END-OF-LIFE%20CARE:%20Module%206

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END-OF-LIFE CAREModule 6

• Venues Systems of Care

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Work Rounds Vignette
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Learning Objectives

• Describe venues for ELC
• Navigate across care systems to meet needs of
  patient and family
• Utilize strategies for making system changes
  within your own institution
• Incorporate this content into your clinical
  teaching

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Outline

• Venues for ELC
• Hospice
• Acute care
• Subacute care
• Enlisting resources
• Break
• Strategies for change
• System change within your institution
• Conclusion and goals

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What exactly is hospice?
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Myths of Hospice

• A place
• Only for people with cancer
• Only for old people
• Only for dying people
• Can help only when family members are able to
  provide care
• For people who dont need a high level of care
• Only for people who can accept death
• Expensive
• Not covered by managed care
• For when there is no hope
• (Naierman, 1998)

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Realities of Hospice 1-5

1. About 80 of hospice care takes place in the home
2. Hospices are increasingly serving people with the
   end-stages of chronic diseases
3. Hospices serve people of all ages
4. Hospice focuses as much on the grieving family as
   on the dying patients
5. Alternative locations or resources may be
   available

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Realities of Hospice 6-8

• 6. Hospice is serious medicine, offering
  state-of-the-art palliative care
• 7. Hospices gently help people find their way at
  their own speed
• 8. Hospice can be far less expensive than other
  end-of-life care. Most people who use hospice are
  over 65 and entitled to the Medicare Hospice
  Benefit, which covers virtually all hospice
  services

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Realities of Hospice 9-10

• 9. MCOs are not required to include hospice
  coverage, but Medicare beneficiaries can use
  their Medicare Hospice Benefit any time, anywhere
  they choose. Those under 65 are confined to the
  MCOs services, but are likely to gain access to
  hospice care upon inquiry
• 10. Hospice helps families see how much can be
  shared at the end of life through personal and
  spiritual connections many family members look
  back on their hospice experience thankful that
  everything possible was done toward a peaceful
  death
• Naierman, 1998

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The Modern Hospice Movement

• In the 1950s, as medical technology developed,
  most people died in hospitals. The medical
  profession increasingly saw death as a failure.
• Physical pain associated with terminal illness
  was not a target of treatment.
• Dame Cicely Saunders, MD, founded St.
  Christophers Hospice in London in the 1960s, in
  an effort to discover practical solutions to
  alleviating human suffering.
• She introduced hospice in the U.S. in a lecture
  at Yale in 1963. This contact set off a chain of
  events which resulted in the development of
  hospice care as we know it today.

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Hospice is...

• (Not necessarily) a place
• A philosophy of care
• A structure for care

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Brainstorm

• What problems do you encounter in trying to refer
  patients to hospice?

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Comparing Hospice and Standard Home Care
Hospice Standard Home Care
Comprehensive, total care Task-oriented care
Medications related to terminal illness covered Medications not covered
Staff on call 24 hours Scheduled visits
Support for family Patient care only
Bereavement support No bereavement support
Physician care not covered (except Medical Director) Physician care not covered
Prognosis-based eligibility Home-bound, skilled care need
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Medicare Hospice Eligibility Requirements

• Medical director and attending physician must
  attest to eligibility
• Terminal illness
• Prognosis lt 6 months
• Patient accepts palliative care
• Hospices may also refuse to admit a patient if
  they have inadequate caregiver support at home

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Brainstorm

• Returning to the vignette we started out with and
  using this information about hospice
• What do you need to know about Mr. Young to see
  if hospice would meet his needs?

