Palliative Care Across the Continuum as presented to the The Palliative Care Summit for PeopleFirst Homecare and Hospice that was held in Snowbird Utah on September 15, 2012, following the Rocky Mountain Geriatric Conference.
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Palliative Care Across the Continuum
1. Shaida Talebreza MD
Haven HealthCare, University of Utah Division of Geriatrics, Veterans Administration
John Evans FNPC
BridgePoint Supportive Care
Jamie Brant MD
Haven HealthCare Bridgepoint Palliative Care Program
Kevin Doyle MD
Granite Mountain
2. Specialized medical care for people with serious illness
Aims to relieve suffering, improve quality of life, optimize function, and
assist with decision making for patients with advanced illness, and their
families
The goal is to improve quality of life for both the patient and the family
Palliative care is provided by a team of doctors, nurses, and other
specialists who work together with a patient's other doctors to provide an
extra layer of support
It is appropriate at any age and at any stage in a serious illness and can be
provided along with curative treatment or as the main focus of care
Available at www.getpalliativecare.org
Pacala JT, Sullivan GM, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 7th ed. New York, NY: American Geriatrics Society; 2010.
3. A defined, integrated model of palliative care at the end
of life
Can be as aggressive as curative care focusing on
Comfort
Dignity
QoL/relationship closure
as directed by patient and family goals and choices
Aims to relieve suffering, improve quality of life, optimize
function, and assist with decision making for patients
with advanced illness, and their families
Ferrell BR, Coyle N. Oxford Textbook of Palliative Nursing, 3rd ed. Oxford: Oxford University Press, 2010.
Quill, TE, et al. Primer of Palliative Care, 5th ed. Glenview, IL: American Academy of Hospice and Palliative Medicine; 2010.
6. Palliative Hospice
Chronic illness Terminal illness
Can seek Not seeking
life-prolonging, curative treatment
Expected
curative treatment prognosis of six
No eligibility
months or less if
criteria the illness runs its
Medicare – part B normal course
Medicare – part A
7. Pre-Palliative Care Model Hospice
Curative/Disease
Controlling Therapy Palliative
Care
Death
Diagnosis of Life
Threatening Illness
10. Colorado’s newly adopted definition of Palliative
Care:
“Palliative Care” means specialized medical care for
people with serious illnesses. This type of care is
focused on providing patients with relief from the
symptoms, pain and stress of serious illness, whatever
the diagnosis.
11. The goal is to improve the quality of life for both
the patient and the family. Palliative care is
provided by a team of physicians, nurses and
other specialists who work with a patient’s other
health care providers to provide an extra layer of
support.
12. Palliative care is appropriate at any age and at
any stage in a serious illness and can be provided
together with curative treatment. Hospice
providers may perform palliative care services that
are separate and distinct from hospice care
services.
CDPHE effective 9-1-12
13.
14. Denver’s Program started small in November,
2008 – 5 new patients in the first two months
First full year – 2009 - 55 new patients and 104
total visits
Approaching 4th anniversary – over 600 patients
have participated in the program
15. 2010
◦ 171 new referrals
◦ 415 established patient visits
An LCSW was added, split between hospice and palliative,
in March 2010
2011
◦ 217 new referrals
◦ 974 established patient visits
A second NP was added in May, 2011
16. Through August 2012
◦ Averaged 20 new referrals monthly and over 100
established visits each month
On target to see about 250 new patients this year and
provide over 1200 established visits in 2012
Since inception, 145 BridgePoint patients
(24.17%) have converted to PeopleFirst hospice
Through August 2012, 44 patients (27%) have
converted to PeopleFirst hospice
17. Kindred LTAC’s
Acute care hospitals
Skilled Nursing or Long Term Care Facilities
Assisted Living Facilities
Private Homes
Day Programs
18. Social Workers
Hospital discharge planners and case managers
Community Case Managers
Eldercare Specialists and advocates
Family members or patients self-refer
Primary care physicians and mid-level providers
or practice staff – triage nurses
Community Agencies and Programs
Nursing Facility Staff
19. Kindred LTAC’s – 22%
SNF/LTC – 35%
Home – 32%
Assisted Living – 9%
Acute Care Hospitals – 2%
20. Focus is on pain and symptom management
Assisting with Advance Care Planning
Support
Connecting patients and families to needed
resources:
◦ Medicaid benefits – assist with applications
◦ VA benefits – assist with applications
◦ Private Duty Care
◦ Skilled Home Care
◦ Home or outpatient rehabilitation
21. Meals on Wheels or Project Angel Heart
Hospice Care
Elder care resources such as legal aid, estate
planning or guardianship
“Translation” Services – explain what the doctor
said and what that means
Navigation assistance through the health care
system
22. There is no requirement for a terminal diagnosis
or condition – only that a patient have a serious
and/or chronic illness
No physician certification is necessary
◦ However the Primary Care (MD, PA, NP) Provider’s
order is necessary
Patients can continue with aggressive treatment
Patients are not required to be homebound
23. Helping patients identify how they define “quality
of life” and helping them achieve it.
