Taking Healthcare by Storm: Industry Insights with CQEL

In this captivating episode of Taking Healthcare by Storm, delve into the world of expert insights as Quality Insights Medical Director Dr. Jean Storm engages in a thought-provoking and informative discussion with Emily Jaffe, MD, MBA, Vice President and Executive Medical Director of Enterprise Palliative Care Strategy and Implementation at Highmark Health and post-acute medical director at Allegheny Health Network. 

Dr. Emily Jaffe discusses the importance of quality of life at the end of life, the roles of palliative and hospice care, and CQEL's initiatives to improve serious illness care in Pennsylvania. She emphasizes the need for patient-centered care, education, and collaboration among healthcare providers to enhance patient outcomes. She also highlights innovations like community-based care models, PA POLST forms, and the potential for policy changes to support better end-of-life care throughout the state. 

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website.

Publication number QI-062725-GK

Transcript

 Welcome to "Taking Healthcare by Storm: Industry Insights," the podcast that delves into the captivating intersection of innovation, science, compassion, and care. 

In each episode, Quality Insights’ Medical Director Dr. Jean Storm will have the privilege of engaging with leading experts across diverse fields, including dieticians, pharmacists, and brave patients navigating their own healthcare journeys. 

Our mission is to bring you the best healthcare insights, drawing from the expertise of professionals across West Virginia, Pennsylvania and the nation.

Subscribe now, and together, we can take healthcare by storm.

Hello everyone and welcome to another episode of Taking Healthcare by Storm. I am Dr. Jean Storm, the medical Director of Quality Insights, and today we are going to be talking about one of my favorite topics and we're gonna be talking about the importance. Of quality of life  particularly in certain times  in individuals lives.

We  today are gonna be talking about CQEL, which is formerly the Coalition of Quality At. At the end of life, and I'm gonna be telling you a little bit about that organization, but first I wanted to tell you a little bit about the guests that we have today. Dr. Emily Jaffe is the Vice President and Executive Medical Director of Enterprise Palliative Care Strategy and implementation for Highmark Health.

She is also the post-acute medical director for Allegheny Health Network. In these roles, Dr. Jaffe is responsible for developing and implementing strategies to maximize care in the home and community for high risk members to achieve a higher level of performance, lower cost, better health outcomes.

Better patient experience, which is  the number one thing, right? A fellowship trained geriatrician with board certification in internal medicine, geriatrics, hospice, and palliative care. Dr. Jaffe holds extensive clinical experience in providing palliative and hospice care in the home and. Nursing facility, so we're talking about nursing homes as well.

She's also  well versed in the management of medical staff utilization, behavioral health and palliative care. She is focused on community-based care in her professional career to explore alternative care models, which is just wonderful, that drive care to the least restrictive environment. She earned her MBA from Boston University and MD from Columbia University College of Physicians and Surgeons.

She served her internal medicine residency at UPMC Presbyterian and her geriatrics fellowship at the University of Chicago. So as I said, today we're gonna be talking about CQEL. It's a coalition of organizations including leading health systems, provider organizations, insurance companies, citizen groups, governmental agencies, and philanthropic.

Faith-based and professional organizations that are concerned about the quality of care that is available to individuals and families in Pennsylvania who are dealing with serious illness, including but not limited to end of life. And we're gonna be talking a lot of, about, a lot of myths and a lot of misinformation around.

Quality at end of life because I  and with individuals who have serious illnesses, because  I think that there's a lot of  misinformation out there. So we're gonna get started. Dr. Jaffe, Emily, thank you very much for joining us today. Thank you, Jean. It's my pleasure to be here and to talk about  CQEL and the work that we're doing and I really appreciate you having me on the show.

I'm really happy to have you as well, and we're gonna be calling each other by our first names. As I said before  we're gonna be comfortable with our first names. So first things first, can you tell us how you came to do what you do? Absolutely. I would love to tell you that it was a straight purposeful path and that I knew that it was gonna lead me here.

But, that wouldn't be a true story and it wouldn't really be a true journey. Right. I actually come from a family of entrepreneurs and did not originally start my career in medicine.  I have an MBA in marketing with a focus on marketing and market research, and  went back to school later to be a physician.

