the withdrawal of nutrition and hydration from Gerald Carpenter, an elderly man who had suffered a stroke in a nursing home.

The death-with-dignity viewpoint on the story is related in a book by assisted-suicide advocate Alan Meisel (here).  The news stories concerning the Carpenter case are no longer available online, so we have posted online here the full text, showing the URLs for where the stories were posted eight years ago

Carpenter could open his eyes and move his arms and legs, but he could not eat.  A nurse at the nursing home said that Carpenter had said he would want life-sustaining treatment. Carpenter’s son hadn’t visited the father in so many months that it was difficult for the nursing home to locate him.  When he was finally contacted, he wanted his father’s feeding tube removed. Dr. Radwany agreed.

Dr. Radwany decided that Mr. Carpenter would not improve, and was therefore “terminal” and should not have hydration and nourishment:

Radwany said it was in Carpenter’s “best interest to discontinue all invasive, life-sustaining measures….” 

“It is the consensus among the physicians that he will not improve from this state,” Radwany testified. “He is terminal.”

 

Bottom line:  It’s all about the coaching.

 

POLST in Care Transitions

The so-called Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is in the news because the Catholic bishops of Wisconsin have issued a warning against the use of POLST.

List of seven popular “interventions” for care transitions,; POLST is one of the interventions. (Slide is from a presentation on “Interact”, from the Health & Human Services Administration on Aging website. [click image to enlarge])
POLST and other advance directives play an important role in the Community-Based Care Transitions Program (CCTP) and Partnership for Patients discussed in a previous post here at Belbury Review.

In order to reduce hospitalizations within a community, participants in the care transitions demonstration projects generally use one of a handful of “intervention” programs. A few of those interventions appear on a useful diagram that is posted at the Administration on Aging website (see illustration at right).  Though the slide was part of a presentation on “Interact” — just one of the interventions  — it presents a good summary of some of the others. POLST is one of those interventions.

CFMC — the National Care Transitions QIO Support Center — is promoting POLST.  One of the tools they offer on their website is a flyer for POLST that was created by the QIO for Pennsylvania, Quality Insights of Pennsylvania.  Quality Insights is actually a program out of the West Virginia Medical Institute.  West Virginia was one of the first states to actively promote POLST, so it is not surprising that Quality Insights is promoting POLST.

A poster advertising POLST was created by the QIO of Pennsylvania and is offered by CFMC as a sample tool for care transitions projects across the country.

While some of the care transitions interventions focus on pressuring patients and families to be responsible for proper medication, symptom identification, doctors’ appointments and so forth, a number of the interventions focus on end-of-life decisions, DNRs, and advance care planning.  This is particularly true of interventions involving patients in nursing homes who are frail and might request another trip to the emergency room.

For example, the tool from Interact on “Tips for Starting and Conducting the Conversation” suggests framing the issue of CPR in the negative context:

 “Sometimes when peoples’ hearts stop, doctors and nurses try to delay
the dying process … Have you considered whether you would want this or not?”

The rest of the discussion contains carefully chosen “facts” to discourage life-saving measures; facts such as:

The possibility of surviving CPR in a nursing home is very low, and CPR
often results in broken ribs and the need for a respirator (“breathing machine”) in
an intensive care unit.

The Interact tool also discusses “Artificial Hydration/Nutrition” and the supposed dangers of feeding tubes.

These are but a few examples of POLST and end-of-life discussions prompted by the “care transitions” project.

Erik Fromme, MD, is a hospitalist at Oregon Health & Science University who specializes in palliative medicine and is frequent co-author with POLST’s developers.  In early 2011 he articulated how POLST and palliative medicine would take a role in “care transitions.”  In an article titled “Transitions in End-of-Life Care:  the Oregon Trail,” Fromme remarked that “transitions” is a malleable term; useful because it can take on a variety of meanings suitable to meet a number of objectives:

Transitions is a broad term that can refer to moving from one care setting to the next, changing goals of care, changing both care setting and goals (as happens with the transition to hospice care), or even death.

