Palliative Care Across the Continuum


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Palliative Care Across the Continuum as presented to the The Palliative Care Summit for PeopleFirst Homecare and Hospice that was held in Snowbird Utah on September 15, 2012, following the Rocky Mountain Geriatric Conference.

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  • Palliative care is interdisciplinary care that aims to relieve suffering, improve quality of life, optimize function, and assist with decision making for patients with advanced illness and their families.2 Palliative care can be delivered concurrently with life-prolonging care or as the main focus of care.1
  • Each hospice makes decisions of what will be offered. Ie: is treating pna a cmfort measure, warfarin?
  • Attending physician not covered by hospice benefit but pt can see them Aide not required to be provided
  • Can only receive one Medicare Part A service at one time for any given medical condition
  • Dementia: Focusing on Quality of life rather than prognosticating, not waiting until Hospice, Prognosticating is notoriously poor Morley JAMDA Feb 2011: Using FAST 7c with 1 serious medical condition in past year: correctly identified those dying within 6 mo only 55% of the time
  • Avaliable since 1989, Medicare Hospice benefit passed 1982 during Reagan era! Contract: Can be on-going or “one-time”
  • Hospice does NOT cover room and board in general as stated by Jamie, with few exceptions Hospice responsible for plan of care – touch on this later regarding lessons learned
  • Facility nurse may have distractions of med pass, treatment of non-terminal diseases and meds, some facility nurses are LPNs Facility RN may not have much experience in end-of-life care or dying process especially: terminal delirium -Uncontrolled sxs: pain, dyspnea, existential suffering, anxiety, depression, nausea, fatigue, insomnia, anorexia, terminal delirium Massage etc not provided by all hospices
  • Hospice Volunteers more specifically trained Social worker: May or may not know resident/family well, may not be medically trained
  • Spill over: facility staff observe the hospice staff and adopt their techniques, also shown as an effect of hospice on the entire medical community
  • With long-term residents, facility staff may feel their caring and knowledge of the patient is not acknowledged by the hospice
  • On all sides
  • Of note, each medical center is individual to what is offered and how these services work.
  • I will be going over the services offered through the Salt Lake VA but how they look at other medical centers can be different. Serves eligible veterans throughout Utah, East Central Nevada and South East Idaho Community Base Outpatient Clinics (CBOC): Nephi, Ogden, Orem, Price, Roosevelt, St. George, West Valley, Idaho Falls (outreach), Pocatello, Elko (outreach), Ely
  • Its complicated. Not all veterans are eligible for enrollment. This can changed based on congress. If they have a service-connected injury, they automatically qualify for enrollment OEF/OIF veterans are eligible for up to 5 years
  • Not go through but this is information on how to enroll.
  • The VBA has additional services for veterans including home loans, vocation rehab, etc. Service-Connection Disability Compensation : monetary benefit paid to veterans who are disabled by an injury or illness that was incurred or aggravated during active military service. Disability ratings range from 0%-100%. VA Pensions: Veterans with low incomes who are either permanently and totally disabled, or age 65 and older , may be eligible for monetary support if they have 90 days or more of active military service ; at least one day of which was during a period of war . Aide & Attendance: is a benefit paid in addition to monthly pension for veterans who need additional assistance.
  • Patient Centered Medical Home model changed to Patient Aligned Care Team. Teamlet consisting of the Primary Care Provider, Program Support Assistant, RN Case Mangaer and the Patient The Primary Care Team Takes collective responsibility for patient care Responsible for providing all the patient’s health care needs Arranges for appropriate care with other specialties as needed
  • The VA offers similar services to those already presented. Some VA’s have inpatient hospice. It is usually VA’s with a Community Living Center. What is unique to our VA is the Inpatient Palliative/Hospice Care Room which I’ll go over in a minute.
  • Our team has over 1,000 consults a year. Again, this is what Salt Lake has so you’ll want to look at the VA in your area. All VA’s don’t necessarily have this.
  • We have two Inpatient Palliative/Hospice Care Rooms. 25% discharged alive.
