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A Fresh Look at End-of-Life Care

Joe Cantlupe, for HealthLeaders Media, September 13, 2013
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ACO focus

Collaboration with community providers is of growing importance as hospitals develop accountable care organizations that include palliative care programs. That has been evident at the UnityPoint Health-Trinity Medical Center. The hospital is one of the CMS Pioneer ACO models. The organization covers a region in northern Iowa with a population of about 100,000.

In a three-year review, the UnityPoint Health-Trinity Medical Center palliative care program has resulted in a 67% reduction of overall costs for chronically ill patients: a savings of $800,000 the first year, $1.8 million the second, and $2.1 million the third year. Under the ACO, the 30-day hospital readmission was reduced by 43%, according to Ihrig, the medical director for palliative medicine.

Despite the steady improvement, the process isn't always easy to carry out. "Between 2005 and 2010, UnityPoint Health grew to four different regional palliative care programs," says Lori Bishop, RN, CHPN, clinical innovations adviser. "We took the opportunity at that time to standardize our definitions and unify our programs. Because of limited reimbursement and the system's investments, we began tracking palliative care metrics—which included operational, financial, clinical, and customer satisfaction—across all our regions."

Those problems are inevitable, adds Ihrig, because "even though we are so far ahead of the curve, we are in the preadolescence of palliative care as a subspecialty. We're still working downstream." It's important that the health system leadership works to engage physicians within the ACO. There is still much confusion about palliative care. "Even though our system is still hanging that shingle out for palliative care, there is misunderstanding what it is. It's not a 'death panel' issue."

The big picture

Looking at the big picture of end-of-life care is what Van Gorder says Scripps Health wants to do. That's one of the reasons it outbid another hospital to purchase a hospice facility through the San Diego Hospice bankruptcy process in April. Van Gorder knows people who have been assisted by palliative and hospice care, and it's important to improve coordination between the two, he says.

The 24-bed San Diego Hospice plummeted into bankruptcy this year after it struggled with what Van Gorder calls the "gap in care" issue. That gap, he says, refers to the need of chronically ill patients who may not receive the care needed for their circumstances. That's what occurred at San Diego Hospice, where many of the patients who had extended stays at the hospice were diagnosed with dementia, he says.

The hospice continued to treat patients who had years left to live, not the six-month limit that CMS imposes for covering hospice costs, Van Gorder says. Of the hospice, he says, "Everybody was incredibly well-intentioned and then it went wrong. They got themselves into so much trouble. There's no question that the most important thing for them was patient care and their heart was in the right place."

While it served more patients, the San Diego Hospice failed to address CMS rules. Eventually, an audit showed that the hospice owed the federal government an estimated $60 million or more. In 2011, for instance, 475 out of San Diego Hospice's 3,700 patients—12.8%—stayed for longer than 180 days. "It's so challenging for families to take care of dementia. The hospice called itself palliative care and hospice, but they didn't have home health, they didn't have acute care," Van Gorder says. "That's why an integrated delivery system like Scripps is so well-suited to deal with these things."

By taking over the hospice, Scripps is caring for the hospice patients as part of its overall palliative and hospice care program and is planning ahead, Van Gorder says.

Scripps was among four of California's health systems whose palliative care programs were evaluated by the state's Palliative Care Quality Network. In a 24-hour evaluation of 130 patients, 46% showed reduced anxiety levels, 40% had reduced nausea, and 100% had improved dyspnea.

While the San Diego Hospice existed, the Scripps Hospital became its largest referral. Now, having the hospice brings Scripps to a level of planning a "tighter continuum of care," Van Gorder says.

Informed choices

An important component of advance care programs is patient engagement and education. Researchers have found that showing patients with advanced cancer a video decision-support tool of simulated cardiopulmonary resuscitation improved their understanding of the intervention and caused more patients to prefer to forgo CPR, say Angelo Volandes, MD, and Aretha Delight Davis, MD, cofounders of Advance Care Planning Decisions, a Massachusetts-based nonprofit that develops such videos to "empower patients with serious illnesses" to make informed choices about their end-of-life care.

Allowing patients to make informed choices is a major focus of end-of-life care, says Scripps' Van Gorder.

"We have to get our arms around it," he says. "There is that certainty: You are going to be born and die; it's going to be a sad experience but not necessarily a negative experience for the family. This is a process in which you, the patient, and the family, can go through a little more at ease than otherwise," he says.

Reprint HLR0913-2


This article appears in the September issue of HealthLeaders magazine.


Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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