◦ Recent addition of Missoula-VITAS Quality of Life Index
Symptoms
Function
Interpersonal
Well-being
Transcendent
24. Often, the BridgePoint NP/LCSW are the only
providers involved in the patient’s care that
interact with all of the patient’s other providers
Post discharge follow-up and education for
patients and caregivers is often provided
25. LTAC to home
The man who liked ice cream
The ALS patient
The recurrent ER patient
29. 25% of Medicare dollars are spent in the last 1
year of life
2.8 % of Medicare dollars are spent on hospice
Robert Wood Johnson Foundation study (Duke
University) found that hospice saves Medicare,
on average, more than $2,300 per patient.
% Hogan C, Lunney J, Gabel J, Lynn J. Medicare beneficiaries’ cost of care in the last year of life. Health Aff (Millwood). 2001;20(4):188-195.
Hospice Centers for Medicare & Medicaid Services, Office of the Actuary, FY 2011 President’s budget (February 2010).
30. Hospice expected prognosis of six months or
less if the illness runs its normal course
◦ Medicare Guidelines to assist with
prognostication
Uses Medicare Hospice benefit
True interdisciplinary care
Hospice will not cover treatment intended to
cure
Emotional shift
Care goals shift
32. Per diem daily rate
All patient care/medication/DME related to
hospice diagnosis included
Minimum requirement is RN, Chaplain,
SW and volunteer
Patient can see designated attending
and/or hospice medical director
33. Primary Care Nurse Volunteers
*Attending Physician Medications
◦ Patient’s choice ◦ For symptom relief
Hospice Physician Medical Equipment
*Hospice Aide and Supplies
Social Worker Bereavement Services
Spiritual Care Coordinator ◦ For one year following a
patient’s death
34. Treatment choices that are meant to cure illness
or prolong life rather than provide symptom control
or pain relief
Long-term room and Board
Care in an emergency room, inpatient facility care,
or ambulance transportation, unless it’s either
arranged by your hospice team or is unrelated to
your terminal illness
35. Medicare Part A
Hospital
Skilled Nursing Facility
Home Health Care
Hospice
37. Do patients have to be DNR to be on hospice?
Do patients have to stop their medications?
Do you have to turn off Pacemakers and ICDs?
Do patients on hospice die sooner?
Does hospice provide 24-7 custodial care?
Do patienst have to have 24 hour caregiver?
Does a physician have to see the patient before
hospice admission?
39. 1 in 5 deaths in US occurs in NH
1/3 of NH admissions die within 1 year
2/3 die within 2 years
THAT’S A 60% DEATH RATE OVER 2
YEARS
Morley JE, J Am Med Dir Assoc 2010
In 2008, about ¼ of all hospice care delivered
in NH
Rodin MB. J Am Med Dir Assoc 2011
40. The long-term resident who develops a
rapid decline/terminal illness
The long-term resident with advancing
dementia*
The short-term patient who doesn’t respond
to therapy/interventions
The patient coming from the hospital
actively dying
Maybe all residents?
41.
42. Monitoring of quality of life required (MDS)
◦ Pain, depression, delirium, pressure ulcers
◦ Care plans must be created and followed
Inter-disciplinary team approach mirrors
hospice
Degree of expertise of Medical Director
varies
◦ Overlap of interests in NH and palliative care
◦ “Certified Medical Director” status
Palliative medicine consults
43. Any “Nursing Home” location
◦ Per diem is the same regardless of where “home” is
Give up Medicare Part A enrollment
◦ Terminal diagnosis
◦ Other diagnoses?