  • Note: these can change based on local policies. These are resources through the VHA not the VBA.
  • If veterans have copayments, they will have a copayment for each day there is a visit/visits. Can we double dip? Speak to Pat. Home Health can be ordered for skilled needs. If veterans do not have insurance, the VA will pay for home health. There may be a per visit per day copayment.
  • We order the homemaker/home health aid separate from other skilled needs. A veteran can receive these services without having PT/OT/RN ordered. If veterans have copayments, they will have a copayment for each day there is a visit/visits. Homemaker should be provided by the hospice, but there are exceptions that can be made.
  • -- veterans may continue to receive outpatient Palliative Care services in our clinic along with any of the previously discussed services GHELP The veteran and support system is evaluated in his/her environment by an interdisciplinary assessment team, a plan of care is developed, immediate interventions are deployed, and the veteran is discharged to primary care for follow-up. Home Based Primary Care (HBPC) Provide comprehensive, interdisciplinary, and primary care in the homes of Veterans with complex medical, social, and behavioral conditions for whom routine clinic-based care is not effective
  • VA uses the term Extended Care Facilities (ECF). Commonly called a VA Contract. VA does NOT pay for Assisted Living Level of Care. NSC veterans may have a per day copayment based on their LTC scores. Example of exception is Radiation/Chemo
  • Medical Foster Home Alternative to nursing home placement by finding caregivers in the community who are willing to take a veteran into their home and provide 24-hour supervision as well as needed personal assistance. $1500 - $3000 per month for their care. Partners with HBPC. Community Residential Care Veterans who do not need the care provided in a nursing home or hospital setting, but who may have difficulty living alone. Sponsor families or homes in the community provide room and board, including three nutritious meals per day, transportation to appointments, assistance with activities of daily living, and general monitoring. Veterans placed in the CRC program will need to have sufficient funds to pay from $800 - $2700 per month for their care.
  • - National Program but program may look different.
  • Palliative Care Across the Continuum

    1. 1. Shaida Talebreza MDHaven HealthCare, University of Utah Division of Geriatrics, Veterans AdministrationJohn Evans FNPCBridgePoint Supportive CareJamie Brant MDHaven HealthCare Bridgepoint Palliative Care ProgramKevin Doyle MDGranite Mountain
    2. 2. Specialized medical care for people with serious illness Aims to relieve suffering, improve quality of life, optimize function, and assist with decision making for patients with advanced illness, and their families The goal is to improve quality of life for both the patient and the family Palliative care is provided by a team of doctors, nurses, and other specialists who work together with a patients other doctors to provide an extra layer of support It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment or as the main focus of careAvailable at www.getpalliativecare.orgPacala JT, Sullivan GM, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 7th ed. New York, NY: American Geriatrics Society; 2010.
    3. 3. A defined, integrated model of palliative care at the end of life Can be as aggressive as curative care focusing on Comfort Dignity QoL/relationship closure as directed by patient and family goals and choices Aims to relieve suffering, improve quality of life, optimize function, and assist with decision making for patients with advanced illness, and their familiesFerrell BR, Coyle N. Oxford Textbook of Palliative Nursing, 3rd ed. Oxford: Oxford University Press, 2010.Quill, TE, et al. Primer of Palliative Care, 5th ed. Glenview, IL: American Academy of Hospice and Palliative Medicine; 2010.
    4. 4. Palliative Care Hospital- Based Hospice Inpatient/Outpatient Home Based Palliative
    5. 5.  Interdisciplinary Holistic Patient and family focused Quality of life Communication Symptom management
    6. 6. Palliative Hospice Chronic illness  Terminal illness Can seek  Not seeking life-prolonging, curative treatment  Expected curative treatment prognosis of six No eligibility months or less if criteria the illness runs its Medicare – part B normal course  Medicare – part A
    7. 7. Pre-Palliative Care Model Hospice Curative/Disease Controlling Therapy Palliative Care Death Diagnosis of Life Threatening Illness
    8. 8. John Evans, FNP-C, CHPN Denver, CO
    9. 9. Colorado’s newly adopted definition of Palliative Care: “Palliative Care” means specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain and stress of serious illness, whatever the diagnosis.
