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HOSPICE NEWS NETWORK

Recent News On End-of-Life Care

Volume 17, Number 9 March 5, 2013

A Service of State Hospice Organizations

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PALLIATIVE CARE IMPROVES QUALITY OF LIFE AND REDUCES COSTS

ElderBranch, a resource for those seeking care providers for seniors, has published a series of articles detailing the present state of end-of-life care in the United States, and examining what programs exist to improve the quality of care in the future. In particular, the reports point towards innovative palliative care models that can improve quality of life at the end of life, reduce costs, and even extend lifespans in the terminally ill.

In the first of four articles, Anila S. Venkat explores the out-of-control costs that are the focus of much discussion around the health care system in general, and end-of-life issues in particular. The article notes a CMS report from 1999, reporting that 28% of Medicare costs came from patients who were in their last year of life. According to CMS, receiving emergency treatment and dying in hospitals may account for much of this expense. “Acute care (in hospital settings) typically accounts for a majority of” these Medicare expenditures.

Of course, if costs were the only issue, most of us would still want seniors to receive the best possible care, regardless of the expense. Yet, Venkat writes, despite the high cost of American health care, “The current system and its programs are unfortunately largely unsuccessful in promoting a high quality of care and quality of life in a patient’s last days.” Many patients die in the hospital, even when they would prefer to die at home. According to a recent study, “Over 75% of patients in their last 30 days of life that go to the emergency room are then admitted to a hospital. And of those admitted, over two thirds die in the hospital.”

In spite of the presently poor record of end-of-life care in the American health system, “well-structured and well-timed palliative care programs can have a positive impact on both costs and quality of care.” Studies are finding that patients who receive effective palliative treatment survive longer, have fewer depressive symptoms, and have overall better quality of life. This treatment means less time spent in the hospital and a higher rate of dying at home, meaning not only a higher quality of life, but greater efficiency for the health care system as a whole.

In the second article, Venkat goes on to examine innovative palliative care models that are improving quality of life at the end of life. The article highlights several key elements in successful programs, including the recruitment of participants, developing an interdisciplinary team, effective initiation of care, and maintaining ongoing care for patients. The article includes brief case studies from effective palliative care systems, which lower cost, improve quality of life, and increase the likelihood of dying at home.

The last two articles in this series are interviews that shed light on two specific palliative care programs. Venkat interviews Susan Enguidanos, PhD, about Kaiser Permanente’s in-home palliative care program, which she helped design in partnership with the Partners in Care Foundation. Enguidanos shares about gaps that are in the present health care system, especially focusing on the importance of early intervention. At the present time, she says, end-of-life care mostly comes in the final weeks of life, but palliative care is usually needed much earlier in the process of health decline.

The US health care system is designed to cure people, says Enguidanos, and so it is a paradigm shift to focus on quality of life. Though in palliative care programs the patients does not give up the right to curative care, studies are demonstrating that patients make different decisions about treatment when their care is holistically-focused. “They’re finding out about their entire health condition and what the trade-offs are. Once [patients are] fully informed... they make different decisions and they are fully supported in their decisions.”

Venkat also interviews Betsy Gornet, who heads up Sutter Health’s Advanced Illness Management (AIM) program. Gornet speaks about the development and results of the AIM program, which has resulted in a 75% reduction in ICU days, 50% reduction in post-enrollment hospitalizations, lower patient costs, and higher patient satisfaction. Gornet says that she is enthusiastic about the amount of experimentation, research and development that is going on right now in the palliative health field, despite the lack of clear profitability for the industry. “It is very courageous of the health system... to get so engaged and really try to develop innovation before there’s a clear mechanism for paying and investing in it.” (USC Davis, 2/2013, gero.usc.edu/2013/02/reexamining-end-of-life-care/; ElderBranch, 1/29, www.elderbranch.com/blog/end-of-life-care-where-we-are-today/; ElderBranch, 2/4, www.elderbranch.com/blog/innovative-palliative-care-models/; ElderBranch, 2/11, www.elderbranch.com/blog/end-of-life-care-kaiser-in-home-palliative-care-program/; ElderBranch, 2/12, www.elderbranch.com/blog/end-of-life-care-sutter-health-aim-program/)

