END-OF-LIFE CARE TRENDS AND INNOVATIVE MODELS Presented by:
Susan Enguidanos, PhD, MPH USC Davis School of Gerontology Co-Facilitated by:
Randy A. Platt, SVP of Operations Silverado Hospice & At Home
#ALFA2014
Agenda • • • •
• •
What is important for individuals at end of life? Current experience of Dying Introduction to Palliative Care Two Models of palliative care Hospital-based Home-based Impact of palliative care on 30-day hospital readmissions A discussion of Hospice and Palliative care in the Assisted Living Environment #ALFA2014
Group Exercise • • • • •
What is important to people at end of life? Where do people want to spend their time at end of life? Is your Community the “home” your resident and their family expect? Are you prepared to have care discussions, to include the resident and family’s end of life goals? Are your associates, nurses and medical directors prepared to have the Palliative or hospice care discussion?
#ALFA2014
Background: Patient & Family Need Current dying experience is far from one that is desired by most Americans • Majority of Americans prefer to die at home (Hays et al., 2001; Gallup, 2000) •33.5% die at home (2009; Teno et al., 2013) • Patients continue to die in pain (Meier, 2006) • Health care providers do not know code status preferred by their patients • 46% of Do Not Resuscitate orders written within 2 days of death #ALFA2014
Impact on Costs of Care 5% of people 65 & up die each year Percent of Total Medicare Spending 29.00%
28.30%
28.00% 27.00% 26.00%
25.10%
25.00% 24.00% 23.00% 1978
2006
(Riley & Lubitz, 2010) #ALFA2014
65+ Medicare Beneficiaries Hospital Use 70.0 60.0
64.5
63.7
62.6
62.5
50.0 40.0 Decedents INP
30.0 20.0
Survivors INP 18.5
16.1
16.5
16.7
10.0 0.0 1978
1988
1997
2006
(Riley & Lubitz, 2010) #ALFA2014
65+ Medicare Beneficiaries Multiple Hospitalizations
(Riley & Lubitz, 2010) #ALFA2014
65+ Medicare Beneficiaries ICU Use
(Riley & Lubitz, 2010) #ALFA2014
Rise in Aggressive Care? 30 25
29
26 24
20 15
10
10
11
11
10
12
14
2005
5 0
2000 2009
ICU 30 days
3 or > INP 90 days
Transition 3 days
Teno et al., 2013 #ALFA2014
Hospice Care • What is hospice care? • Do you know someone who has had hospice care? • What was it like?
#ALFA2014
Hospice Enrollment Trends (NHPCO, 2011, 2012)
#ALFA2014
What is Palliative Care? • Type of care for seriously ill patients that is focused on quality of life: • • • •
Pain & Symptom control Optimizing functioning Helps patients and families make important decisions Provides psychological & spiritual support
#ALFA2014
Goal of Palliative Care “…to prevent and relieve suffering & to support the best possible quality of life for patients & their families, regardless of the stage of the disease or the need for other therapies.”
#ALFA2014
Core Components of Palliative Care • Interdisciplinary team: physician, nurse, social worker, chaplain • Physical, medical, psychological, social & spiritual support
• Patient & family education & training
• Develop plan of care • Train patients and families on how to manage symptoms
• Coordinated, patient-centered care • Pain & symptom management
#ALFA2014
Curative / remissive therapy
Presentation
Death
Palliative care
Hospice
Adapted from Lynn and Adamson, 2003 #ALFA2014
Palliative Care vs. Hospice Physicians not required to give a 6 month prognosis Patients do not have to forego curative care Palliative care physician coordinates care to prevent service fragmentation
#ALFA2014
Organ Failure Trajectory
#ALFA2014
Palliative Care Models Hospital-based Palliative Care Programs
Home-based Palliative Care
#ALFA2014
Inpatient Palliative Care Consultation Teams
#ALFA2014
Hospital-based Palliative Care • Consultative IPC service involves family meeting with patients/family
