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A Fresh Look at End-of-Life Care

Joe Cantlupe, for HealthLeaders Media, September 16, 2013

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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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?