Fromme concludes:

Strong palliative care teams, statewide outreach and education, and programs like POLST allow hospitals and healthcare systems to support patients, families, and clinicians in the inner work of letting go.

Not all of the care transitions interventions focus on “letting go,” but coaching patients and families in end-of-life decisions is a key feature in many contexts.

ObamaCare’s $1 Billion Community Organizing (and rationing) Project

Here’s a scheme that’s sure to fundamentally transform America’s health care system, from top down and bottom up. The Administration is pairing Alinsky-style organizing with Berwickian rationing, and using your tax dollars to do it.

In a series of YouTube videos posted last fall, Joanne Lynn, MD (right-to-die activist, bioethicist, and wife of Rev. Barry Lynn of Americans United for Separation of Church and State) described a $1 billion “care transitions” project that was established via Section 3026 of the Affordable Care Act (Obamacare).

The new Innovation Center at CMS is spawning community-based organizations through the federal QIO network. CFMC – the Colorado QIO – is the National Care Transitions Quality Improvement Organization Support
Center (Integrating Care For Populations and Communities, or ICPC).  The map above is by Traci Archibald, MBA, presented at the 2012 Annual Meeting of the American Geriatrics Society)

Lynn explains that “care transitions” means “how you move across settings” in healthcare. The Centers for Medicare & Medicaid Services (CMS) at HHS has been bothered that their clientele — elderly, frail fee-for-service patients — keep going back to the emergency room after they are discharged from the hospital. According CMS, “unnecessary hospital re-admissions” cost roughly $12 billion a year. Supposedly one in five patients returns to the hospital, but Lynn remarks that “in some areas, even higher rates apply; some populations certainly return more often.”

The answer: Use the federal government’s QIO network to establish community-based organizations for health care (re)distribution.

In response to the perceived crisis, CMS is starting with one billion dollars to change health care delivery systems across the country. Lynn says half a billion for “Community-Based Care Transitions Program” (CCTP), and the other half billion goes to “Partnership for Patients.” (Elsewhere, CMS describes CCTP as a sub-project of Partnership for Patients.) Lynn calls CCTP a “marvelously fertile endeavor,” and hopes that the CCTP demonstration project will spawn thousands of coalitions across the country:

“. . . [CCTP is] a very interesting program; half a billion dollars over five years, trying to have leadership organizations in the country – leadership communities, really – figure out how you can build community, . . . reduce the rate of hospitalizations and re-hospitalizations, by involving community-based organizations….”

These test sites will be the foundation for a permanent restructured delivery system over the next few years.

The Partnership for Patients “stakeholders”: left-wing nonprofits, crony capitalists, big labor and big government. (Graphic: from National Quality Forum presentation, April 2012)

Though the coalitions are local, the federal government determines which organizations are allowed on the team. Lynn says that to qualify for funding, the lead organization must be

“. . . a community-based organization which has adequate representation of the provider stakeholders and adequate representation of the consumers on its board – so it’s a very special organization – Medicare has determined that public organizations like a Department of Health can qualify, and that Area Agencies on Aging can qualify, but you’ll have United Way agencies and others that might be able to do this

The end result will be a coalition with clout.

The coalition will have its own board and will funnel large amounts of money. The organization is paid a flat rate per person, but then the organization decides how to allot the funds, determining which patients will receive more services, and which patients will get less. Lynn explains:

The community-based organization is the one that will get paid; they must be working with one or more hospitals. It’s an advantage to be working with hospitals with high re-admission rates. You submit an application that gives a blended rate, that says for every patient in our target population, we will be paid a certain amount, and then we will figure out, within ourselves, the patients that need a whole lot of services, and the patients who need less.

Joanne Lynn is not just a random observer. Lynn is an insider. She spent about a year advising CCTP’s headquarters in Colorado. During the mid- to late-‘90s she collaborated with Donald Berwick and his Boston-based Institute for Healthcare Improvement in projects aimed at decreasing hospital admissions by increasing the use of living wills and other advance directives. (Not surprisingly, before he left CMS, Donald Berwick was one of CCTP’s principal champions.) Lynn is probably best known for devising “Medicaring,” a program that manipulates Medicare reimbursements to discourage chronically ill patients from requesting life-saving measures.