Contract
required between hospice
agency and facility
◦ Hospice pays facility
44. Hospice covers cost of meds and DME
◦ Related to terminal illness
Hospice is responsible for plan-of-care
Medicaid/Medicare Dual Eligible
◦ Process can vary state by state
◦ Possible disincentives for facilities to enroll in hospice
45. Pearls
◦ Need 24-hour RN for Inpatient Hospice Status
◦ Can have Medicare A status AND Hospice if patient
needs SNF for non-terminal diagnosis
Room and Board
Ex: CHF and hip fx
◦ Both Medicare Nursing Home and Hospice Regulations
Apply
Ex: NH certification visits/Hospice face-to-face visits
Ex: weight monitoring
46. Additional support to healthcare team
◦ Hospice RN focuses on quality of life issues exclusively
Provides support to facility nurse
◦ Hospice RN and MD/NP with expertise in symptom
management
available 24 hours a day
◦ May decrease likelihood of burdensome transition
(Gozalo et al, NEJM 365:13, 2011)
47. Most NH don’t have
◦ Chaplain or bereavement services
◦ Massage or Aromatherapy*
◦ Music Thanatologist*
Most NH have limited
◦ Volunteers/One-to-one activities
◦ Staff = limited TIME
Most NH Do have
◦ Support for family while resident living
◦ Social worker on staff
◦ PT/OT
48. Other residents may benefit when hospice
in building
◦ Education to facility staff – annual in-services
required
◦ “Spill-over” effect (Miller SC. J Pall Med 1998)
◦ Change in philosophy of the staff
49. End-of-life care can “skill” for Medicare
Part A
◦ Room and Board = $$$
Medicaid Disincentive
Patient/Family ambivalence
Lack of education of NH healthcare
providers and nurses (Parker-Oliver D, J Am Med Dir
Assoc 2002)
50. Communication and Collaboration
◦ Hospice staff “come in here and write notes and leave
without talking to anyone”
Parker-Oliver D. J Am Med Dir Assoc 2002
51. Communication and Collaboration
◦ Consistent staffing by the hospice in facility
◦ Hospice involved in care-plan meetings
◦ Facility staff engaging with hospice team
◦ Social events to build rapport
◦ Investment by the DONs of both companies
Professionalism
Integrity
54. Brief
overview of the Veterans Affairs Salt
Lake City Health Care System
(VASLCHCS)
◦ Eligibility
◦ Enrollment
◦ Financial benefits
◦ Patient Aligned Care Teams (PACT)
SLCVA Palliative Care Services
VASLCHCS Resources and Benefits
55. George E. Wahlen
Department of Veterans
Affairs Medical Center
56. Based on:
◦ Type and time of service
◦ Injuries occurred
◦ Finances
57. Veterans can enroll by
◦ Presenting to the Enrollment office,
◦ Online at www.1010ez.med.va.gov/sec/vha/1010ez/, or
◦ Call 1-877-222-VETS (8387)
Documents
◦ 10-10EZ
◦ DD214 (discharge papers)
Priority groups determine copayments for
medical treatment and medications.
62. Integrated palliative care model
Interdisciplinary Team including
◦ Palliative Care Medical Director, +2 physician, 2 Nurse
Practitioners, Social Worker, Chaplain, Psychologist, and
Administrative Support.
Palliative Care Consultation in the hospital
Palliative Care Clinic (outpatient)
Hospice and Palliative Care Committee
Inpatient Palliative /Hospice Care Room
Supportive care in collaboration with veterans
primary care team and specialty care team(s).
63.
64. Palliative care rooms provide a private place of
solace and introspection to both the patient and
family while also meeting any required medical
needs.
The medical team in consultation with the
Palliative Care Consult Team will frequently
review the patient’s status and recommend
continued care in the palliative care room or
transfer to home or a community facility.
65. Resources and Benefits
VHASLCHCS
http://www.va.gov/opa/publications/benefits_b
ook/2012_Federal_benefits_ebook_final.pdf
66. Home Health
◦ PT, OT, ST, RN, infusion services
◦ All enrolled veterans are eligible for n-home skilled
nursing care services.