HOSPICE NOTES

* A new POLST form released by the state of New Jersey and the New Jersey Hospital Association seeks to clarify end-of-life decisions for patients and their families. The newly released form will enable terminally ill patients to decide what kind of treatment they want, while they are still able to make that determination themselves. (NJ Spotlight, 2/25, www.njspotlight.com/stories/13/02/24/new-form-helps-clarify-end-of-life-decisions-for-patients-and-families/)

* A Colorado hospice worker has been sentenced to 90 days in jail for faking a cancer diagnosis in order to solicit donations. “A grand jury indicted [the worker] on charges of theft and charitable fraud last year.” (The Denver Channel, 2/28, http://www.thedenverchannel.com/news/local-news/jail-time-for-hospice-worker-jennifer-risa-stover-who-faked-cancer)

* San Diego Hospice, which will be closing its doors following a Medicare audit, has been under HHS scrutiny before. In 1997, San Diego Hospice was asked “to return $2.1 million paid to care for 37 patients who, a government investigation concluded, received hospice reimbursement for an average of 523 days.” (UT San Diego, 2/23, www.utsandiego.com/news/2013/feb/23/sd-hospice-similar-audit/)

* Connolly, one of four CMS RAC Audit Contractors, announced on 2/4 that it is conducting RAC audits on hospices. According to information on their website, Connolly says, “Providers are billing with Core-Based Statistical Area (CBSA) codes that are invalid or no longer in use.” NHPCO’s "Regulatory News" informed members that Connolly says, “These audits are chosen at random, there is no special guideline being used to determine whose claims are requested.” (Connolly, 2/4, www.connolly.com/healthcare/pages/ApprovedIssues.aspx; NHPCO, 2/25)

END-OF-LIFE NOTES

* The IOM Committee on Transforming End-of Life Care held its first meeting on February 20-21. The video webcast of the event is now available online, including welcome and introductions; perspectives from members of the public; a Q&A session; overviews of previous IOM reports; and further discussion. (IOM Webcast, 2/2013, www.iom.edu/Activities/Aging/TransformingEndOfLife/2013-FEB-20/February-20-2013/1-Salerno.aspx; Meeting Agenda: www.iom.edu/~/media/Agenda1_WebsitePosted.pdf)

* Pro Publica and The Washington Post co-published an article by Charles Ornstein, board president of the Association of Health Care Journalists. Ornstein shares about how his mother’s death changed his thinking around end-of-life issues. “I’d never realized how little the costs to the broader health-care system matter to the family of a patient.” This article, also covered by The Wall Street Journal, has received numerous reader comments. (Pro Publica, 2/28, www.propublica.org/article/how-moms-death-changed-my-thinking-about-end-of-life-care; The Washington Post, 2/27, www.washingtonpost.com/opinions/i-thought-i-understood-health-care-then-my-mom-went-into-the-icu/2013/02/27/e7d44510-7a3a-11e2-9a75-dab0201670da_story_2.html; The Wall Street Journal, 2/28, www.wall-street.com/have-you-had-to-make-end-of-life-care-decisions-share-your-experience-2/)

* In an opinion piece for The New York Times, Richard Thaler calls for “a requirement that all patients meet with their doctors or trained end-of-life counselors and prepare living wills.” Thaler, a professor of economics and behavioral science at the Booth School of Business at the University of Chicago, is clear that patients should not be pushed into any particular decisions, but that they should have the opportunity to be aware of their options. Thaler’s article examines the legal and medical systems that are “obstacles to better health care.” (The New York Times, 2/24, www.nytimes.com/2013/02/24/business/overcoming-obstacles-to-better-health-care.html)

