Conceptual Shift for Palliative Care Medicare Hospice Benefit Life Prolonging Care Dx Death Not this Palliative Care Bereavement Hospice Care Life Prolonging Care But this 2

Hospice Eligibility restricted by prognosis/willingness to give up disease Rx 46% of all U.S. deaths served (2014) Median length of service: 17 days At home: 60% Over age 65: 84% Outcomes: better QOL, lower cost https://www.nhpco.org/sites/default/files/public/Statistics_Research/2015_Facts_Figures.pdf

Doubling in Number of Hospices 2000 - 2015 Source: MedPAC March 2017 Report to Congress

Geographic Variation in Access: % of Medicare Decedents Receiving Hospice – CY2014 21-39% 40-49% 50-59% > 60% Source: CMS Hospice PUF Files, October 2016 for patients who received at least 1 day of hospice care in CY2014 Click on a state to change color

Geographic Variation in Total Hospice Days per Beneficiary – FY2014 Source: Source: Abt Associates analysis of 100% Medicare Hospice Claims (FY2014); Estimates exclude hospice service in U.S. outlying territories and the District of Columbia

Hospital Palliative Care Growth in the U.S. In 2015, hospital programs were serving over 8MM patients each year. Palliative care prevalence and # of patients served has more than tripled since 2000. 100% of the U.S. News 2014 – 2015 Honor Roll Hospitals Have a Palliative Care Team. 100% of the U.S. News 2014 – 2015 Honor Roll Children’s Hospitals Have Palliative Care Teams.

Palliative Care is Present at: 97% of the Council of Teaching Hospitals member organizations 87% of the National Cancer Institute’s designated comprehensive cancer centers 100% Of the top 20 NIH-funded medical schools 87%

Geographic Variation in Hospital Palliative Care https://reportcard.capc.org/ http://online.liebertpub.com/toc/jpm/0/0

Palliative Care Improves Value Quality improves Symptoms Quality of life Length of life Family satisfaction Family bereavement outcomes MD satisfaction Costs reduced Hospital cost/day Use of hospital, ICU, ED 30 day readmissions Hospitality mortality Labs, imaging, pharmaceuticals

Mr. B 2015: An 88 year old man with dementia admitted via the ED for management of back pain due to spinal stenosis and arthritis. Pain is 8/10 on admission, for which he is taking 5 gm of acetaminophen/day. Admitted 3 times in 2 months for pain (2x), falls, and altered mental status due to constipation. His family (83 year old wife) is overwhelmed.

Mr. B: Mr. B: “Don’t take me to the hospital! Please!” Mrs. B: “He hates being in the hospital, but what could I do? The pain was terrible and I couldn’t reach the doctor. I couldn’t even move him myself, so I called the ambulance. It was the only thing I could do.” Modified from and with thanks to Dave Casarett

Before and After Usual Care Palliative Care at Home 4 calls to 911 in a 3 month period, leading to 4 ED visits and 3 hospitalizations, leading to Hospital acquired infection Functional decline Family distress Housecalls referral Pain management 24/7 phone coverage Support for caregiver Meals on Wheels Friendly visitor program No 911 calls, ED visits, or hospitalizations in last 2 years

Access to Palliative Care in Community Settings ?

How do we get from here to there? Today’s sessions will demonstrate a number of serious illness models shifting care for patients like Mr. B. out of EDs and hospitals and into homes and community. Listen for the common characteristics. Think about policy and delivery system changes necessary to make the community based care and social service supports you will hear about today into the standard of care for people with serious illness.