But immediately, as soon as I got out on the floors in my third year of medical school, I noticed that we were seeing a lot of the same patients again and again, and sort of took a more operational view of what was going on in the hospital. And it occurred to me that the system is really set up for the people who use it the least.

And we might use some language around patients that we see a lot in the hospital. We might talk about them as a bounce back, or we have some other ways in the industry that we talk to each other about them. But really I think what it is, is that all caregivers get some frustration around that.

Because if someone is. Has a lot of medical complexities. We don't always have the tools or the time to take care of them the way that we need to.  And that led me into geriatrics.  And the more time that I spent as a geriatrician the more that I realized how dangerous actually the hospital can be for someone who's frail.

Who may not be able to advocate for themselves and really got into models of care that take care of people in the community and where they are. So like you mentioned in the introduction I've taken care of people in their homes, in the nursing home  in outpatient clinics, in hospice. And really as I got further into this.

Started to think about how can I change the system from the outside rather than the inside. And so  I made a transition to Highmark, which is a health insurance company about eight years ago now. And really I am working on how do we use medical policy reimbursement. To give providers the tools that they need to be able to  take care of people in place and in the community.

Such important work and I don't know.  I think it's really important, especially now with all the changes going on in health policy, that people really understand how important these issues are. CQEL brings together a diverse group of stakeholders to improve serious illness and end of life care in Pennsylvania.

Can you share some of the coalition's most impactful? Initiatives and how they've shaped care across the state. Absolutely. So it started locally and I think the biggest accomplishment although there are many, so it would be hard to kind of just pick one out though, but it's really the work around the POLST program in Pennsylvania.

So for people who are listening and may not know what the POLST is, P-O-L-S-T it's a physician order for life sustaining treatment. And we, this is not a state recognized form from a legislative standpoint, but it is recognized in the medical community. Where we can have a document that has a physician order for the kind of care that somebody may want in the last part of their lives.

And the PA POLST program is supported and administered under SQL as well as the Jewish Healthcare Foundation.  And if you go to that site, what you will find are the form itself educational materials. So. Materials for providers, materials for patients to understand what the form is for, what the different things on the form means.

There are courses that you can take in a self-study manner and there's also opportunities to have people come and teach stakeholders in your organization about how to administer the polst. The POLST I feel like as an individual has filled out many, has looked at many. It's an art  I will say it's such a very important document.

I mean, it really describes someone's most important wishes. Regarding their life. So if anyone has any questions around the polst, I mean, you can reach out to me, I'd be happy to walk you through it or you know, take a look at the CQELS website which is links to the POLST program in Pennsylvania.

 You know, they have just wonderful resources around the POLST. There's something I would add to that too, is that around the educational materials, I think two big misconceptions around the POLST are that we use it for everyone, right? And that it's really appropriate to use it in the last one to two years of someone's life.

And the other thing that is important is to realize that. Providers filling that out. So I think people who maybe have not had training with the POLST form may hand it to a patient and say, take it home and look at this. But it's in, it uses medical language. And so I think it's really important for people to be educated and be agile to your point that it's an art because you're speaking to a patient about.

What their wishes are and what their goals are. And then as a provider, it's our responsibility to translate that into medical terms and an order so different than a living will. Absolutely.  That someone may fill out themselves. This is something that a provider needs to fill out. Yeah.  And I think people need to understand 

it's a physician's order. You know, even like similar to like a, if you had a medication, you know it's something that is very important. And  just in, in the nursing home setting, it is a neon pink document because that is something, you know, when you, see an individual who is not doing well.

And they're not able to communicate with you. That is something that is so very important. And then during my time in nursing homes, that is something that I try to really instill in staff, that when you have an individual that you find that they are altered, they're not, if they're in their baseline and they're not able to communicate with you, and they are having some kind of medical event that is urgent, that.

You get in the habit of saying, where's the POLST? So you can know immediately where we're going on now on this journey with this resident, this patient, this individual who's in front of us, who's having this changing condition where are we going? We're not just gonna go, oh, we send to the hospital.