* When end-of-life care is misrepresented in the media, the hospice and palliative care community should be able to respond, writes Shaida Talebreza Brandon. Responding to an NPR blog, Brandon says, “Imagine if our community of hospice and palliative care providers had a mechanism for an immediate... unified response to topics that misrepresented palliative care and end-of-life care...” (GeriPal, 2/22, www.geripal.org/2013/02/opportunities-to-educate-public.html)

* US News & World Report’s Money blog features an article about how to develop end-of-life plans that address legal and communications issues. (US News & World Report Money, 2/26, money.usnews.com/money/blogs/the-best-life/2013/02/26/how-to-develop-effective-end-of-life-plans)

* The Visiting Nurse Associations of America has announced a new President and CEO, Tracey Moorhead, who stepped into the role on March 4. (VNAA, 2/26, vnaa.org/Files/Newsroom/Releases/NewCEO_TraceyMoorhead_VNAA_2_26_13.pdf)

PALLIATIVE CARE NOTES

* A recently published study in The Journal of Palliative Medicine finds that although relatives of suffering family members positively evaluate the use of palliative sedation, they also indicate discontent with how information is provided, and communication in general. (The Journal of Palliative Medicine, 2/19, online.liebertpub.com/doi/abs/10.1089/jpm.2012.0410?journalCode=jpm)

* “The widespread preference for home-based [end-of-life] care indicates public health interventions are needed to promote good home deaths,” concludes a report published in The Journal of Palliative Medicine. (The Journal of Palliative Medicine, 2/19, online.liebertpub.com/doi/abs/10.1089/jpm.2012.0262)

* Dr. Diane E. Meier, Director of the Center to Advance Palliative Care, is featured in a video in which she outlines 10 important steps in palliative care, based on decades of research and practice. The video is aimed to be a training tool and guide for health care providers and families. (GetPalliativeCare.org, 2/2013, www.getpalliativecare.org/2013/02/palliative-care-and-the-human-connection-ten-steps-for-what-to-say-and-do/)

POLICY NOTES

* Time published a lengthy expose by Stephen Brill, “Bitter Pill: Why Medical Bills Are Killing Us.” The article is an in-depth examination of the medical practices and costs in the country. Detailed minutiae and case studies provide a multi-perspective view of current health care costs and challenges. End-of-life care and life-extending care are addressed in several segments of the article. Brill also considers some solutions. (Time, 3/4, http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-killing-us/#ixzz2MVr2fG8J)

* The Obama administration has announced, “States could cut Medicaid payments to many doctors and other health care providers to hold down costs in the program.” “The statement has infuriated health care providers and advocates for low-income people. But it may encourage wavering Republican governors to go along with the expansion.” (The New York Times, 2/25, www.nytimes.com/2013/02/26/us/politics/states-can-cut-back-on-medicaid-payments-administration-says.html)

* Rep. Earl Blumenauer (D-OR) has introduced a bill that would stop federal government intervention in medical marijuana programs and providers in states where they are legal. The bill aims to reschedule marijuana and allow its medical use in the various states where it is legal. (Stop The Drug War, 2/27, stopthedrugwar.org/chronicle/2013/feb/27/blumenauer_pushes_states_rights)

Correction: Last week’s HNN mistakenly reported that the New Jersey House voted to create a committee to craft legislation regarding end-of-life decisions. This occurred in the New Hampshire House. For more information about this story, please read: www.concordmonitor.com/home/4522885-95/bill-state-committee-program

Thanks to Kathy McMahon, Don Pendley and Jeff Lycan for contributions.

Glatfelter Insurance Group is the national sponsor of Hospice News Network for 2013. Glatfelter Insurance Group provides property and liability insurance for hospices and home healthcare agencies through their Hospice and Community Care Insurance Services division. Ask your insurance agent to visit their website at www.hccis.com.

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