◦ The VA will pay for care with one of our contracted
hospice agencies if a veterans insurance will not cover
the services or the veteran does not have insurance.
◦ Copayments may apply
67. Homemaker/Home Health Aide
◦ Homemaker
Veterans at risk of nursing home placement
2 hours 1xweek + based on needs assessment
◦ Home Health Aide
Veterans at risk of nursing home placement
1 hour 3xweek + based on needs
Home OT Consult
◦ Lives in Salt Lake valley
◦ Frequent falls, difficulty with ADLs or IADLs, cognitive
impairment raising safety issues, known safety hazards, need
home safety evaluation
68. Hospice
◦ All enrolled veterans are eligible for hospice care
services.
◦ The VA will pay for care with one of our contracted
hospice agencies if a veterans insurance will not cover
the services or the veteran does not have insurance.
◦ VA paid hospice services include the same benefits as
Medicare paid hospice services.
69. GHELP
◦ Geriatric High Risk Evaluation and Liaison to
Primary Care Program
◦ Prevent unnecessary and inappropriate nursing
home placements, emergency room visits, re-
hospitalizations, and unscheduled outpatient clinic
visits
Home Based Primary Care (HBPC)
70. VA pays for a skilled nursing facility at a
contracted facility.
70% service connected veterans or 60% service
connected with unemployability are eligible for
an indefinite contract.
Enrolled veterans with no private insurance are
eligible for a 31 Day VA Contract for
rehabilitation.
Exceptions can be made based on the situation
and need.
71. Medical Foster Home
◦ Skilled Nursing Home alternative.
Community Residential Care
◦ Assisted Living equivalent.
◦ Sponsor families or homes in the community.
72. All enrolled veterans are eligible for an End of Life
Contract
Criteria
◦ Prognosis is weeks to months/6 months
◦ Veteran agreeable to hospice services
SNF: VA pays for room and board at a contracted
facility
Hospice: Medicare/Private/VA pay for hospice
services
73. Respite
◦ Up to 30 days of respite per calendar year.
◦ VA Contracted Nursing Home, Homemaker/Home Health
Aide, and/or Contracted Adult Day Care.
Caregiver Support Group
Caregiver Program
◦ www.caregiver.va.gov
◦ 1-855-260-3274
◦ Enhanced benefits for all enrolled veterans and caregivers.
◦ Comprehensive assistance for Family Caregivers for eligible
veterans who were disabled in the line of duty since Sept. 11,
2001
74. Reviews VA Death Benefits
◦ Burial flag
◦ Grave marker
◦ US President Memorial Certificate
◦ Burial at any military, veteran or national
cemetery
75. High quality,
temporary lodging to
families of active duty
http://www.fisherhousesaltlakecity.co military personnel and
m
Veterans who are
undergoing medical
treatment at the
VASLCHCS
20 private suites
Common areas
include: kitchen,
laundry facilities,
spacious dining room
and an inviting living
room with a library
and toys for children
Notas do Editor
Palliative care is interdisciplinary care that aims to relieve suffering, improve quality of life, optimize function, and assist with decision making for patients with advanced illness and their families.2 Palliative care can be delivered concurrently with life-prolonging care or as the main focus of care.1
Each hospice makes decisions of what will be offered. Ie: is treating pna a cmfort measure, warfarin?
Attending physician not covered by hospice benefit but pt can see them Aide not required to be provided
Can only receive one Medicare Part A service at one time for any given medical condition
Dementia: Focusing on Quality of life rather than prognosticating, not waiting until Hospice, Prognosticating is notoriously poor Morley JAMDA Feb 2011: Using FAST 7c with 1 serious medical condition in past year: correctly identified those dying within 6 mo only 55% of the time
Avaliable since 1989, Medicare Hospice benefit passed 1982 during Reagan era! Contract: Can be on-going or “one-time”
Hospice does NOT cover room and board in general as stated by Jamie, with few exceptions Hospice responsible for plan of care – touch on this later regarding lessons learned
Facility nurse may have distractions of med pass, treatment of non-terminal diseases and meds, some facility nurses are LPNs Facility RN may not have much experience in end-of-life care or dying process especially: terminal delirium -Uncontrolled sxs: pain, dyspnea, existential suffering, anxiety, depression, nausea, fatigue, insomnia, anorexia, terminal delirium Massage etc not provided by all hospices
Hospice Volunteers more specifically trained Social worker: May or may not know resident/family well, may not be medically trained
Spill over: facility staff observe the hospice staff and adopt their techniques, also shown as an effect of hospice on the entire medical community
With long-term residents, facility staff may feel their caring and knowledge of the patient is not acknowledged by the hospice
On all sides
Of note, each medical center is individual to what is offered and how these services work.
