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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

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End of life care delivery systems

End of Life Care Delivery Systems

Barry M. Kinzbrunner, MD

Joel S. Policzer, MD


Definitions

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


Definitions1

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


Definitions2

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


Definitions3

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


Definitions4

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

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


Hospice1

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

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 benefit1

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 benefit2

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 benefit3

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 benefit4

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 benefit5

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 benefit6

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 benefit7

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 benefit8

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 benefit9

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 benefit10

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 benefit11

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

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



Palliative care programs1

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 programs2

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 programs3

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 programs4

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 programs5

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 programs6

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

Hospice

Curative / disease modifying

therapy

Last

Weeks

of life

Family Bereave-ment care

Time Course of Illness

Hospice/Palliative Care Interface

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 interface1

Hospice

Curative / disease modifying

therapy

Palliative care

Time course of illness

Last weeks of life

Family Bereavement care

Hospice/Palliative Care Interface

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 interface2

Hospice

Curative / disease modifying

therapy

Palliative care

Family Bereavement care

Time course of illness

Last months of life

Hospice/Palliative Care Interface

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.


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