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A Fresh Look at End-of-Life Care

Joe Cantlupe, for HealthLeaders Media, September 13, 2013
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The AIM program has had substantial impact, Stuart says. In a two-year review of 185 patients in the program, those who lived at least 30 days had 68% fewer hospitalizations than similar patients who were not in AIM. Those who lived 90 days had 63% fewer hospitalizations, according to Stuart.

There were also significant cost savings, he says: The average savings per patient was more than $2,000 per month. Of all patients who entered the program, about two-thirds went to hospice with longer lengths of stay in hospice than those who had not been enrolled in AIM.

Patients welcome the program, Stuart says. Of all patients offered enrollment in AIM, only 2% have refused.

Early outreach

Gundersen Health System has initiated a pilot program with the Centers for Medicare & Medicaid Services that allows prospective patients with advanced illnesses and their families to consider outpatient palliative care even before they are admitted to the hospital. Gundersen officials say they have succeeded in changing the mind-set of those within the health system and the community by embracing discussions about end-of-life care that are not about dying.

Since establishing the program, Gundersen has rates among the highest in the nation for advance care planning, with unusually low end-of-life hospital costs. It has 95% of its severely or terminally ill patients on an advance care plan, compared to the national average of 50%. In addition, 98% of the time, Gundersen has had consistency between the known care plan and the treatment provided, compared to the national average of 50%.

"Our goal is to try to enroll patients much earlier, identifying them much earlier in their care," says Bernard "Bud" Hammes, PhD, director of Medical Humanities and Respecting Choices for Gundersen. He also chairs the institutional review board and ethics committee at Gundersen. Essentially, the hospital works with patients and their families to integrate patient choices and direction before a time when the patients can't make their own medical decisions.

"We believe people want to stay functional in their homes," Hammes adds. "That's the goal. It's not only better for the patient but also turns out to be cheaper for healthcare. You invest this time, it's relatively low-tech and low-cost care, you prevent three days of hospitalization, and you come out ahead. That's not too difficult to figure out. We realize there are limits to how much a patient wants."

Service line focus

Palliative care programs traditionally have focused on cancer patients. Vanderbilt University's palliative care program, however, sees a diverse patient mix, including oncology, trauma, chronic heart failure, ICU, and dementia patients, says Karlekar, head of the palliative care program.

"Vanderbilt's palliative care program consists of both inpatient and outpatient services. The inpatient services consist of a consultative service and a dedicated inpatient palliative care unit. It includes six physicians, two nurse case managers, a social worker, a chaplain, and three nurse practitioners. A key element of this team is that we provide multidisciplinary care to our patients and families," she says.

The palliative care team strives to help patients develop a plan of care that is consistent with their values, is medically appropriate, and assists with symptom management and the transition of patients to hospice, Karlekar says.

Vanderbilt's palliative program began in 2005 with a small consultation service and expanded over the past several years, she says. The service initially received approximately 35 new consultations per month and now sees on average more than 160 new referrals monthly. While the bulk of referrals are medicine-geriatrics patients and those from the medical ICU, approximately 10%–15% of referrals come from oncology, another 10% from heart failure, 10%–12% from trauma, and 10%–15% from neurosciences.

Outpatient focus

Although much hospital work is moving toward outpatient, palliative care has been slow to adapt. Some hospitals, however, are initiating palliative care programs on an outpatient basis, often with cooperative agreements with private palliative care programs and hospices.

That's what the Gilbert and Chandler hospitals have been doing, says Donna Nolde, RN, MA, MS, CHPN, CEC, of the palliative care unit.

The hospitals' outpatient palliative care program is coordinated with community organizations, agencies, and a hospital foundation, Nolde says. Two years ago, the outpatient program was established. "There was a big realization that chronically ill patients were going home without any resources, sometimes with no one to check on them. They were not truly understanding their medication regime or getting follow-up care with a physician," she says.

The hospital has relationships with hospices, community organizations, and skilled nursing facilities for the so-called "transitional" palliative care plan on an outpatient basis, especially for formerly hospitalized patients, Nolde says. A major element of the program involves follow-up visits and calls from nurses when patients leave the hospital. Within 24 hours of a discharge, there's a visit by a nurse or physician and weekly visits will continue for at least four weeks and then as long as needed. As a result, "patients can leave the hospital a little sooner than they might otherwise," Nolde says.

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