1. Readmission and Chronic illness that could benefit from end of life discussions.

2.  Palliative care is an Interdisciplinary specialty that aims to relieve suffering and improve quality of life for patients with advanced illness, and their families. It is provided simultaneously with all other appropriate medical treatment.

3.  Pain and Symptom Control  Goal setting  Prognostication  Psycho-Spiritual support  Integration at start of a life threatening illness—not just in the final days of life.

4.  Hospice is both a philosophy, and a health care reimbursement system ◦ Restrictions on eligibility (< 6 months prognosis) ◦ Restrictions on treatments (palliative intent and only treatments that are financially feasible).  Palliative Care has no restrictions on eligibility or use of treatments.  Hospice is a subset of Palliative Care, for patients who meet the hospice eligibility requirements.

5.  http://diabetes.niddk.nih.gov/dm/pubs/america/c ontents.htm http://diabetes.niddk.nih.gov/dm/pubs/america/c ontents.htm United States is estimated to be about 120,000 individuals age >19 years and about 300,000- 500,000 individuals of all ages.  Having diabetes or pre-diabetes puts you at increased risk for heart disease and stroke.  Diabetes is the most common cause of kidney failure, accounting for nearly 44 percent of new cases. 1 Nearly 24 million people in the United States have diabetes, 2 and nearly 180,000 people are living with kidney failure as a result of diabetes. 1 1 2 1

6. http://www.cdc.gov/nchs/fastats/copd.htm  Number of noninstitutionalized adults who have ever been diagnosed with emphysema: 4.9 million  Percent of noninstitutionalized adults who have ever been diagnosed with emphysema: 2.2%  Source: Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2009, tables 3, 4Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2009, tables 3, 4 Nursing home care  Number of residents with chronic obstructive pulmonary disease: 190,000  Percent of residents with chronic obstructive pulmonary disease: 13%  Source: 2004 National Nursing Home Survey, Residents, table 33B2004 National Nursing Home Survey, Residents, table 33B

7. http://www.cdc.gov/dhdsp/data_statistics/fact_shee ts/fs_heart_failure.htm  Around 5.8 million people in the United States have heart failure. About 670,000 people are diagnosed with it each year. 1  About one in five people who have heart failure die within one year from diagnosis. 1  Heart failure was a contributing cause of 282,754 deaths in 2006. 1  In 2010, heart failure will cost the United States $39.2 billion. 1 This total includes the cost of health care services, medications, and lost productivity.  The most common causes of heart failure are coronary artery disease, high blood pressure, and diabetes.

8. http://www.careimprovementplus.com/newsroom/CCM.asp x  More than 133 million Americans live with chronic illnesses. 1  Chronic diseases such as diabetes and heart failure are the leading cause of death and disability in the U.S.,accounting for 70 percent of all deaths. 1, 2  Nearly 80 percent of Medicare beneficiaries have at least one of the following chronic conditions: stroke, diabetes, emphysema, heart disease, hypertension, arthritis, osteoporosis, Parkinson's disease or urinary incontinence. 2  People with chronic conditions are the most frequent users of health care in the U.S. They account for 81 percent of hospital admissions; 91 percent of all prescriptions filled; and 76 percent of all physician visits 4  About one-fourth of people with chronic conditions have one more daily activity limitations 5

9. http://tdi.dartmouth.edu/documents/publications/2009Feb _JPalliatMed_Berke.pdf Excerpt from full article “Our analyses show that a cohort definition based on a union of Part A and Part B Medicare claims data, using a 180-day window prior to death, includes the largest number of patients while still overlapping with hospice patients with a principal diagnosis of cancer. The 180-day window corresponds to the 6-month eligibility criteria established by Medicare,10 and is consistent with data showing that the majority of patients enroll in hospice in the 180 days prior to death.” “Using a cohort definition based on joined Medicare Part A and B data and a primary or secondary diagnosis of cancer, with a more severe secondary diagnosis, appears to yields the most appropriate nationally representative sample of cancer deaths for age older than 65.”

10. http://www.ncqa.org/Portals/0/PublicComment/HEDIS2009/Medicare_Me mo_and_Workup_PDF.pdf  The vast majority of older adults take medication to address at least three or more chronic conditions. Many have multiple prescribing physicians and use more than one pharmacy.  Furthermore, approximately two out of five seniors report that they are not taking medication because of the cost, side-effects, perceived lack of effectiveness or belief that they do not need the medication (National Survey of Seniors and Prescription Drugs 2003).  Additionally, for those elderly patients who appear to be noncompliant with drug regimens, their regimens tend to be more complex, making it difficult for them to manage medications.

11.  Readmission Registry allows opportunity to: ◦ Have conversation with attending provider as to belief of life expectancy. ◦ Ask the Question “ do you believe that this patient will decline over the next year up to and possibly include death?” ◦ Ask the patient “ Do you believe that your health is as good as it was last year or even 6 months ago?” ◦ Ask the Provider “ Do you think a palliative consult might encourage the patient to think about limiting treatment ?”