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A Fresh Look at End-of-Life Care

Joe Cantlupe, for HealthLeaders Media, September 16, 2013

Terminology aside, many hospitals are expanding the scope of their palliative care programs. Some, such as the Vanderbilt University Medical Center in Nashville, are expanding programs beyond primary care to other service lines, including oncology and cardiology.

The 325-bed Gundersen Health System in La Crosse, Wis., extends palliative care to outpatient services, while inside the hospitals, its hospitalists are becoming more involved in leadership of palliative care programs. Citing a need to improve patient and family education about palliative care, hospitals are tapping into educational programs and using tools such as videos to increase awareness about end-of-life care.

Less than a decade ago, hospitals were just scratching the surface on developing palliative care programs. Yagnesh Patel, MD, vice president of medical staff at Chandler Regional and Mercy Gilbert Medical Centers in Chandler, Ariz., recalls in 2004 when the hospital's former CEO "asked the group who knows anything about palliative care."

One hospital official "chimes in, I know a little bit." The CEO responded, "You are it," meaning he should direct the program. That set in motion a small palliative care program for Chandler Regional. When Mercy Gilbert Medical Center was built in 2007, it also started a palliative care program. The hospitals have a joint palliative care program that includes inpatient beds and a staff of 11.

Over the past several years, the number of inpatient visits for the hospitals' palliative care programs increased steadily, from 2,800 in 2009 to 3,212 in 2012, and also now averages 52 referrals a month to the outpatient palliative care program, Patel says. By coordinating the palliative care and hospice program, the hospitals also have reduced readmission rates. The palliative care readmissions rate was listed at 1.5%, compared to the overall hospital rate of up to 10%, he adds.

A growing elderly population in Arizona and a lengthy list of congestive heart failure and cancer patients prompted the hospitals to begin their palliative care specialty. Before the palliative care programs were launched, there "was a lack of symptom management and support was lacking," Patel says. "There wasn't enough advocacy for patients' needs, and it wasn't addressed in the acute care setting. As a result, the patients ended up back in the hospital.

"We believed it was necessary to enhance the transition between hospital and home, and we developed an outpatient program two years ago. Once we began our focus on palliative care instead of end-of-life, community hospices came to us and asked how they could support our endeavor to help this special population who were falling through the cracks." Patel says medication reconciliation and illness education are key components of any hospital's plan to reduce readmissions.

Integrated programs

"It's time consuming when you are doing it," Timothy Corbin, MD, medical director for hospice and palliative care services at Scripps Health, says of palliative care. "In a hospital when you are in crisis mode and there's a sudden change in someone's health status, everybody is scrambling, but palliative care needs time. The patient doesn't always hear what's being told and you have to take the time to have these conversations."

That's why it's important to have an integrated program that involves hospitals, medical groups, and home- and community-based services, especially for patients with late-stage chronic illness, says Brad Stuart, MD, CMO at Sutter Care at Home, which is part of the 24 hospitals and more than 5,000 physicians affiliated with the Sutter Health system based in Sacramento, Calif.

Sutter has included care management and palliative services under the umbrella of the Advanced Illness Management program that Stuart and his team created for what he terms a "vulnerable and growing population." While palliative care is often focused on the "relief of symptoms and suffering," Stuart says, "our focus is much more comprehensive and positive."

Multidisciplinary teams that include physicians, nurses, social workers, therapists, and nutritionists are part of Sutter's palliative care program. Various elements focus on the specific needs—and wants—of patients. While physicians often outline the medication needs for patients, the AIM program always considers "what does the patient want?" Stuart says. It's the "little things" that matter that are too often lost in traditional medical care, he adds.

"We are taking more seriously those little things that a patient wants or needs," Stuart says. "It's like the patient walking to the dinner table with their family, or seeing a granddaughter graduate from high school. We make those personal goals the priority and then design care plans to match those. That causes a very interesting shift in priorities, not only for the care team but for people being cared for."

To develop its AIM program, Sutter received $13 million from the Center for Medicare & Medicaid Innovation under a three-year grant. The money came after Sutter's Sacramento region showed positive outcomes from its AIM program, such as reduced hospitalizations and improved care transitions.

