EndofLife Care in the Department of Veterans Affairs

1
End-of-Life Care in the Department of Veterans
Affairs

• Jon Fuller, MD
• James Hallenbeck, MD
• James Breckenridge, PhD
• VA Palo Alto HCS

2
Purpose

• Discuss recent mandates related to end-of-life
  care in the VA
• Present recent data showing where veterans die
  and how much this costs
• Suggest ways facilities can come into better
  compliance with mandates, save money through
  cost-shifting and facilitate better care

3
Key Points

• Veterans are dying in record numbers
• End-of-life care as currently provided is very
  expensive
• Too many veterans are dying in ICUs and acute
  care
• Too few veterans are receiving good end-of-life
  care in dedicated palliative care beds or home
  hospices
• Shifting patients into better, less expensive
  venues of care can save money

4
Questions for VA Facilities

• Should the VA invest more in palliative care?
• Is such care cost-effective?
• Could adequate dollars be cost-shifted or avoided
  to justify such an investment?

Is palliative care a luxury the VA cannot afford,
or can the VA not afford not to have palliative
care?
5
FANTASY DEATH EXERCISE
6
Mandates and other Pressures

• Millennium Bill
• Palliative Care Consult Memorandum
• Call for dedicated Palliative Care Beds (GEC
  Strategic Plan, National Policy Board 2/12/02)
• Lots of very sick and dying veterans on your
  doorstep
• ICU and acute care bed pressure
• Not enough money

7
Good News!

• Shifting workload out of acute care into
  dedicated palliative care beds, HBPC or community
  hospices can
• Help you meet Millennium Bill targets
• Meet evolving mandates for palliative care
  services
• Save you money
• Increase high VERA reimbursement
• Create excellent PR for your facility
• Help veterans exercise choice in where and how
  they die

8
Veteran Deaths Basic Facts

• 29 of Americans dying each year are veterans
• The majority of dying veterans are not enrolled
  for by care by VA
• A majority of enrolled veterans do not die in VA
  facilities
• A small shift of very sick and dying veterans not
  currently served by VA into the VA could swamp
  the system

9
Annual Veteran Deaths
A small percentage of veterans die as inpatients
in VA facilities
10
(No Transcript)
11
Demographics and Associated Costs of Dying for
Enrolled VeteransPreliminary Findings

• James Breckenridge, PhD
• James Hallenbeck, MD
• Co-Principal Investigators
• VA Palo Alto HCS
• Susan Ettner, PhD, UCLA,
• Karl Lorenz, MD, West LA VA
• - Co investigators

Preliminary data do not cite
Funded by the Robert Wood Johnson Foundation
12
Dying Veterans over 3 Fiscal Years

• Identified 148,122 veterans who died nationwide,
  who had at least 1 inpatient stay
• Identified last inpatient stay
• ICU, Acute Care (non-ICU), Nursing Home, Other,
  Dedicated Palliative Care Bed
• Calculated how many veterans died, associated
  costs and related statistics

13
Patients dying during last institutional stay

• 79, 216 (53 ) died in an institutional setting
  at some time over three year period

41 of VA acute care deaths in ICU as compared
to 16.9 under Medicare
14
Costs of Terminal Stays

• Annual direct cost of terminal admits
  387,367,000
• 67 of costs in acute care

15
Cost per Day and Average LOS
16
Average Cost Per Day for Terminal Stays
Direct DSS Cost
17
ICU Deaths by VISN
18
ICU Deaths as General Medicine Unique Patients
19
ICU Utilization in Last Six Months of Life
20
VISN 21
VISN 22
21
Direct Costs of Care for Last Six Months and Last
Year of Life
22
VA Cost per Veteran for Last Year of Life
ESTIMATED DIRECT AND INDIRECT COST 1,749,608,000
Estimated total VA cost per veteran in last year
of life 44,124
Comparison Medicare Claims Data age 65-74
31,800 /year
Hogan et al. Health Affairs 2001, based on 1997
claims data
23
What percent of the VHA Budget is Spent on the
Last Year of Life?
Of approximately 17,000,000,000 allocated per
year by VHA for clinical care 10 is for care
in the last year of life
For 1.3 of enrolled veterans
24
The question is not whether or not we should
provide end-of-life care we already are

• The question is whether we are using resources
  wisely in the provision of this care
• And
• Whether or not we can honor veterans preferences
  as to where they wish to die

25
(No Transcript)
26
Things to consider

• Develop palliative care consult teams
• Identify a palliative care coordinator to help
  with
• Community hospice referrals
• Staff education regarding palliative care options
• Liaison to the community
• Develop dedicated bed programs, where not present

27
SUMMARY

• Veterans are dying in record numbers
• End-of-life care as currently provided is very
  expensive
• Too many veterans are dying in ICUs and acute
  care
• Too few veterans are receiving good end-of-life
  care in dedicated beds or home hospices
• Shifting patients into better, less expensive
  venues of care can save you money