Oh, we're gonna do chest compressions. Like we're gonna really. You know, take a moment  and make sure that we're really honoring and respecting someone's wishes. Absolutely. Yeah. Very important. So given that CQEL includes health systems, insurers, government agencies, and community organizations, what are some key lessons you've learned about fostering collaboration among these groups to improve patient outcomes?

So  that's a really good question. Because we really do a wide range of activities through CQEL. So, you know, I told you about this accomplishment about supporting and administrating the POLST form for Pennsylvania. However, we also have a big education mission and a really a support,  mission as well for each other and advocacy. So it's a very, very interesting group of people.  And anyone can certainly join CQEL meetings by going to the website and participating. What the most important thing is this, a shared mission and a shared goal, so. Anyone who's participating in CQEL recognizes that we have opportunity not only in the state of Pennsylvania, but of course in the country to improve the experience for people at end of life.

And that may not, when we say that we don't just mean you know, the final days or weeks of someone's life, we're talking about people. Can live a very long time with chronic disease. And really what we want people to do is to have the highest quality of life and to live as long as they possibly can with the goals that they define as quality of life.

And so the group itself is focused on. What can we do to either improve legislation, reimbursement awareness, outreach around the ideas and concepts of palliative care as well as hospice? And what I've learned most is that even though we all may come with a different lens or competing.

Priorities sometimes that we can get a lot of work done and share a lot of knowledge by using quality of care for the last part of someone's life as our North Star. I love that quality of care at the end of life as the North Star. I mean, that is beautifully said. So you mentioned palliative care and you mentioned hospice, and I just know.

In my experience  and what I've heard from others that many individuals get very kind of confused. They kind of combine them both together. They really don't know the difference. So can you describe for us, in your own words, the difference between palliative care and hospice? Sure. So they do definitely get confounded.

So I'm glad that you're asking me that question. People get nervous when they hear both of those words, right? People, you'll hear someone say you know, some of the work we do around palliative care at the Allegheny Health Network or out in the community through our community-based palliative care program at Highmark.

People will say they're not ready. And I often tell this story of one of my, one of my jobs that I had, the very first week I was on the job, I saw a woman come in and she was in a lot of pain. She had a urinary tract infection and we diagnosed the infection and I wrote her for an antibiotic and then I said to her, you need something for pain.

'cause you're probably not gonna feel better for a day or two. And so I wrote her something for pain and I heard the nurses in the next room whispering, 'cause they didn't know me saying she suffered her something for pain in like, it in a good way, right? That she acknowledged that.  And so palliation is just the relief of pain and suffering.

So, you know, if you had your knee replaced and you took some Tylenol you're palliating your knee pain. So. Everyone is ready for palliation at any time. And it doesn't only have to be pain. Um, It can be other symptoms, nausea anxiety shortness of breath, fatigue. So palliative care is taking care of the symptoms and the suffering that comes along with having a medical diagnosis.

Or can come along with having a medical diagnosis and should be a part of all care plans. And part of sort of a checklist when we do a typical, let's say, review of systems to see how diseases or illnesses may be affecting someone, and then how do those symptoms affect their quality of life or function?

Hospice in particular. Is a medical benefit which is a model of care that people can opt for in the last part of their lives. And really we define it as two medical providers say that it's reasonable to think this person may not be alive in six months from now. So. Not everybody dies who goes into hospice.

Some people either improve and disenroll or  some people actually will revoke, and that's a term that we use for someone who disenrolls themself because they've decided to take a more curative pathway. So it isn't one way. And I think people get sort of frightened or confused by language or stories that they hear.

And one of our jobs at CQEL and as healthcare providers are to educate people that life is a journey, as is the last part of your life. And you are part of the team that directs how that goes. So, we wanna hear from you about what your goals are, how you're feeling and then creating a care plan around that.

That will include palliation if necessary, and hospice when appropriate. That's was very well said, and I hope people now maybe that clears things up a little bit. Despite the growing need for palliative and hospice care in nursing homes and outpatient settings, because we have an aging population, we have.

Many individuals in our population who have chronic diseases. So many people still associate these services with giving up. Well, I've heard many people say, I'm not just gonna give up, you know?  So they feel that way rather than. Then understanding that it can, these services can really improve quality of life and therefore maybe even they've shown in some studies that enrolling in palliative care or hospice can actually lengthen your life because we're improving quality of life.

