The Social Context. If you are young and thin, you will be happy and live forever! (Assuming you have an iphone )

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1 Improving Care Transitions through Better Use of Palliative Care Resources Cooper Linton, MSHA, MBA VP Marketing and Business Development The Social Context Forget the 2.3 kids and the white, picket fence, the REAL American Dream is If you are young and thin, you will be happy and live forever! (Assuming you have an iphone ) Death is just as natural as birth. (Well it sure doesn t feel like it ) This morning, after losing a courageous 9-month battle with pregnancy, Suzy delivered a baby. We used to die at home with our loved ones with pastors and friends as the midwives of death. According to surveys, we overwhelmingly still want to. But we don t. Most of us die in a healthcare facility. 1

2 How do you think you will die? Facts from 2.5 Million U.S. Death (2010 Statistics) Bear Attack (1) Shark Attack (2) Hit by Lightning (62) Electrocution (500) Airplane Crash (941) Hit by a Car (1,100) Firearm Discharge (1,150) Choking (3,200) How Do Most People Really Die? > 90% from Predictable Chronic Illness (about 38% will get Hospice care) aka Brain Failure We Rarely Get Sick and Die 2

3 The Boring Stuff aka Origins of the Word Palliate: to relieve or lessen without curing; to mitigate or alleviate Pallium: a cloak: In palliative medicine, we intend to cloak the patient in comfort. Palliative Care (more boring stuff) Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with lifethreatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. World Health Organization (emphasis added) We Need to Separate Palliative Care from Hospice All hospice is palliative care. Not all palliative care is hospice or leads to hospice. Palliative care is a valuable resource for managing patient care and outcome with or without hospice services. 3

4 End-of-Life Care is Not Just Hospice Not every terminal patient wants or qualifies for hospice We have to broaden our discuss beyond that less than 6 months thing Some patients want curative care to the end Hospice usually interrupts Medicare skilled days in a SNF Palliative care can help patients navigate changes in their disease trajectory Palliative Care vs. Hospice Palliative Care Palliative care can be concurrent with curative care Patient doesn t have to be dying Paid under Medicare Part B; 20% co-pay Best quality of life Hospice Comfort care only Patient MUST be terminal & accepts mortality Paid under Medicare Part A; 100% Best quality of living and dying Example Components of Continuum of Care Home Health Care: Medicare-certified home health to help manage transitions Physician Practice Palliative Care: medical practice sometimes with mobile staff Hospice: Medicare-certified hospice offering a full palliative spectrum of care 4

5 Example of Palliative Care Continuum The Who and Where of Palliative Care Who Physicians and Nurse Practitioners (billable) Social worker (usually not billable) Registered Nurse (not billable) Where Hospitals Skilled Facilities Assisted Living Facilities Private residences Primary Reasons WHY We Get Palliative Care Referrals 1) Pain & Symptom Management (36%) 2) End-of-Life Decision Making (34%) 3) Goals of Care (21%) 4) Patient/Family Support ( 7%) Family conflicts about medical decision-making Assistance with advance care planning Patient has a terminal diagnosis and is not ready for hospice Assistance with complex medical decision-making Continuing palliative care which was started in the hospital 5

6 What Happens During a Palliative Care Consultation? Comprehensive assessment and development of plan to manage physical symptoms Assistance to identify personal goals and to process related decisions Assessment of psychological and spiritual needs Assessment of support systems Assessment and communication of estimated survival Coordination with other medical providers Some Key Decision Points in Palliative Care The balance between quality and quantity of life Symptom management and therapeutics Help determine appropriateness of diagnostic studies Assist with determining appropriateness of: Nutritional/Fluid intervention and feeding tubes Antibiotics, radiation or chemotherapy therapy Transfusions and use of biologicals Withholding or withdrawal of life support CPR/DNR/AND/MOST Assessment of when Hospice is appropriate The Benefits to the Patient and their Family For patients & families, palliative care is a key to: Relieve symptom distress less stress on pt/family Navigate a complex and confusing medical system Understand the plan of care Help coordinate care options Allow simultaneous palliation of suffering along with continued disease modifying treatments (no requirement to give up curative care) Provide practical and emotional support for exhausted family caregivers including bereavement care. 6

7 The Benefits to Clinicians For clinicians, palliative care is a key tool to: Save time by helping to handle repeated, intensive patientfamily communications, coordination of care across settings, comprehensive discharge planning Bedside management of pain and distress of highly symptomatic and complex cases, 24/7, thus supporting the treatment plan of the primary physician Promote patient and family satisfaction with the reduction in patient suffering and hence the clinician s quality of care Nut and Bolts of Palliative Care Can be used with Medicare Home Health and SNF Skilled Days with no interruption of care or payment!!! Paid under Medicare Part B (80/20) It s like consulting any other subspecialty, e.g., cardiology, podiatry Billing and payments through the physician practice No contract is necessary in ALFs or SNFs Can accompany curative therapeutic efforts Patient may move from palliative care to full hospice care at appropriate time Transitional Risk Points for Care Changes in: The Who of Care (changes in medical staff) The What of Care (levels and/or types of care) The Where of Care (changes in setting of care) 7

8 Changes in the Who of Care Palliative care physicians can help pass the baton between providers. PCP to hospitalist Hospitalist to rehab/snf Medical Director Rounding physician at ALF Return to PCP Changes in What Type of Care Palliative care can help clarify the goals involving different types of care. Intensive care Medical Surgical Medicare skilled rehab days SNF long term care days Home health Changes in the Where of Care Palliative care can help bridge the transitions between locations of care. Hospital to home Hospital to Rehab/SNF Rehab/SNF to ALF SNF to home health 8

9 Palliative Care Should Adapt to Settings of Care Hospitals Nursing Homes (SNFs) Assisted Living Facilities (ALFs) Private home In Hospitals Less pain/symptom management More goal setting and decision making Compassionate truth telling In Nursing Homes More pain and symptom management More coordination of care Advanced care planning MDS scores can be used to trigger palliative care consults Can help SNF with survey compliance 9

10 Residential Palliative Care Assisted living setting or private home Usually dealing with patient s PCP and community specialist Navigation of family dynamics Home health OBQI scores can be used to trigger palliative care consults ALFs: Important to understand issues related to adult care home regs Palliative Home Health Some home health programs have a bridge program. (Where does the bridge go to?) As an example, 50% of our home health patients are also in our palliative care program These tend to be nursing heavy with therapies available We utilize a hospice on-call model to avoid unnecessary hospitalizations. It won t keep you young, thin, and beautiful, but it can help With transition points in care delivery Reduce emergent care Avoid unnecessary re-hospitalizations Achieve patient-defined goals. (You should still get an iphone though ) 10

11 Questions Disclaimer: This speaker does not guarantee intelligent answers. 11

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