End of Life Care Delivery Systems Barry M. Kinzbrunner, MD Joel S. Policzer, MD

Definitions Palliative care “palliare” latin: to cloak “care provided to treat the symptoms of an illness without curing or affecting the underlying illness” Examples insulin “palliates” diabetes lasix “palliates” congestive heart failure

Definitions Supportive Care “aspects of medical care concerned with the physical, psychosocial, and spiritual issues faced by persons with a particular illness (i.e. cancer).” Includes family and community Includes palliation of symptoms of the disease and management of untoward effects of treatment

Definitions End of Life Care Care rendered to individuals who are near death or for whom death is expected in a relatively finite period of time. Includes supportive care, palliative care, hospice care May be provided in virtually any setting where someone may die ICU Acute care hospital LTCF ALF Private residence

Definitions Hospice Care Team-oriented approach to end of life care Expert in medical care, pain and symptom management, and emotional and spiritual support Tailored to the patient’s needs and wishes Support to loved ones as well Provided in any setting

Definitions Palliative Care Extends principles of hospice care to a broader population Earlier in disease course than hospice Comprehensive and specialized Pain and symptom management, advance care planning, psychosocial and spiritual support, coordination of care Definition may be able to be expanded to all aspects of medical care

Hospice “hospes” Latin for “host” or “guest” Origins traced to early Middle ages as a way station for travelers between Europe, Africa, and the Middle East Modern hospice as care for the dying England Dame Cicely Saunders St. Joseph’s and St.Christopher’s Hospice Primarily inpatient based

Hospice Hospice in the US began in 1970s in Connecticut Home based rather than facility based Inpatient care confined to situations where patient could not be cared for at home Demonstration project at end of 1970s Medicare Hospice Benefit-1982 Defines hospice in the United States to this day

Medicare Hospice Benefit Patient Eligibility Part A Medicare Benefit Prognosis of 6 months or less if the terminal illness runs its normal course Based on the clinical judgment of two physicians Hospice Medical Director or designee Attending physician Patients elect hospice via informed consent May voluntarily leave hospice at any time through the process of “revocation”

Medicare Hospice Benefit Benefit Periods Two 90-day Benefit Periods Unlimited 60-day Benefit Periods Re-certification Hospice Medical Director must recertify, based on his or her clinical judgment, that the patient continues to have a prognosis of six months or less if the illness runs its normal course

Medicare Hospice Benefit Reimbursement Per diem payment to hospice based on “Level of Care” through Medicare Part A Hospice physician services for patient visits billable through Medicare Part A in addition to per diem Attending physician professional services (visits) and care-plan oversight billable under Part B Annual payment cap

Medicare Hospice Benefit Levels of Care Routine Home Care Basic services provided in the patient’s primary place of residence, including ALF or LTCF Continuous Home Care General In-patient Care Respite In-patient Care

Medicare Hospice Benefit Covered Services Interdisciplinary Team care: Nursing services Medical social services Pastoral counseling Medical direction and physician care plan oversight Home health aide and homemaking services Bereavement services Dietary counseling

Medicare Hospice Benefit Covered Services Medical consulting services Physical therapy, occupational therapy, speech therapy Drugs and biologicals Durable Medical Equipment Medical supplies Laboratory and diagnostic studies

Medicare Hospice Benefit Continuous Care 8-24 hours of care per day provided in the home setting Paid hourly (Day starts at 12 MN) More than 50%of care has to be provided by a nurse Hours do not need to be “continuous” Clinical indications similar to general inpatient care

Medicare Hospice Benefit General Inpatient Care Care that cannot be managed in the home setting Per Diem rate May be provided in a variety of venues Free-standing Leased space in a hospital, LTCF, ALF Contract bed in hospital or LTCF Reimbursement limited to no more than 20% of a hospice program’s billable days of care

Medicare Hospice Benefit Indications for General Inpatient Care and Continuous Care Uncontrolled pain Respiratory distress Severe decubitus ulcers or other skin lesions Intractable nausea, emesis Other physical symptoms not controllable on a routine level of care Severe Psychosocial Symptoms or acute breakdown in family dynamics

