On Lok improves its model end-of-life care
When On Lok Senior Health Services in San Francisco launched a comfort care (pain/symptom management vs. cure) improvement project two years ago, it already led the national averages for the percentages of chronic illness deaths with comfort care plans. Nearly six out of 10 On Lok participants with advanced chronic illnesses were in comfort care.
But director Kate O’Malley says staff found much room for improvement as they compared themselves with the best practices from the Boston-based Institute for Healthcare Improvement’s collaborative on improving care at the end of life.
Here is the goal statement that helps On Lok offer comfort care to all of its participants who eventually die of chronic illnesses:
• 100% of chronically ill, dying participants receive comfort care prior to death.
• Comfort care is provided at least 28 days prior to death.
• 100% have pain assessment and management.
• 80% receive psychosocial and spiritual support.
• 90% have evidence of a family conference to discuss the plan.
(For details on the project, see charts, "Achievement of Aims," at right, and "Prevalency and Duration of Comfort Care Plans," p. 33.)
Although On Lok’s structure differs from other health care systems, some of its end-of-life (EOL) care practices bear replication in any elder care setting.
Last service system before death
On Lok serves low-income people in their mid-80s and is typically the last service system they will encounter before they die. Working out of five community centers, the six interdisciplinary teams serve 800 frail elderly.
Since 1983, On Lok has had Medicare and Medicaid waivers, thus receiving a monthly per-capita payment through both programs. It is the prototype of the PACE (Program of All-inclusive Care for the Elderly) model that currently has programs in 30 states.1
On Lok provides home and clinic care, transportation, home-delivered meals, and adult day care. One unique aspect of the service is a spiritual assessment of the participant’s worship preferences, if any, as well as beliefs that would influence the direction of EOL care.
Dealing with different belief systems
O’Malley concedes that her program has the advantage of building relationships with participants and their families over time.
From the outset, the majority of On Lok participants have been Asian American, but lately more Hispanic and African American patients have enrolled. "We’ve struggled with how to provide sensitive care in communities whose beliefs are outside of our largely Western European values," O’Malley notes.
Too often, when providers don’t have the advantage of building relationships with consumers and their families, they go to default care methods, which are usually heavy on medical interventions and expenses.
"Oftentimes a conversation with the family and patient would be best where we explain what we’ve observed about the natural course of a chronic illness and what comfort care can offer to ease pain and symptoms," O’Malley says.
With the program’s average seven-week participation in comfort care, such conversations are realistic objectives even where families are reluctant to let go of the loved one.
The next phase of quality improvement for On Lok is the creation of pain assessment indicators in people with advanced dementia or language barriers, or cultural differences that inhibit communication about pain levels. So far, she explains, they have identified the following indicators:
• a change in walking or sitting postures;
• uncharacteristic restlessness or change in sleeping positions.
Regarding the effect of managed care payment structures for EOL care, both in On Lok and other systems, O’Malley says she sees it as either an asset or a liability.
A peaceful end at home
"People who are in managed care plans are often afraid that if they stop the interventions, the plans will withhold care and that they will not have pain management and support," O’Malley says.
"But in our case, capitation is a help because we have a set number of dollars for each patient and many of the patients don’t want the expensive interventions when they understand that we can give them a comfortable, peaceful death in their own homes," she says.
(For further discussion of the issues in EOL care, see this month’s cover story, "Your quality program isn’t complete without end-of-life, palliative care.")
Reference
1. Eng C, Pedulla J, Eleazer GP, et al. Program of all-inclusive care for the elderly (PACE): An innovative model of integrated geriatric care and financing. In special series, ed. Reuben DB, Models of geriatrics practice. J Am Geriatr Soc 1997; 45:223-232.
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