Hospice and EMS: Transformative Approach to End-of-Life Care€¦ · CONFIDENTIAL- NOT FOR...
Transcript of Hospice and EMS: Transformative Approach to End-of-Life Care€¦ · CONFIDENTIAL- NOT FOR...
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Hospice and EMS: Transformative Approach to End-of-Life Care
April 2019
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Today’s Presenters
Lorna Canlas, RN
Director,Strategy, Performance & Innovation
Visiting Nurse Service of New York
Ritchell Dignam, MD
Hospice Medical Director, VNSNY Hospice Program
Chief Medical Officer, VNSNY, Provider Services
Visiting Nurse Service of New York
Kevin Munjal, MD
Medical Director, Community Paramedicine
Assistant Professor, Emergency Medicine
Icahn School of Medicine at Mount Sinai
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Agenda
• EMS – Hospice Partnership
• Community Paramedicine Overview
• VNSNY Hospice Community Paramedicine Model & Outcomes
• Future of Hospice – EMS Partnerships
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Case Presentation
• 86 year old male, on home hospice
• Primary diagnosis: COPD, history of Lung Cancer
• HHA in the home found patient “not as responsive as he was when he was put on the toilet”
• What are possible outcomes of this situation?
-Will the HHA or family call 911?
-Will the non-hospice PCP recommend to call 911?
-Will the HHA call the hospice team?
-What are the goals of care of the family?
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Hospice Hospitalizations Lead to Significant Costs
6.7%of all hospice
admissions result in ED visit,
observational stay or in-patient
admission
45%of inpatient
hospital stays were admitted
through ED
>$10,000Average charge to hospice provider
for an ED visit and hospitalization
Impact of Hospice Patient Hospitalization on Health Care System
Source:Phontankuel, Veerawat, et al,“Why do Hospice Patients Return to Hospital? A Study of Hospice Providers Perspective.” Journal of Palliative Medicine, 2016, 19(1): 51-56; Olsen, Mary L.et al., “Characterizing Care of Hospice Patients in the Hospital Setting,” Journal of Palliative Medicine, 2011, 14(2); 185:189; Population Health Advisor Research and Analysis.
Burton, S. ‘Innovative Partnership Breaks Cycle of Rehospitalization in Hospice,’ accessed 2 April 2019, https://www.emsworld.com/article/11290277/innovative-partnership-breaks-cycle-rehospitalization-hospice.
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Why do Hospice Patients Return to the Hospital?
• Not fully understanding hospice
• Lack of clarity about disease prognosis
• Desire to continue receiving care from non-hospice physicians and hospitals
• Caregiver burden
• Distressing/difficult to manage signs and symptoms
• Caregivers’ reluctance to administer morphine
• 911’s faster response time compared to hospice
• Families’ difficulty accepting patient’s mortality
Source: Phontankuel, Veerawat, et al.,“Why do Hospice Patients Return to Hospital? A Study of Hospice Providers Perspective.” Journal of Palliative Medicine, 2016, 19(1): 51-56; Olsen, Mary L.et al., “Characterizing Care of Hospice Patients in the Hospital Setting,” Journal of Palliative Medicine, 2011, 14(2); 185:189; Population Health Advisor Research and Analysis.
Areas of partnership opportunity
with EMS
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Coordination or (Lack Of) With EMS: Benefits & Risks
Patient receives care in line with hospice principles
Avoid ED transport and hospitalization costs
Avoid revocation of hospice benefits
Improved EMS-Hospice Provider relationship
Unwanted treatment inconsistent with hospice principles
Incurred costs for hospice providers and health system
Revocation of hospice benefits
Goals of care not met and confusion of patient wishes by EMS and ED providers
Benefits Risks
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Hospice – EMS Partnership
• Provide timely symptom management
• Provide more effective and efficient healthcare
• Prevent unnecessary emergency room visits
• Reduce hospital readmissions
• Prevent revocation of hospice benefits and unnecessary medical costs
VNSNY Hospice - Community Paramedicine Program Goals
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VNSNY Hospice
• Founded in 1983
• Largest hospice provider in NYC
• Served 6,101 hospice patients in 2018
• ADC in 2018 was 1,090
• ALOS 71.7 days in 2018
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VNSNY Hospice – Community Paramedicine Model Key Components
Hospice Team Managers & After-Hours Managers
• Notified of patients’ symptom crisis
• Triages based on VNSNY Hospice standard practices, CP Procedure and Clinical Scenarios
• Activates CP by calling Mount Sinai Transfer Center
• Participates in CP encounter
Community Paramedic
• Arrives in patient’s home within 30 to 60 minutes
• Initiates conference with Hospice Clinical Manager, Hospice Medical Director and OLMC physician
• Performs enhanced assessments including diagnostic tests
• Provides treatment and follows through with physician orders
Post CP Encounter
• Mount Sinai sends Post-Encounter Clinical Documentation and Patient Follow-Up Action Plan to VNSNY Hospice
• Hospice Team Manager communicates with patient’s physician, updates plan of care and schedules patient visits as needed
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VNSNY Hospice – CP Model Clinical Scenarios
Clinical ScenarioWhat Community Paramedicine Can Do
for This Patient
Uncontrolled severe Shortness of
Breath (Dyspnea)
Perform advanced assessment
Determine oxygen saturation (SpO2)
Administer supplemental oxygen
Administer nebulizer treatments (albuterol, ipratropium)
Administer steroids for COPD exacerbation
Administer morphine to reduce “air hunger”
