End of Life Care Delivery Systems Barry M. Kinzbrunner, MD Joel S. Policzer, MD.

End of Life Care Delivery Systems

Barry M. Kinzbrunner, MDJoel S. Policzer, MD

Definitions

Palliative care• “palliare” latin: to cloak• “care provided to treat the symptoms

of an illness without curing or affecting the underlying illness”

• Examples – insulin “palliates” diabetes– lasix “palliates” congestive heart failure

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 community• Includes palliation of symptoms of the

disease and management of untoward effects of treatment

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 care

• May be provided in virtually any setting where someone may die– ICU Acute care hospital– LTCF ALF– Private residence

Definitions

Hospice Care• Team-oriented approach to end of life care• Expert in medical care, pain and symptom

management, and emotional and spiritual support

• Tailored to the patient’s needs and wishes• Support to loved ones as well• Provided in any setting

Definitions

Palliative Care• Extends principles of hospice care to a

broader population• Earlier in disease course than hospice • Comprehensive and specialized• Pain and symptom management, advance

care planning, psychosocial and spiritual support, coordination of care

• Definition may be able to be expanded to all aspects of medical care

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 East

• Modern hospice as care for the dying– England– Dame Cicely Saunders– St. Joseph’s and St.Christopher’s Hospice– Primarily inpatient based

Hospice

• Hospice in the US began in 1970s in Connecticut

• Home based rather than facility based• Inpatient care confined to situations where

patient could not be cared for at home• Demonstration project at end of 1970s• Medicare Hospice Benefit-1982

– Defines hospice in the United States to this day

Medicare Hospice Benefit

Patient Eligibility• Part A Medicare Benefit• Prognosis of 6 months or less if the terminal

illness runs its normal course• Based on the clinical judgment of two

physicians– Hospice Medical Director or designee– Attending physician

• Patients elect hospice via informed consent– May voluntarily leave hospice at any time through

the process of “revocation”

Medicare Hospice Benefit

Benefit Periods• Two 90-day Benefit Periods• Unlimited 60-day Benefit Periods• Re-certification

– Hospice 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

Medicare Hospice Benefit

Reimbursement• Per diem payment to hospice based on “Level

of Care” through Medicare Part A• Hospice physician services for patient visits

billable through Medicare Part A in addition to per diem

• Attending physician professional services (visits) and care-plan oversight billable under Part B

• Annual payment cap

Medicare Hospice Benefit

Levels of Care• Routine Home Care

– Basic services provided in the patient’s primary place of residence, including ALF or LTCF

• Continuous Home Care• General In-patient Care• Respite In-patient Care

Medicare Hospice Benefit

Covered Services• Interdisciplinary Team care:

– Nursing services– Medical social services– Pastoral counseling– Medical direction and physician care plan

oversight– Home health aide and homemaking services

• Bereavement services• Dietary counseling

Medicare Hospice Benefit

Covered Services• Medical consulting services• Physical therapy, occupational therapy,

speech therapy• Drugs and biologicals• Durable Medical Equipment• Medical supplies• Laboratory and diagnostic studies

Medicare Hospice Benefit

Continuous Care• 8-24 hours of care per day provided in the

home setting• Paid hourly (Day starts at 12 MN)• More than 50%of care has to be provided by

a nurse• Hours do not need to be “continuous”• Clinical indications similar to general inpatient

care

Medicare Hospice Benefit

General Inpatient Care• Care that cannot be managed in the home

setting• Per Diem rate• May be provided in a variety of venues

– Free-standing– Leased space in a hospital, LTCF, ALF– Contract bed in hospital or LTCF

• Reimbursement limited to no more than 20% of a hospice program’s billable days of care

Medicare Hospice Benefit

Indications for General Inpatient Care and Continuous Care

• Uncontrolled pain• Respiratory distress• Severe decubitus ulcers or other skin lesions• Intractable nausea, emesis• Other physical symptoms not controllable on

a routine level of care• Severe Psychosocial Symptoms or acute

breakdown in family dynamics

Medicare Hospice Benefit

Respite Inpatient Care• Care provided to give the family care-giver’s

respite from the rigors of taking care of the patient

• Per Diem rate• Limited to a maximum of 5 days at any one

time• Under-utilized due to poor reimbursement

rate compared to other levels of care

Medicare Hospice Benefit

State of Hospice Access Today• Almost 1 million patients admitted in 2004• 2003 NHPCO National Data Set

