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
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