So how do you address these misconceptions and what strategies do you believe are most effective in shifting public perception? I'm smiling when you asked me this question because I was in a meeting this morning with about 10 other providers who do palliative care and we were having this discussion.

Exactly. So we don't have the best language to be honest. We use language like let's say someone is on hospice, we may use the term comfort measures only, which to me sounds like you're not getting something when we use the words only. Right? But actually to keep somebody comfortable and to give them a high quality of life is actually you're giving more care at that time.

You're being really aggressive. About making sure that their dignity is preserved and that they're comfortable on their journey. So that's one language that we use. We also talk about withdrawing care. So again, I would argue that actually we're ramping up care because when someone is in the last part of their life, they require a lot of.

As needed medications, their condition changes, so it takes a certain vigilance to make sure that their symptoms are well controlled. And we'll often talk about pulling back. We're really, what we mean is we're shifting the focus and there's not, you know, every single person will die one day.

There's just no way around that. So avoiding that conversation or not addressing it is actually probably doing a disservice. Because what people want is to be told the truth, right? They want the information about what are the outcomes, the likely outcomes of different treatments, and what are the costs that come with those treatments.

So as long as you remain patient centered, as long as you talk to someone and understand what are their values. So it may be I wanna remain in my home, someone may say I want to die doing everything medically I possibly can. Somebody may say I wanna get to a grandchild's wedding, or if I can't feed myself.

That's not acceptable to me. If I don't recognize my family, that's not acceptable to me. So once you understand what somebody values, then you're able to design a care plan around that. And it can be scary to have that conversation, not only as a provider to bring it up, but you know, you have to realize that's scary for the patient.

And so not everyone that you bring this up with is going to, take it in stride, right? You should expect an emotional reaction. You should expect some anxiety, maybe some anger at first.  And as long as you stay curious and you stay present with that person you will be able to bring them along in that journey.

So it's really about. Education consistency, calmness, curiosity, and making sure that you're building trust with that person that they know you have their best interest in mind. We recently were saying among my colleagues that if you bring up hospice, if every time you bring up hospice or you bring up palliative care.

A patient and family agrees with you, you're probably not bringing it up enough. So everybody's gonna have a different threshold for when they are ready for care in their home. And by the way, you know, this has been studied in about 80% of people in this country would like to die in their home and receive care in their home.

The threshold of when you're ready for that is different. So you should be normalizing it and putting it on the table as an option and understand that somebody may take it and they may not, but keeping them educated and normalizing it as part of the journey. Yeah, absolutely. Meeting each patient where they are and is very important.

So you have extensive experience developing community-based, home-based care models for high risk patients. As you just said, the majority of. People would like to have their final days in their home.  So what are some of the biggest challenges in implementing palliative and hospice care? Maybe bringing them  you know, into the home maybe even in nursing homes.

And what innovative approaches have you found to be most effective in ensuring these patients receive the best possible care? And I'm, thinking that maybe. Money might be part of this, which I hate to kind of bring into this conversation.  But care does, you know, cost money. Yeah that's fair.

So what, let's start with challenges. And really I think time and training and comfort level is one of the biggest challenges. So, to have the kind of conversation that I just described with you takes time.  And you're correct about money. So our reimbursement models need to reward people for having those conversations.

So, you know, for a long time in this country we were solely on what we call a fee for service model. So. If I see a patient, I bill for the patient. If I do a procedure, I bill for the procedure. And what we ended up building unintentionally, was a system that rewarded quantity and not quality. And now we're moving away from that as a country and we're rewarding quality.

So when we put health systems, at risk where we build incentive programs around outcomes, we then say yeah, we will pay you a certain amount of money to see a patient. However we are expecting a certain outcome from that. And if you achieve that outcome, then they'll either be reimbursement or some kind of bonus for that.

So we'll, we would provide a bonus for those outcomes and we are definitely in a period of transition right now in this country and that country. We are recognizing that we do a lot of care in the last part of life.

Our outcomes are not different than other countries. In some countries. As far as access and quality, it's actually lower. And that we don't have, you know, it's unusual to have somebody say. That was a wonderful experience. I understand exactly. I understood exactly what was gonna happen. I felt supported through the process  when they lose a loved one.