Assist with administration of medications in hospice comfort pack
Fluid Overload
Heart Failure
Non-Heart Failure (End Stage
Liver Disease, Cancer)
Determine oxygen saturation (O2 Sat) IV Lasix can be administered at home
Uncontrolled Anxiety / Agitation Perform advanced assessment
Administer benzodiazepines (diazepam, midazolam)
Assist with administration of medications in hospice care package
Uncontrolled severe pain Perform advanced assessment
Administer morphine for pain management
Assist with administration of medications in hospice comfort pack
Chest pain (not GI distress related) Perform advanced assessment, including 12-lead EKG
Administer nitroglycerin, morphine, aspirin
Assist with administration of medications in hospice comfort pack
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Community Paramedicine - Overview
Community Paramedicine: Rapid evaluation and in-home treatment for patients with acute symptoms
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Community Paramedicine - Overview
• Program started in 2017• More than 400 patient
encounters• Servicing 21 physician
partners and groups• VNSNY Hospice is only
hospice provider partnered with program
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Community Paramedicine – Better Patient Experience
Upon Arrival • Expanded physical assessment
Advanced Life Support
• Advanced cardiac life support• Advanced airway management• EKG interpretation• IV Access
Medications for Treatment
• Acute congestive heart failure• Asthma and COPD• Allergic reactions• Diabetic emergencies
Patient Comfort• Morphine• Zofran
• Community Paramedics operate with guidance from Online Medical Control (OLMC) Physician
Community Paramedic Skills & Formulary
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Community Paramedicine – Encounter Process
1. Call Transfer Center
For authorized providers only
2. Provide Hand-Off
Chief Complaint
Medical History
Allergies DNR StatusLocation Access
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Community Paramedicine – Encounter Process
3. Paramedic Assessment
Completed in 30-60 minutesDiagnostics (EKG, BGL, etc.) Sent
Electronically or Vsee
4. Video Conference with Medic, OLMC MD, Hospice MD
Immediate Treatments
Additional Diagnostics
Goals of CarePatient’s Own Medications
Comfort Pack
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Community Paramedicine – Encounter Process
5. Create Action Plan
Self-Care Instructions
Medications Adjustments
Follow-Up Treatments
Transport if need to Hospice contracted
facility
6. Documentation Sent to VNSNY Hospice Post-Encounter
Paramedic Patient Care Report
Action PlanOLMC Physician Note
in EPIC
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VNSNY Hospice Model - Encounters by Clinical Reason
0
2
4
6
8
10
12
14
KEY TAKEAWAY: 37.5% of patients were experiencing breathing problems
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VNSNY Hospice Model - Patient Disposition Post Community Paramedicine Encounter
4
4
24
Transferred, treat and release Transferred w/Admission GIP Unit No Transfer
75% NOT TransferredNo revocation of Hospice benefits
N=32
Diagnosis:Cancer = 14CHF = 11COPD = 1Pulmonary Fibrosis = 2Dementia =2ESRD =1Cerebral Atherosclerosis = 1
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Better Outcomes & Better Value
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Success Story Case 1
• 86 year old male
• Primary diagnosis: COPD, History of Lung Cancer
• HHA in the home found patient “not as responsive as he was when he was put on the toilet” and called the Hospice After Hours Supervisor
• Paramedics arrived in 31 minutes and performed assessment and findings conferred with the OLMC MD, ENW Supervisor and Hospice MD on-call. Administered Tylenol suppository for fever of 101.8 and 500 ml NS bolus x 2.
• CP Scene time: 2 hours, 46 minutes
• Patient’s mental status returned to baseline and allowed patient to remain at home honoring family’s wishes
Testimonial: “Wife expressed gratitude for the Community Paramedics and hospice’s assistance in keeping her husband at home”.
• Disposition: Patient remained at home and died peacefully two days later
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Case 2
• Female patient, day 2 on home hospice, full code, cardiac comfort pack has not been ordered yet.
• Primary hospice diagnosis: CHF• Patient with SOB and congestion and daughter requesting to take patient to the
hospital to be diuresed• Patient refusing to take morphine according to daughter• Paramedics arrived in 32 minutes and performed assessment and findings
conferred with the OLMC MD and Hospice MD on-call. Administered Lorazepam and oxygen
• CP Scene time: 2 hours• Disposition: Patient remained at home and died on Continuous care 5 1/2 weeks
after CP intervention
Hospice Physician Testimonial:“It was a superb collaboration. Mt. Sinai doctor and their ambulance crewtreated this patient with a very holistic and patient-centered approach….makingsure patient’s DME and functional needs were addressed, we were able to keepthis patient home without much difficulty. I was literally blown away.”
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Future of Hospice – EMS Partnerships
• Partnerships are critical for Population Health strategies Drives alignment of financial incentives in value-based environment
Improves overall performance and promotes data sharing
Key to successful clinical and quality outcomes
Reduces costs of end-of-life care
Promotes coalition building
• Challenges Continue Lack of knowledge of Mobile Integrated Health and capabilities
Communication and collaboration with EMS
Lack of awareness and opportunities to innovate
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Questions