1. Todays Message… We must provide end-of-life care - not doing so is not an option We must provide end-of-life care - not doing so is not an option Options are.. Options are.. Where its provided, its quality and associated costs Where its provided, its quality and associated costs Significant disparities exist among VISNs and facilities in their provision of this care Significant disparities exist among VISNs and facilities in their provision of this care Evidence suggests that the provision of palliative care results in cost savings relative to acute care alternatives Evidence suggests that the provision of palliative care results in cost savings relative to acute care alternatives

2. What is Palliative Care in VA? Care focused on enhancing quality of life for patients with life-limiting and terminal illnesses Care focused on enhancing quality of life for patients with life-limiting and terminal illnesses Utilizing Utilizing Dedicated nursing home beds Dedicated nursing home beds Consult teams Consult teams Coordination of home hospices and management in HBPCs Coordination of home hospices and management in HBPCs

3. Assumptions and Possibilities… Assumption: Instituting or expanding a palliative care program would just be an additional expense we cannot afford… Assumption: Instituting or expanding a palliative care program would just be an additional expense we cannot afford… Possibility: Maybe a palliative care program would more than pay for itself through shifting workload, resulting in net cost savings Possibility: Maybe a palliative care program would more than pay for itself through shifting workload, resulting in net cost savings

4. Assumptions and a Certainty… Assumption: We have no choice where people die (or how much it costs) because… Assumption: We have no choice where people die (or how much it costs) because… Deaths are unpredictable Deaths are unpredictable Patients want aggressive care Patients want aggressive care Deaths in acute care are fundamentally different from those on a hospice ward Deaths in acute care are fundamentally different from those on a hospice ward Certainty: If veterans who cannot die at home have no alternative to acute care, that is where they will die Certainty: If veterans who cannot die at home have no alternative to acute care, that is where they will die And its going to be Expensive… And its going to be Expensive…

5. Where to die? Veteran choice or the default mode – ICU and Acute Care? Very few people want to die in acute care or the ICU Very few people want to die in acute care or the ICU Veteran choice is most affected by having no choice Veteran choice is most affected by having no choice If veterans cannot die at home and only acute care is available, they will die in acute care by default If veterans cannot die at home and only acute care is available, they will die in acute care by default Where would YOU want to die, if unable to die at home?

6. Demographics of Dying in VA – the Need… Serving an older, sicker population because of WWII generation Serving an older, sicker population because of WWII generation 674,461 estimated veteran deaths in 2001 (28% total national deaths) – 1,800 per day* 674,461 estimated veteran deaths in 2001 (28% total national deaths) – 1,800 per day* Veteran deaths peak in 2005 at 687,273 Veteran deaths peak in 2005 at 687,273 *Office of the Actuary, Vet Pop2000

7. TAPC Survey Highlights 80/107 facilities had some palliative care in nursing homes 80/107 facilities had some palliative care in nursing homes 41 dedicated bed programs for 403 beds total 41 dedicated bed programs for 403 beds total 45//109 facilities had palliative care/hospice consult teams 45//109 facilities had palliative care/hospice consult teams 30 HBPC programs included some palliative care 30 HBPC programs included some palliative care

8. TAPC Worrisome Findings 29 respondents reported never using community hospice resources 29 respondents reported never using community hospice resources 63 facilities reported never using fee basis for home hospice care 63 facilities reported never using fee basis for home hospice care 64% of facilities reported serving <100 patients per year…

9. Palliative Care - ? A Good Investment? Zero-Sum Game financing: Zero-Sum Game financing: To spend more on palliative care in the short run means to spend less on something else To spend more on palliative care in the short run means to spend less on something else However, if workload shifts and if net cost- savings are realized, in the long run you will save money However, if workload shifts and if net cost- savings are realized, in the long run you will save money

10. Management Argument: We cannot afford palliative care Assumptions- Assumptions- We have a choice as to whether or not to care for very ill and dying patients We have a choice as to whether or not to care for very ill and dying patients Palliative care service would just be an additional expense without true cost savings Palliative care service would just be an additional expense without true cost savings

11. Management Arguments for Why Palliative Care Cannot be Expanded We cannot afford it We cannot afford it Just an additional cost – no cost savings Just an additional cost – no cost savings We have no choice as to where patients die or how much this costs We have no choice as to where patients die or how much this costs Implied Message…

12. Management: Deaths in acute care are unavoidable because… Patients have different illnesses Patients have different illnesses We do not know these patients are going to die We do not know these patients are going to die Selection bias – some patients choose more aggressive care and others less aggressive (cheaper) care Selection bias – some patients choose more aggressive care and others less aggressive (cheaper) care

13. What does this suggest? Good evidence that the provision of palliative care is less expensive than acute/ICU care for dying patients Good evidence that the provision of palliative care is less expensive than acute/ICU care for dying patients Most veterans dying in acute care have serious, life-limiting illnesses Most veterans dying in acute care have serious, life-limiting illnesses Program development may affect where people die in your facility Program development may affect where people die in your facility The provision of palliative care services may save you money (and its a nice thing to do) The provision of palliative care services may save you money (and its a nice thing to do)