Medicare Hospice Benefit Respite Inpatient Care Care provided to give the family care-giver’s respite from the rigors of taking care of the patient Per Diem rate Limited to a maximum of 5 days at any one time Under-utilized due to poor reimbursement rate compared to other levels of care

Medicare Hospice Benefit State of Hospice Access Today Almost 1 million patients admitted in 2004 2003 NHPCO National Data Set ALOS 55.6 days Median LOS 22.3 days Continuous Care 0.9% General Inpatient 3.4% Respite Inpatient 0.2% Admissions by Dx: Cancer 49.1% Heart 11.1% Dmentia 9.7%

Medicare Hospice Benefit Barriers to Hospice Access 6 month prognosis requirement Communication Physicians do not want to tell patients Patients and families do not want to be told Lack of inpatient relationships between hospices and hospitals Hospice reluctance to allow “disease-directed” therapy

Palliative Care Programs Goals: Increase patient access to end-of-life care Reach patients who are not currently being reached by hospice Overcome barriers to hospice access

Comparison of Hospice and Palliative Care Programs

Palliative Care Programs Hospital Based Palliative Care Interdisciplinary or Multi-disciplinary Typically Physician led Physician consults with supplementation by other disciplines Some academic centers and hospitals have discreet inpatient units ICU consults to facilitate end of life decision making reduces ICU utilization

Palliative Care Programs Hospital Based Palliative Care Reimbursement through traditional system No specific reimbursement stream for “palliative care” Physician consults DRGs for hospital care Savings by reducing ICU and inpatient days Improved quality of inpatient care May partner with a hospice to provide more comprehensive services

Palliative Care Programs Long-term Care Facility Palliative Care Need for palliative care for patients accessing Medicare Part A for Nursing Home care Physician Consult services Partnerships with hospices

Palliative Care Programs Home-Based Palliative Care Home health agency services May be independent or affiliated with a hospice program Patients need to be Home-care eligible Pre-hospice “Bridge” programs Affiliated with hospice Reimbursed as Home Health agencies Hospice or hospice trained staff

Palliative Care Programs Home-Based Palliative Care Pre-hospice “Bridge” programs Affiliated with hospice and reimbursed as HHA Hospice or hospice trained staff Supplementary funding for non-covered services Longer median survival (52 vs. 20 days) Patients living > 6 months doubled from 6-13% Patients were hospice eligible May have desired treatment hospice was unwilling to provide No data on why patients did not elect hospice

Palliative Care Programs Disease-Based Palliative Care Focused on special needs of patients with specific chronic and potentially terminal illnesses Cancer HIV Pediatrics Dementia

Hospice/Palliative Care Interface Curative / disease modifying therapy Time Course of Illness Last Weeks of life Family Bereave-ment care Traditional Model of Health Care From Emanuel, von Gunten, Ferris. Plenary 3:EPEC series and reproduced in Kinzbrunner. Palliative Care Perspectives, Chapter 1 in Kuebler, Davis, Moore Palliative Practices, An Interdisciplinary Approach, 2005, p. 21.

Hospice/Palliative Care Interface Curative / disease modifying therapy Time course of illness Last weeks of life Palliative care Family Bereavement care Integrated Palliative Care Model Modified From Emanuel, von Gunten, Ferris. Plenary 3:EPEC series and reproduced in Kinzbrunner. Palliative Care Perspectives, Chapter 1 in Kuebler, Davis, Moore Palliative Practices, An Interdisciplinary Approach, 2005, p. 22.

Hospice/Palliative Care Interface Curative / disease modifying therapy Time course of illness Last months of life Palliative care Family Bereavement care Integrating Palliative Care and Hospice Modified From Emanuel, von Gunten, Ferris. Plenary 3:EPEC series and reproduced in Kinzbrunner. Palliative Care Perspectives, Chapter 1 in Kuebler, Davis, Moore Palliative Practices, An Interdisciplinary Approach, 2005, p. 22.