I will be going over the services offered through the Salt Lake VA but how they look at other medical centers can be different. Serves eligible veterans throughout Utah, East Central Nevada and South East Idaho Community Base Outpatient Clinics (CBOC): Nephi, Ogden, Orem, Price, Roosevelt, St. George, West Valley, Idaho Falls (outreach), Pocatello, Elko (outreach), Ely
Its complicated. Not all veterans are eligible for enrollment. This can changed based on congress. If they have a service-connected injury, they automatically qualify for enrollment OEF/OIF veterans are eligible for up to 5 years
Not go through but this is information on how to enroll.
The VBA has additional services for veterans including home loans, vocation rehab, etc. Service-Connection Disability Compensation : monetary benefit paid to veterans who are disabled by an injury or illness that was incurred or aggravated during active military service. Disability ratings range from 0%-100%. VA Pensions: Veterans with low incomes who are either permanently and totally disabled, or age 65 and older , may be eligible for monetary support if they have 90 days or more of active military service ; at least one day of which was during a period of war . Aide & Attendance: is a benefit paid in addition to monthly pension for veterans who need additional assistance.
Patient Centered Medical Home model changed to Patient Aligned Care Team. Teamlet consisting of the Primary Care Provider, Program Support Assistant, RN Case Mangaer and the Patient The Primary Care Team Takes collective responsibility for patient care Responsible for providing all the patient’s health care needs Arranges for appropriate care with other specialties as needed
The VA offers similar services to those already presented. Some VA’s have inpatient hospice. It is usually VA’s with a Community Living Center. What is unique to our VA is the Inpatient Palliative/Hospice Care Room which I’ll go over in a minute.
Our team has over 1,000 consults a year. Again, this is what Salt Lake has so you’ll want to look at the VA in your area. All VA’s don’t necessarily have this.
We have two Inpatient Palliative/Hospice Care Rooms. 25% discharged alive.
Note: these can change based on local policies. These are resources through the VHA not the VBA.
If veterans have copayments, they will have a copayment for each day there is a visit/visits. Can we double dip? Speak to Pat. Home Health can be ordered for skilled needs. If veterans do not have insurance, the VA will pay for home health. There may be a per visit per day copayment.
We order the homemaker/home health aid separate from other skilled needs. A veteran can receive these services without having PT/OT/RN ordered. If veterans have copayments, they will have a copayment for each day there is a visit/visits. Homemaker should be provided by the hospice, but there are exceptions that can be made.
-- veterans may continue to receive outpatient Palliative Care services in our clinic along with any of the previously discussed services GHELP The veteran and support system is evaluated in his/her environment by an interdisciplinary assessment team, a plan of care is developed, immediate interventions are deployed, and the veteran is discharged to primary care for follow-up. Home Based Primary Care (HBPC) Provide comprehensive, interdisciplinary, and primary care in the homes of Veterans with complex medical, social, and behavioral conditions for whom routine clinic-based care is not effective
VA uses the term Extended Care Facilities (ECF). Commonly called a VA Contract. VA does NOT pay for Assisted Living Level of Care. NSC veterans may have a per day copayment based on their LTC scores. Example of exception is Radiation/Chemo
Medical Foster Home Alternative to nursing home placement by finding caregivers in the community who are willing to take a veteran into their home and provide 24-hour supervision as well as needed personal assistance. $1500 - $3000 per month for their care. Partners with HBPC. Community Residential Care Veterans who do not need the care provided in a nursing home or hospital setting, but who may have difficulty living alone. Sponsor families or homes in the community provide room and board, including three nutritious meals per day, transportation to appointments, assistance with activities of daily living, and general monitoring. Veterans placed in the CRC program will need to have sufficient funds to pay from $800 - $2700 per month for their care.
- National Program but program may look different.