Presentation on theme: "End of Life Care Delivery Systems"— Presentation transcript:
1 End of Life Care Delivery Systems Barry M. Kinzbrunner, MDJoel S. Policzer, MD
2 Definitions Palliative care “palliare” latin: to cloak “care provided to treat the symptoms of an illness without curing or affecting the underlying illness”Examplesinsulin “palliates” diabeteslasix “palliates” congestive heart failure
3 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 communityIncludes palliation of symptoms of the disease and management of untoward effects of treatment
4 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 careMay be provided in virtually any setting where someone may dieICU Acute care hospitalLTCF ALFPrivate residence
5 Definitions Hospice Care Team-oriented approach to end of life care Expert in medical care, pain and symptom management, and emotional and spiritual supportTailored to the patient’s needs and wishesSupport to loved ones as wellProvided in any setting
6 Definitions Palliative Care Extends principles of hospice care to a broader populationEarlier in disease course than hospiceComprehensive and specializedPain and symptom management, advance care planning, psychosocial and spiritual support, coordination of careDefinition may be able to be expanded to all aspects of medical care
7 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 EastModern hospice as care for the dyingEnglandDame Cicely SaundersSt. Joseph’s and St.Christopher’s HospicePrimarily inpatient based
8 Hospice Hospice in the US began in 1970s in Connecticut Home based rather than facility basedInpatient care confined to situations where patient could not be cared for at homeDemonstration project at end of 1970sMedicare Hospice Benefit-1982Defines hospice in the United States to this day
9 Medicare Hospice Benefit Patient EligibilityPart A Medicare BenefitPrognosis of 6 months or less if the terminal illness runs its normal courseBased on the clinical judgment of two physiciansHospice Medical Director or designeeAttending physicianPatients elect hospice via informed consentMay voluntarily leave hospice at any time through the process of “revocation”
10 Medicare Hospice Benefit Benefit PeriodsTwo 90-day Benefit PeriodsUnlimited 60-day Benefit PeriodsRe-certificationHospice 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
11 Medicare Hospice Benefit ReimbursementPer diem payment to hospice based on “Level of Care” through Medicare Part AHospice physician services for patient visits billable through Medicare Part A in addition to per diemAttending physician professional services (visits) and care-plan oversight billable under Part BAnnual payment cap
12 Medicare Hospice Benefit Levels of CareRoutine Home CareBasic services provided in the patient’s primary place of residence, including ALF or LTCFContinuous Home CareGeneral In-patient CareRespite In-patient Care
13 Medicare Hospice Benefit Covered ServicesInterdisciplinary Team care:Nursing servicesMedical social servicesPastoral counselingMedical direction and physician care plan oversightHome health aide and homemaking servicesBereavement servicesDietary counseling
14 Medicare Hospice Benefit Covered ServicesMedical consulting servicesPhysical therapy, occupational therapy, speech therapyDrugs and biologicalsDurable Medical EquipmentMedical suppliesLaboratory and diagnostic studies
15 Medicare Hospice Benefit Continuous Care8-24 hours of care per day provided in the home settingPaid hourly (Day starts at 12 MN)More than 50%of care has to be provided by a nurseHours do not need to be “continuous”Clinical indications similar to general inpatient care
16 Medicare Hospice Benefit General Inpatient CareCare that cannot be managed in the home settingPer Diem rateMay be provided in a variety of venuesFree-standingLeased space in a hospital, LTCF, ALFContract bed in hospital or LTCFReimbursement limited to no more than 20% of a hospice program’s billable days of care
17 Medicare Hospice Benefit Indications for General Inpatient Care and Continuous CareUncontrolled painRespiratory distressSevere decubitus ulcers or other skin lesionsIntractable nausea, emesisOther physical symptoms not controllable on a routine level of careSevere Psychosocial Symptoms or acute breakdown in family dynamics
18 Medicare Hospice Benefit Respite Inpatient CareCare provided to give the family care-giver’s respite from the rigors of taking care of the patientPer Diem rateLimited to a maximum of 5 days at any one timeUnder-utilized due to poor reimbursement rate compared to other levels of care
19 Medicare Hospice Benefit State of Hospice Access TodayAlmost 1 million patients admitted in 20042003 NHPCO National Data SetALOS daysMedian LOS daysContinuous Care 0.9%General Inpatient 3.4%Respite Inpatient 0.2%Admissions by Dx: Cancer 49.1%Heart %Dmentia 9.7%
20 Medicare Hospice Benefit Barriers to Hospice Access6 month prognosis requirementCommunicationPhysicians do not want to tell patientsPatients and families do not want to be toldLack of inpatient relationships between hospices and hospitalsHospice reluctance to allow “disease-directed” therapy
21 Palliative Care Programs Goals:Increase patient access to end-of-life careReach patients who are not currently being reached by hospiceOvercome barriers to hospice access
22 Comparison of Hospice and Palliative Care Programs
23 Palliative Care Programs Hospital Based Palliative CareInterdisciplinary or Multi-disciplinaryTypically Physician ledPhysician consults with supplementation by other disciplinesSome academic centers and hospitals have discreet inpatient unitsICU consults to facilitate end of life decision making reduces ICU utilization
24 Palliative Care Programs Hospital Based Palliative CareReimbursement through traditional systemNo specific reimbursement stream for “palliative care”Physician consultsDRGs for hospital careSavings by reducing ICU and inpatient daysImproved quality of inpatient careMay partner with a hospice to provide more comprehensive services
25 Palliative Care Programs Long-term Care Facility Palliative CareNeed for palliative care for patients accessing Medicare Part A for Nursing Home carePhysician Consult servicesPartnerships with hospices
26 Palliative Care Programs Home-Based Palliative CareHome health agency servicesMay be independent or affiliated with a hospice programPatients need to be Home-care eligiblePre-hospice “Bridge” programsAffiliated with hospiceReimbursed as Home Health agenciesHospice or hospice trained staff
27 Palliative Care Programs Home-Based Palliative CarePre-hospice “Bridge” programsAffiliated with hospice and reimbursed as HHAHospice or hospice trained staffSupplementary funding for non-covered servicesLonger median survival (52 vs. 20 days)Patients living > 6 months doubled from 6-13%Patients were hospice eligibleMay have desired treatment hospice was unwilling to provideNo data on why patients did not elect hospice
28 Palliative Care Programs Disease-Based Palliative CareFocused on special needs of patients with specific chronic and potentially terminal illnessesCancerHIVPediatricsDementia
29 Hospice/Palliative Care Interface Curative / disease modifyingtherapyTime Course of IllnessLastWeeksof lifeFamily Bereave-ment careTraditional Model of Health CareFrom 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.
30 Hospice/Palliative Care Interface Curative / disease modifyingtherapyTime course of illnessLast weeks of lifePalliative careFamily Bereavement careIntegrated Palliative Care ModelModified 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.
31 Hospice/Palliative Care Interface Curative / disease modifyingtherapyTime course of illnessLast months of lifePalliative careFamily Bereavement careIntegrating Palliative Care and HospiceModified 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.
Your consent to our cookies if you continue to use this website.