Lynn recognizes that developing coalitions across the country will be tricky. She warns that people will be suspicious at first. She advises,

You need to build a level of trust, and then you need to govern by consensus, probably, for a while; and then figure out . . . what’s the governing board really going to look like; are we going to incorporate; are we going to be able to take on grants or funding; are we going to be able to take on the management of any records, or monitoring the situation, or speaking to the public? You have to think a couple years down the road.

This is where the Alinsky-style organizing comes into the picture.

Organizing for Health poster, originally posted at the website of  Colorado Foundation for Medical Care (CFMC)

The QIO for Colorado  Colorado Foundation for Medical Care (CFMC) – brought in Organizing for Health to help train and recruit organizers for coalition building via an online seminar that ran from February through May of this year.  CFMC is the national coordinating center for a CMS program called Integrating Care For Populations and Communities (ICPC), and as such CFMC helps community-based organizations apply for the CCTP program.

Organizing for Health is spearheaded by Marshall Ganz and his department at Harvard’s Kennedy School of Government.  From the Organizing for Health website:

Building on experience with Marshall Ganz, known for his campaigns with Cesar Chavez and California’s migrant grape workers in the 1970s, and Barack Obama’s 2008 grassroots presidential campaign, Kate Hilton, JD, MTS, is leading a team focused on supporting the capacity of leaders to organize and create sustainable conditions for transforming health and care.

For the record: Ganz focused on faith-based organizing, and his proteges at Organizing for Health specialize in leveraging faith-based organizations as well. The two trainers for the CFMC series – Kate Hilton and Ella Auchincloss – picked up community organizing experience while working for the Episcopal Church. Kate Hilton, the daughter of a hospice doctor, brings conflicts over end-of-life decisions into the debate. She has done community organizing through Donald Berwick’s Institute for Healthcare Improvement, the Mott Foundation, National Council of La Raza, and The Middle East Initiative at Harvard University.

Ella Aunchinloss, director of the Hauser Center for Nonprofit Organizing at Harvard’s Kennedy School of Government, stressed throughout CFMC’s four-month training series that there are many “change theories,” but community organizing involves using resources to build power, with emphasis on collective action.

A slide from the CCTP training session conducted by Organizing for Health

“If the change you want to see involves mobilizing people and involves mobilizing all of the resources available by virtue of that collective, then you’re using the right theory of change for the challenge that you face. To give you an example, if you wanted to find a cure for cancer, organizing as a theory of change may not be the right theory. . . .If there was a scientific breakthrough that did involve the use of a scarce resource of, say, some sort of or drug protocol, you might consider using community organizing in order to shift the power dynamics that make that drug protocol either scarce or scarce to your community.”

Slide from Organizing for Health training. The “opposition” were two physicians who wanted to care for sick patients.

In one session, participants were taught how to “map actors.” They were taught how to identify constituents (Auchincloss reminds the organizers that “patients are not constituents”), and and how to target supporters and competitors who have resources to which the movement wants access. Mapping also includes identifying who is the “opposition.” Auchincloss turned to one of the QIO members to provide a real-life example of mapping actors. It turns out the “opposition” was a team of physicians who said they were there to treat sick people. Doctors do usually treat sick people; that’s a good thing. Nevertheless, the physicians were identified as resisters because supposedly they just wanted to make money.

Hilton and Auchincloss, in the footsteps of their mentor Ganz, taught the organizers to begin their public relations campaigns with a “story of self”, a personal anecdote that will tug at their audience’s heartstrings, or conjure a fear. Organizers were told to cull their community for stories of “intolerable situations” to “create a compelling story or narrative of why people need to take action.” The series ended on May 24 with a call to action: “Contact a patient or family representative in your community by June 15th to learn what you can about their experiences.”

Sharpen your discernment skills; the propaganda blitz is on its way.