– ALOS 55.6 days– Median LOS 22.3 days– Continuous Care 0.9%– General Inpatient 3.4%– Respite Inpatient 0.2%– Admissions by Dx: Cancer 49.1%

Heart 11.1%Dmentia 9.7%

Medicare Hospice Benefit

Barriers to Hospice Access• 6 month prognosis requirement• Communication

– Physicians do not want to tell patients– Patients and families do not want to be told

• Lack of inpatient relationships between hospices and hospitals

• Hospice reluctance to allow “disease-directed” therapy

Palliative Care Programs

Goals: • Increase patient access to end-of-life care• Reach patients who are not currently being

reached by hospice• Overcome barriers to hospice access

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Comparison of Hospice and Palliative Care ProgramsCharacteristic Hospice Palliative Care Eligibility Prognosis < 6 months None required

Determined by program Professional Services

Interdisciplinary team Physician Nurse Social Worker Pastoral counselor Certified nursing assistants Others as need

Inter or multidisciplinary team Physician Nurse Social Worker Others as needed

Other services Medications DME Bereavement care Others (see Table 1-2)

No required services. Determined by program.

Location of services Comprehensive Home care LTCF Inpatient

Based on program Some Comprehensive Some inpatient only Some LTCF based Some require networking between hospital and hospice or home based home-health programs

Funding Medicare Hospice Benefit State Medicaid programs HMOs and commercial insurers Charity (not for profit hospices)

Traditional hospital coverage Traditional home care coverage Support from hospitals and hospice partner organizations Grants Charity

Palliative Care Programs

Hospital Based Palliative Care• Interdisciplinary or Multi-disciplinary• Typically Physician led• Physician consults with supplementation by

other disciplines• Some academic centers and hospitals have

discreet inpatient units• ICU consults to facilitate end of life decision

making reduces ICU utilization

Palliative Care Programs

Hospital Based Palliative Care• Reimbursement through traditional system

– No specific reimbursement stream for “palliative care”

– Physician consults– DRGs for hospital care

• Savings by reducing ICU and inpatient days• Improved quality of inpatient care• May partner with a hospice to provide more

comprehensive services

Palliative Care Programs

Long-term Care Facility Palliative Care• Need for palliative care for patients accessing

Medicare Part A for Nursing Home care• Physician Consult services• Partnerships with hospices

Palliative Care Programs

Home-Based Palliative Care• Home health agency services• May be independent or affiliated with a

hospice program• Patients need to be Home-care eligible• Pre-hospice “Bridge” programs

– Affiliated with hospice– Reimbursed as Home Health agencies– Hospice or hospice trained staff

Palliative Care Programs

Home-Based Palliative Care• Pre-hospice “Bridge” programs

– Affiliated with hospice and reimbursed as HHA– Hospice or hospice trained staff– Supplementary funding for non-covered services– Longer median survival (52 vs. 20 days)– Patients living > 6 months doubled from 6-13%– Patients were hospice eligible– May have desired treatment hospice was unwilling

to provide– No data on why patients did not elect hospice

Palliative Care Programs

Disease-Based Palliative Care• Focused on special needs of patients with

specific chronic and potentially terminal illnesses– Cancer– HIV– Pediatrics– Dementia

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Hospice/Palliative Care Interface

Traditional 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.

HospiceHospice

Curative / disease modifying Curative / disease modifying therapytherapy

Time Course of IllnessLastWeeksof life

Family Bereave-ment care

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Hospice/Palliative Care Interface

Integrated 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.

HospiceHospice

Curative / disease modifying Curative / disease modifying therapytherapy

Time course of illness Last weeks of life

Palliative carePalliative care

Family Bereavement care

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Hospice/Palliative Care Interface

Integrating 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.

HospiceHospice

Curative / disease modifying Curative / disease modifying therapytherapy

Time course of illness Last months of life

Palliative carePalliative care

Family Bereavement care