#ALFA2014
Clinical Impact of IPC • LOS 30% • Pain by 86% • Dyspnea by 64%
(Ciemins, Blum, Nunley, Lasher, Newman, 2007)
#ALFA2014
Fewer ICU Admissions at Readmission 25
21
20 15
12
10 5 0
Usual Care
IPC
(Gade, Venohr, Connor et al., 2008) #ALFA2014
Lower Costs of Care
$25,000
Lowered cost by $4855
$21,252
$20,000 $15,000 $10,000
$14,486
Usual Care IPC
$5,000 $0
(Gade, Venohr, Connor et al., 2008) #ALFA2014
Home-based Palliative Care
#ALFA2014
Home-based Palliative Care (HBPC) • Eligibility • Diagnosis of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or cancer • Life expectancy about 1 year • Primary care physician “would not be surprised” if the patient died
in the next year
• Palliative Care • Home visits provided by interdisciplinary team • Access to all usual medical care services
#ALFA2014
Satisfactory Scores by Study Group Satisfaction with Care
45 40
39.35
40.88
43.56 40.89
35 30
Enrollment
25
90 Days Follow-up
20 15 10
Usual Care
Palliative Care
p=.02
Brumley, Enguidanos, Jamison et al., 2007 #ALFA2014
Percent Using
Acute Care Service Use (n=297) 60%
Palliative
50%
Usual Care
40% 30%
32%
58%
36%
20%
20% 10% 0% *ED
*Hospital
Brumley, Enguidanos, Jamison et al., 2007 #ALFA2014
Unadjusted Medical Service Use (n=297) 30
Mean Number of Days/Visits
30 Palliative
Usual Care
25 20 15
12.39 9.11
7.34
10 5
0.29 0.67
2.2
1.77
3.18
4.42
0 *ED
*Hospital
SNF
* P<.01
*MD Office
*Home Visits
Brumley, Enguidanos, Jamison et al., 2007 #ALFA2014
Site of Death (n=217) 80% 71% 70%
Palliative Care
Usual Care
60% 51% 50% 40% 30%
24% 14%
20% 11%
9%
10%
9%
11%
0% Home
Hospital
SNF
InPt. Hospice
â&#x20AC;˘ Studies show that most people prefer to die at home* â&#x20AC;˘ Patients enrolled in the Palliative Care program were significantly more likely to die at home (71% vs. 51%: p=.001)
P=.013 *(Townsend, Frank, Fermont, et al., 1990; Karlsen & Addington-Hall, 1998; Hays et al., 2001)
#ALFA2014
Total Service Costs Palliative
Usual Care
$25,000
$20,221
$20,000 $15,000
$12,670
â&#x20AC;˘ Adjusted costs of care for those in PC were 32.6% less than those receiving UC
â&#x20AC;˘ Saves $7,551
$10,000 $5,000 $0 All Costs p<.001
#ALFA2014
30-Day Readmission among Seriously Ill Older Adults: Why Do They Come Back?
#ALFA2014
AIMS • Determine rate of and factors associated with 30 day readmissions among Inpatient Palliative Care (IPC) patients • Characterize patient and family perspectives on 30day readmissions • aligned with desired plan of care? • avoidable? Enguidanos, Vesper, & Lorenz (2012). 30 day readmissions among Seriously Ill Older Adults. Journal of Palliative Medicine, 1-6. #ALFA2014
Readmission Rates Among IPC Patients • Among IPC patients discharged, overall readmission rate = 10% • Overall hospital readmission = 15% • Reduced readmission by 1/3
#ALFA2014
Type of Care at Discharge (n=408) (Enguidanos et al., 2012) 70.0% 60.0%
58.8%
50.0% 40.0% 30.0% 20.0%
14.7%
10.0%
14.2% 3.7%
8.6%
0.0% Hospice
Home-based Home Health PC
Nursing Facility
Home-No Care
#ALFA2014
Readmission Rate by Post Discharge Service Use (Enguidanos et al., 2012) 70% 60%
58.8%
Care at D/C % Readmitted
50% 40% 30% 20% 10%
25.7%
24.1% 14.7% 4.6%
8.3%
13.3% 3.7%
14.2% 8.6%
0% Hospice
Home-based PC
Home Health Nursing Facility Home-No Care
#ALFA2014
Predictors of 30-Day Readmit Examined age, gender, ethnicity, marital status, pain, diagnosis, # chronic conditions, anxiety, ADs, and their association with 30 day readmit No Advance Directive 2.7x’s more likely
Added discharge disposition to the model Nursing Facility 5x’s & Home (no care) 3.7x’s more likely Enguidanos, Vesper, & Lorenz (2012). 30 day readmissions among Seriously Ill Older Adults. Journal of Palliative Medicine, 1-6. #ALFA2014