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Medicare Hospice Financing

• Reimbursement on a per diem basis
• Emphasizes care at home
• Brief acute care and 5-day admits are possible
• Continuous care
• If nursing home care is needed, hospice can
  continue there

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Steps to Making a Hospice Referral

• Identify whether patient meets eligibility
  standards
• Discuss goals of care with patient and family
• Negotiate about specific needs
• Activate referral mechanism

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Hospice is Not Appropriate for Every Patient

• Too sick to leave the ICU
• If residential hospice is not available
• Homelessness
• No caregiver available at home
• Not old enough for Medicare
• Needs more skilled care
• Doesnt accept that he is dying

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Precepts of Palliative Care

• Respecting patient goals, preferences, and
  choices
• Comprehensive caring
• Priority on comfort
• Utilizing the strengths of interdisciplinary
  resources
• Acknowledging and addressing caregiver concerns
• Building systems and mechanisms for support

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Options for Dying in Acute Care

• Consultation teams
• Designated beds

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What You Can Do if Patient is Imminently Dying

• Medical support
• Inform discharge planner
• Shift focus to quality of life
• Review medications
• System support
• Take opportunity to change mind-set to
  palliative-oriented acute care
• Find other allies
• Social support
• Involve the family
• Involve the team in the familys support

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Extended Care Options

• Subacute unit
• Nursing home or skilled nursing facility (SNF)
• Rehabilitation unit
• Residential care facility

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Subacute Unit

• Strengths
• Higher staffing ratio than in nursing home or SNF
• More complex care
• Many people see ELC as subacute level care

• Weaknesses
• Discharge planner may not be aware of such a unit
  in your community
• May see their focus as being on rehabilitation
• May not specialize in ELC

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Nursing Home or Skilled Nursing Facility

• Strengths
• Most Medicare will follow patient for 2 months
  after acute admit
• Hospice could follow
• Recognized as appropriate for long-term care
• Some specialize in ELC

• Weaknesses
• Variation in quality
• Lower staffing ratio
• May not provide ELC
• May not be able to provide technologically
  complicated care
• Aversion of many people to nursing homes

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Rehabilitation

• Strength
• Appropriate if there is a concrete rehabilitation
  goal

• Weakness
• If patient has no rehabilitation potential, can
  lead to sense of failure discouragement, loss
  of hope

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Residential Care Facilities (Assisted Living)

• Strengths
• Excellent option if facility has experience
  willingness
• Number of facilities is growing

• Weaknesses
• Requires hospice waiver
• State laws may restrict availability of hospice
  in assisted living facilities
• Funds for care and caregiving must be available

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Inpatient Hospice/Palliative Care Wards

• Hope for the future

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Brainstorm

• If an extended care option were appropriate for
  Mr. Young, what further information would you
  need, to be able to match his needs to what is
  available?

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What You Can Do

• Find out about extended care options in your
  community that specialize in ELC
• Talk with your home hospice people who do they
  have contacts with in SNFs and nursing homes?
• Facilitate a family conference
• Enlist other resources

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Enlisting Resources

• What resources might be available in your
  community that you are currently not utilizing as
  well as you might?
• Within your system
• Within the community

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Continuum of System Change

• Macro-changes
• e.g., improve reimbursement system
• Local system change
• e.g., how your institution works
• Micro-changes
• e.g., different physician behaviors provide an
  incentive for others to change

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Quality of ELC at the Local System Level

• Given the strengths and weaknesses of your
  institution, what kinds of changes would you like
  to see in this system, to improve care of the
  dying?

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A Strategy for Change

• Assess priorities
• Assess feasibility
• Obtain buy-in

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Key Ways to Obtain Buy-in

• Find allies
• Build networks
• Build on strength
• Avoid major barriers
• Appeal to the good

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Measuring Changea Powerful Tool in Effecting
Change Itself

• Allows people to see what has been accomplished
• Creates tension to promote buy-in
• Facilitates adjustment to improve results

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Three Ways to Measure Change

• Calculate numerator/denominator
• Collect pre/post data
• Benchmark against a standard

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Promoting the Cycle of Change

• To keep the cycle of improvement going, how might
  we insure that positive change is recognized, and
  peoples efforts rewarded?

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In Your Institution, Where Can You Makea
Difference in ELC?

• Education
• Pain
• Non-pain symptoms
• Psychosocial aspects of care
• Spiritual aspects of care
• Decision making

• Ethics
• Communication
• Awards
• Venues of care
• Research
• By next Tuesday
• Spontaneous changes

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Learning Objectives

• Returning to the vignette we started out with and
  using this information about hospice
• Describe venues for ELC
• Navigate across care systems to meet needs of
  patient and family
• Utilize strategies for making system changes
  within your own institution
• Incorporate this content into your clinical
  teaching