2. Conceptual Shift for Palliative Care
Medicare Hospice Benefit
Life Prolonging Care Dx
Death
Not this
Palliative Care
Bereavement
Hospice Care
Life Prolonging
Care
But this 2

4. Hospice
Eligibility restricted by prognosis/willingness to give up disease Rx
46% of all U.S. deaths served (2014)
Median length of service: 17 days
At home: 60%
Over age 65: 84%
Outcomes: better QOL, lower cost

5. Doubling in Number of Hospices 2000 - 2015
Source: MedPAC March 2017 Report to Congress

6. Geographic Variation in Access: % of Medicare Decedents Receiving Hospice – CY2014
21-39%
40-49%
50-59%
> 60%
Source: CMS Hospice PUF Files, October 2016 for patients who received at least 1 day of hospice care in CY2014
Click on a state to change color

7. Geographic Variation in Total Hospice Days per Beneficiary – FY2014
Source: Source: Abt Associates analysis of 100% Medicare Hospice Claims (FY2014); Estimates exclude hospice service in U.S. outlying territories and the District of Columbia

8. Hospital Palliative Care Growth in the U.S.
In 2015, hospital programs were serving over 8MM patients each year.
Palliative care prevalence and # of patients served has more than tripled since 2000.
100% of the U.S. News 2014 – 2015 Honor Roll Hospitals Have a Palliative Care Team.
100% of the U.S. News 2014 – 2015 Honor Roll Children’s Hospitals Have Palliative Care Teams.

9. Palliative Care is Present at:
97%
of the Council of Teaching Hospitals member organizations
87%
of the National Cancer Institute’s designated comprehensive cancer centers
100%
Of the top 20 NIH-funded medical schools
87%

10. Geographic Variation in Hospital Palliative Care

11. Palliative Care Improves Value
Quality improves
Symptoms
Quality of life
Length of life
Family satisfaction
Family bereavement outcomes
MD satisfaction
Costs reduced
Hospital cost/day
Use of hospital, ICU, ED
30 day readmissions
Hospitality mortality
Labs, imaging, pharmaceuticals

12. Mr. B
2015: An 88 year old man with dementia admitted via the ED for management of back pain due
to spinal stenosis and arthritis.
Pain is 8/10 on admission, for which he is taking 5 gm of acetaminophen/day.
Admitted 3 times in 2 months for pain (2x), falls, and altered mental status due to constipation.
His family (83 year old wife) is overwhelmed.

13. Mr. B: Mr. B: “Don’t take me to the hospital! Please!”
Mrs. B: “He hates being in the hospital, but what could I do? The pain was terrible and I couldn’t reach the doctor. I couldn’t even move him myself, so I called the ambulance. It was the only thing I could do.”
Modified from and with thanks to Dave Casarett

14. Before and After Usual Care Palliative Care at Home
4 calls to 911 in a 3 month period, leading to
4 ED visits and
3 hospitalizations, leading to
Hospital acquired infection
Functional decline
Family distress
Housecalls referral
Pain management
24/7 phone coverage
Support for caregiver
Meals on Wheels
Friendly visitor program
No 911 calls, ED visits, or hospitalizations in last 2 years

15. Access to Palliative Care in Community Settings?

16. How do we get from here to there?
Today’s sessions will demonstrate a number of serious illness models shifting care for patients like Mr. B. out of EDs and hospitals and into homes and community.
Listen for the common characteristics.
Think about policy and delivery system changes necessary to make the community based care and social service supports you will hear about today into the standard of care for people with serious illness.