Qualitative Interviews Interviews with IPC CHF & CA patients/caregivers following 30 day hospital readmission to determine patient/caregiver perspective (n=7)
#ALFA2014
Themes â&#x20AC;˘ Three themes identified: 1. Lack of Support & Purpose 2. Rehospitalization as appropriate care 3. Lack of access to care/information
#ALFA2014
Theme: Lack of Support & Purpose • Lack of support & purpose • Living alone and lack of support • “I wasn’t cooking for myself, I wasn’t doing anything…I just wasn’t eating” • “It’s just a matter of me …motivating me” • “If there was something I could look forward to…”
#ALFA2014
Theme: Appropriate Care Hospital care most appropriate for medical condition “ I get to retaining the fluids again and then right back to where we were [hospital]” Preference for aggressive care “ I ain’t going nowhere, and I’m fighting”
#ALFA2014
Theme: Lack of Access to Care/Information • “I should be comfortable. I shouldn’t have to go, ‘Oh, I got pain I need pain meds.’ I shouldn’t be going after pain medication…I was told I should come back to the ER to get my pain medicine.” • “Sometimes I have questions” • “I could have REALLY used a • hospital bed” • Inability to physically transport spouse to specialist appt.
#ALFA2014
Theme: Lack of Access to Care/Information
“We need to look at my overall picture…I have a number of problems that I need to resolve both medical and …psychological. There’s some psychological problems, there’s some financial problems…when I go home, ok, I’m faced with a whole group of problems that I have to resolve which is enough to give a person a heart attack to begin with, and every day that I’m out, it gets worse.”
#ALFA2014
Silverado Communities Clinical Outcomes SILVERADO
SKILLED NURSING
COMPANY-WIDE
FACILITIES (nonSilverado)
ยนASSISTED LIVING
% TRANSFERS TO ER/URGENT CARE
2.2%
8.0%
34.6%
% of HOSPITAL READMISSIONS WITHIN 30 DAYS
0.3%
16.9%
% of ACUTE HOSPITALIZATIONS
3.6%
20.0%
89.4%
33.1%
CLINICAL OUTCOMES: COMMUNITIES
1. 2010 National Survey of Residential Care Facilities The NSRCF was conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS). The survey methodology and data dictionary are available from the NCHS website. (http://www.cdc.gov/nchs/nsrcf/nsrcf_questionnaires.htm). % of DEATHS RECEIVING HOSPICE SERVICE
23.9%
1. 2010 National Survey of Residential Care Facilities The NSRCF was conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS). The survey methodology and data dictionary are available from the NCHS website. (http://www.cdc.gov/nchs/nsrcf/nsrcf_questionnaires.htm).
#ALFA2014
Silverado Hospice Clinical Outcomes SILVERADO COMPANY-WIDE (Year ending, 2013)
NATIONAL Average (Year ending, 2012 NHPCO)
HOSPITAL READMISSION RATE WITHIN 30 DAYS (CMS)
2.7%
5.4%
REVOCATION RATE (NHPCO)
6.3%
14.4%
CONVERSION RATE
77.0%
75.0%
CLINICAL OUTCOMES: HOSPICE
Silverado Hospice has earned The Joint Commission’s Gold Seal of Approval
#ALFA2014
Group Exercise â&#x20AC;˘ What are the benefits of palliative care? â&#x20AC;˘ How can palliative care and hospice care be better integrated into assisted living facilities? â&#x20AC;˘ What is the potential business case for integrating palliative care and hospice care into existing care services?
#ALFA2014
How to reach usâ&#x20AC;Ś. Susan Enguidanos, PhD, MPH USC Davis School of Gerontology enguidan@usc.edu Randy A. Platt, Senior Vice President of Operations Silverado At Home and Hospice rplatt@Silveradocare.com 949-240-7200
#ALFA2014
END-OF-LIFE CARE TRENDS AND INNOVATIVE MODELS Presented by:
Susan Enguidanos, PhD, MPH USC Davis School of Gerontology Co-Facilitated by:
Randy A. Platt, SVP of Operations Silverado Hospice & At Home
#ALFA2014