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1 comments on "A Fresh Look at End-of-Life Care"


Carol J. Eblen (9/20/2013 at 8:32 PM)
In 1991, The Congress, at the request Of Medicare, passed the Patient Self Determination Act (PSDA) which together with the 1986 Hospice/Palliative Entitlement, was intended to solve or stem the problems of overtreatment of the elderly that produced the fiscal problem of expensive end-of-life care in the nation's ICUs and CCUs that was covered by Medicare and private insurance. Elderly patients might spend weeks in ICU and finally die [INVALID]or survive to go home, or to a nursing home [INVALID]-and then return to ICU to die in the last year of their lives. It was envisioned that The PSDA would permit elderly patients to elect to shorten their lives to shorten their suffering, even if the refused life-saving or life-extending treatments weren't deemed "medically futile" by the physician/hospital. Unfortunately, the AMA lobbied against physicians/clinics being placed under the mandate of the 1991 PSDA. While Congress and Medicare [INVALID]d two distinct standards of care that would be reimbursed by Medicare/Hospice, the physicians (primarily the specialists) didn't want the legal burden and expense of SEEKING INFORMED CONSENT from their elderly patients for one standard of care as opposed to the other. Because the for-profit incorporated clinics and physicians' specialist practices were not covered under the PSDA, and because clinics/physicians (the specialists) were reimbursed up to the Diagnosis Group Cap for treatment of life threatening cancers/diseases no matter the age and co-morbidities of the elderly patients (because of the Age Discrimination Statute) they had/have no incentive or legal duty to discuss the other legal standard of care [INVALID]d and reimbursed by Medicare, i.e. Hospice/palliative care, with their elderly patients with life threatening diseases/cancers. (In the past few years, some of the states have passed new laws that do impose a legal obligation on the physicians to inform their elderly (and all) patients about Palliative Care/transition to Hospice. Unfortunately, there has been no clarification of the PSDA at the federal level, even though there has been much "noise" and a few proposed bills concerning end-of-life conversations and treatments. In this age of specialization, the Primary Physicians, in keeping with their oaths, refer their very ill and threatened patients to specialists. The primary physicians didn't think it was their responsibility to talk to the specialists' patients about the two different standards of care. Elderly patients on Tricare-for-Life and other Insurance can self-refer to specialists, etc., and bypass their primary physicians. When both the specialist and the primary physician rejected any responsibility to have these end-of-life conversations, the Acute Care Hospitals then were put in the position of promoting hospitalists/palliative care teams, etc. who would consult within the hospital with inpatients with life-threatening diseases about end-of-life choices and the two standards of care. Even this, however, was not terribly successful because physicians were still over treating with chemo and radiation in the outpatient setting. Patients were not referred to palliative care/transition to Hospice in a timely manner and were often unaware that the treatment they were getting was merely palliative and that, in reality, there was no chance of cure. (We see lately that the Department of Justice is moving against Oncologists who have been over treating for profit) Palliative care which has become a board certified specialty (outside of pain clinics) since the 1991 PSDA was passed into law is practiced within the hospital inpatient setting. The hospitals have to contribute as much as 50% (more or less) of the operating expenses of in-house palliative teams and do so with the view that the palliative teams will refer more patients to Hospice earlier in the course of their diseases/cancers. It was envisioned that the Palliative Teams within hospitals would produce earlier voluntary entrance by patients into Hospice but, of course, the requirement of physician certification of 6 months or less to live worked against this vision. NOW, we see that a TRIAL is planned by Medicare wherein elderly/disabled and all patients will be entitled to be on BOTH the Medicare and the Hospice entitlement at the same time. With Obama Care, over treatment of the elderly/disabled on Medicare/Medicaid will be a problem of the past because already and for the past ten years or more, under both political parties, CMS and its private partners in BIG Insurance have NOT been reimbursing physicians/hospitals for over treatment, mistake, error, and the complications thereof, and the hospitals have had to eat these costs. This has produced a very hostile environment for the elderly/disabled who have exceeded DRG caps or who are the victims of over treatment, or mistakes/errors, and the complications thereof. Unilateral DNRs are being misused to shorten the lives of elderly patients without their informed consent when Hospitals/physicians KNOW that there will be no further reimbursement from CMS and the private insurers. It appears, however, that the solution [INVALID]-if Hospice Care, after the trials, will no longer be a separate entitlement where curative care is abandoned and merely part of Medicare, etc. [INVALID]-that the specialists will still not have to SEEK informed consent from elderly Medicare/Medicaid patients for curative treatment, as opposed to doing nothing and accepting palliative care and transition to Hospice. What do you think?