When people use palliative care, we do see that.  And that's where we're trying to move healthcare to. So that's really the challenge. Another part of it is fragmentation, right? So we're all very busy, and if I have a very high quality conversation with you as a provider in the nursing home, to your point how does a person in the hospital or a primary care doctor who sees that patient afterwards know the outcome of that conversation?

So. You know, we talked about the POLST form. Being able to see those forms across the care continuum or understanding those notes across the care continuum are really important. And educating families to be able to advocate for themselves and to understand that when those forms have been filled out, what they mean and that they can speak to them even if the form is not.

Accessible or visible to another healthcare provider that they're in front of. So, innovations that I've seen you know, these are some things that we do where I work but they're not exclusive to where I work. And  I do think Highmark has been a leader in palliative care nationally. I.

We have incentive programs that if we have high risk members, we don't ask hospitals to have those deep conversations with our members. We don't think there's, there is time there and we're not really sure it's the right setting for the conversation, depending what's going on. But we do have a community-based palliative care program.

That  we ask hospitals to refer to or to any community-based service. So home health agencies and nursing homes will often be better at having these conversations 'cause there's more time and people are not as acutely ill and things are not moving as quickly. So building those incentive programs are important.

We have a, partnership with a platform where we store our advanced directives so that they're easily visible to the nursing home, to the primary care doctors, and to the hospital. So no matter where the patient is in the continuum, they're able to find those documents easily. Really neat thing that's happening now.

 Is hospital at home and SNF at home. So rather than having the patient cross the care continuum and have changes in their setting, which usually leads to changes in medication, changes in diet, changes in routine able to bring those services to patients in their home so that they are comfortable and that often.

Leads to decreased confusion decreased anxiety and actually helps people maintain their function. Those just sound wonderful and we probably could talk  for hours about that, but maybe ano another time. So last question. As CQEL continues to evolve, what do you see as the organization's key priorities in the future?

We are in a ever changing, rapidly changing healthcare landscape. Currently as everybody probably realizes when they turn on the news. Are there any new initiatives, partnerships, or policy efforts on the horizon that you believe will have a significant impact on improving serious illness care in Pennsylvania?

Yeah, I think  a couple of areas. So in the area of advocacy we will continue the work around the POLST. Depending on the timing and who is in office we would like to see a day where the POLST form is recognized by the state. Some people may not realize, but there's a second form in Pennsylvania called the out of hospital DNR.

So even though, you may have a POLST form that says that you don't want to be resuscitated or you wouldn't wanna be put on a breathing machine. If that, if an EMT walks into your home, that can be on your refrigerator. But the EMT actually has to call medic Central to get an order from a medical director not to resuscitate you.

Which they will do, but an out of hospital DNR is something that they have to follow. And so we would like to address that to prevent any confusion. So that's something that remains on our docket. Some states right now are looking at incorporating a palliative care benefit, particularly into Medicaid, and that's something that we have been talking about and bringing people.

To discuss. So certain states will pay a palliative provider a monthly fee to offer these services to Medicaid recipients. And that's something that we're interested in. And then. We'll always continue in our work in training and in education because the more people who are aware of these issues and are educated about it, the more likely our citizens in the state of Pennsylvania will continue to have a better experience in the last part of their lives.

I, I agree and I look forward to the day when. A palliative benefit is offered just like a hospice benefit. \ That would be absolutely wonderful and I think would really change the healthcare landscape. Dr. Emily Jaffe, thank you so much for joining me today. This was a wonderful conversation.

I enjoyed it so much, and I'm sure our listeners gained some important. Information in making decisions. So thank you very much for joining us. Thank you. Appreciate you having me.

Thank you for tuning in to Taking Healthcare by Storm: Industry Insights with Quality Insights Medical Director Dr. Jean Storm. We hope that you enjoyed this episode. If you found value in what you heard, please consider subscribing to our podcast on your favorite platform.

If you have any topics or guests you'd like to see on future episodes, you can reach out to us on our website. We would love to hear from you.

So, until next time, stay curious, stay compassionate, and keep taking healthcare by storm.