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A Fresh Look at End-of-Life Care

Joe Cantlupe, for HealthLeaders Media, September 16, 2013

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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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?