-BY SATYANSH SAMBYAL, RIYA PRAJAPATI & ATULYA RASHI

Hospice is a home for sick or terminally ill people, which provides support and care for those in the last phases of life-limiting illness also recognizes dying as part of the normal process of living and affirms life and neither hastens nor postpones death while focusing on quality of life for individuals and their family caregivers.

 Home – the patient’s or loved one’s home  Nursing Facility  Assisted Living Facility  Hospital  Hospice residence or unit  Correctional setting, homeless shelter – wherever the person is located

 Medicare  Medicaid  Insurance and HMOs  Private pay  Sometimes a combination of these…

 The patient's personal physician  Hospice physician (medical director)  Nurses  Home health aides  Social workers  Clergy or other counselors  Speech, physical, and occupational therapists  Trained volunteers

Develops the plan of care Manages pain and symptoms Attends to the emotional, psychosocial and spiritual aspects of dying and care giving Teaches the family how to provide care Advocates for the patient and family Provides bereavement care and counseling

Patient/family focused Interdisciplinary team care Provides a range of services: Interdisciplinary case management Pharmaceuticals Durable medical equipment Supplies Volunteers Grief support

 Hospices offer additional services, including: Hospice residential care (facility) Inpatient hospice care Palliative care Complementary therapies Specialized pediatric team Caregiver training Community bereavement services

 To qualify for hospice care, these are the general requirements: Life-limiting illness, prognosis is 6 months or less if the disease takes normal course Live in service area Consent to accept services Forgo other medical interventions for the terminal illness

All of the subgroups coming together with the same goal of helping the particular patient. The patient, and those closest to them, are the most important part of the structure; therefore they are at the top of the hierarchy because they call all the shots regarding their care. A benefit to this kind of structure is that more than a few people have a voice when it comes time to make decisions. Additionally, it allows for different perspectives.

Controlling or alleviating the patient’s symptoms Allowing the patient and caregiver to be involved in the decisions regarding the plan of care Encouraging the patient and caregiver to live life to the fullest Providing continuous support to maintain patient/family confidences and reassurances to achieve these goals Educating and supporting the primary caregiver in the home setting that the patient chooses

The approach taken in all matters affecting the patient and caregiver is as honest and straightforward as possible. It is thought that the fear of the unknown is always greater than the fear of the known. Educating the caregiver in symptom management, hands-on care of the patient, caring for body functions, and teaching regarding the signs and symptoms of approaching death are important to relieve fears.

Hospice care does not conclude once the patient dies but usually continues for at least 1 year with bereavement support. Even though the family feels they have prepared for the death, facing the future without the person who died is difficult. The hospice staff also go through a grieving period for each patient who dies. Each hospice provides support to their staff with support meetings and time to vent their feelings and to heal.

 According to the National Hospice and Palliative Care Organization, there are more than 6,000 hospice programs in operation in the United States, including both primary locations and satellite offices.  Hospice administrators oversee hospice programs in all 50 states. These programs range from small, volunteer agencies to corporate chains that care for thousands of patients every day. The vast majority (79 percent in 2014) of hospices, however, have 500 or fewer admissions each year.  Most hospice programs (60 percent) are independent, freestanding agencies. Others are part of a hospital system, home health agency, or nursing home. The majority (93 percent) possess certification through the Centers for Medicare and Medicaid Services.

Job titles for professionals in hospice administration often include:  Hospice administrator  Hospice director  Hospice branch manager  Hospice and advanced illness administrator  Director of hospice operations  Director of clinical services  Executive director, hospice  Hospice director of operations

Palliative care is not curative in nature but is designed to relieve pain and distress and to control symptoms of the disease. Quality, and not quantity, of life is emphasized with hospice care. Palliative care is not giving up hope; it is full of hope of a good, fulfilling life.

 The study found:  Hospitals saved on average $3,237 per patient, over the course of a hospital stay, when palliative care was added to their routine care as compared to those who didn't receive palliative care.  Palliative care was associated with a cost savings— per hospital stay—of $4,251 per patient with cancer and $2,105 for those with non-cancer diagnoses.  Savings were greatest for patients with the highest number of co-existing illnesses.

 By 2021, health care spending is projected to grow to 19.6% of the GDP, likely crowding out spending in other areas. The 2010 Affordable Care Act (ACA) attempts to curb health care spending by incentivizing high-value care through the creation of Accountable Care Organizations (ACOs), which assume financial risk for patient outcomes. With this financial risk, health systems creating ACOs will be motivated to pursue innovative care models that maximize the value of care. Palliative care, as an emerging field with a growing evidence base, is positioned to improve value in ACOs by increasing high-quality care and decreasing costs for the sickest patients. ACO leaders may find palliative care input valuable in optimizing high-quality patient-centered care in the accountable care environment; however, palliative care clinicians will need to adopt new models that extrapolate their direct patient care skills to population management strategies. We propose that palliative care specialists take on responsibilities for working with ACO leaders to broaden their mission for system wide palliative care for appropriate patients by prospectively identifying patients with a high risk of death, high symptom burden, and/or significant psychosocial dysfunction, and developing targeted, “triggered” interventions to enhance patient-centered, goal-consistent, coordinated care. Developing these new population management competencies is a critical role for palliative care teams in the ACO environment.

 After an event to celebrate and remember people who have died at JHC Hospice in Worcester, Massachusetts, Rev. John G. Pastor, reflected on changes he’s seen in Massachusetts hospice care since the narrow defeat of the proposed Death with Dignity initiative in In an interview with The Worcester Telegram & Gazette, he remarked the most notable change has been more and more people are talking about hospice in a positive light: “It’s good to have increased conversations, and even debates, about honoring wishes at end of life. Even though [the initiative] failed, it brought to light and affirmed our work in so many ways. There is really an awareness.”Massachusettsinterview with The Worcester Telegram & Gazette  Others at the hospice event, including some who opposed the bill, also acknowledged the Death with Dignity initiative broadened the public discussion about hospice care. JHC Hospice Director Ann Marie LeBoeuf noted, “In our society, people are not comfortable talking about death. It is dark. But now that it was a public issue, people do speak of it and talk about what they want.”

 This has also been the case in states with Death with Dignity laws (Oregon, Washington, and just this year, Vermont). Prior to Oregon voters approving the Death with Dignity Act in 1994, many hospice workers expressed concern that the mere existence of the law would encourage people to request the medication rather than pursue other end-of- life options like hospice and palliative care. Unfortunately, this false dichotomy persists even today in states without Death with Dignity laws. In reality, shortly after the Oregon law went into effect in 1997, many doctors and other healthcare workers found conversations about end-of-life care improved.found