    10. 10. The goal is to improve the quality of life for boththe patient and the family. Palliative care isprovided by a team of physicians, nurses andother specialists who work with a patient’s otherhealth care providers to provide an extra layer ofsupport.
    11. 11. Palliative care is appropriate at any age and atany stage in a serious illness and can be providedtogether with curative treatment. Hospiceproviders may perform palliative care services thatare separate and distinct from hospice careservices.  CDPHE effective 9-1-12
    12. 12.  Denver’s Program started small in November, 2008 – 5 new patients in the first two months First full year – 2009 - 55 new patients and 104 total visits Approaching 4th anniversary – over 600 patients have participated in the program
    13. 13.  2010 ◦ 171 new referrals ◦ 415 established patient visits  An LCSW was added, split between hospice and palliative, in March 2010 2011 ◦ 217 new referrals ◦ 974 established patient visits  A second NP was added in May, 2011
    14. 14.  Through August 2012 ◦ Averaged 20 new referrals monthly and over 100 established visits each month  On target to see about 250 new patients this year and provide over 1200 established visits in 2012 Since inception, 145 BridgePoint patients (24.17%) have converted to PeopleFirst hospice Through August 2012, 44 patients (27%) have converted to PeopleFirst hospice
    15. 15.  Kindred LTAC’s Acute care hospitals Skilled Nursing or Long Term Care Facilities Assisted Living Facilities Private Homes Day Programs
    16. 16.  Social Workers Hospital discharge planners and case managers Community Case Managers Eldercare Specialists and advocates Family members or patients self-refer Primary care physicians and mid-level providers or practice staff – triage nurses Community Agencies and Programs Nursing Facility Staff
    17. 17.  Kindred LTAC’s – 22% SNF/LTC – 35% Home – 32% Assisted Living – 9% Acute Care Hospitals – 2%
    18. 18.  Focus is on pain and symptom management Assisting with Advance Care Planning Support Connecting patients and families to needed resources: ◦ Medicaid benefits – assist with applications ◦ VA benefits – assist with applications ◦ Private Duty Care ◦ Skilled Home Care ◦ Home or outpatient rehabilitation
    19. 19.  Meals on Wheels or Project Angel Heart Hospice Care Elder care resources such as legal aid, estate planning or guardianship “Translation” Services – explain what the doctor said and what that means Navigation assistance through the health care system
    20. 20.  There is no requirement for a terminal diagnosis or condition – only that a patient have a serious and/or chronic illness No physician certification is necessary ◦ However the Primary Care (MD, PA, NP) Provider’s order is necessary Patients can continue with aggressive treatment Patients are not required to be homebound
    21. 21.  Helping patients identify how they define “quality of life” and helping them achieve it. ◦ Recent addition of Missoula-VITAS Quality of Life Index  Symptoms  Function  Interpersonal  Well-being  Transcendent
    22. 22.  Often, the BridgePoint NP/LCSW are the only providers involved in the patient’s care that interact with all of the patient’s other providers Post discharge follow-up and education for patients and caregivers is often provided
    23. 23.  LTAC to home The man who liked ice cream The ALS patient The recurrent ER patient
    24. 24. Jamie Brant, MDHaven Healthcare
    25. 25.  25% of Medicare dollars are spent in the last 1 year of life 2.8 % of Medicare dollars are spent on hospice Robert Wood Johnson Foundation study (Duke University) found that hospice saves Medicare, on average, more than $2,300 per patient.% Hogan C, Lunney J, Gabel J, Lynn J. Medicare beneficiaries’ cost of care in the last year of life. Health Aff (Millwood). 2001;20(4):188-195.Hospice Centers for Medicare & Medicaid Services, Office of the Actuary, FY 2011 President’s budget (February 2010).
    26. 26.  Hospice expected prognosis of six months or less if the illness runs its normal course ◦ Medicare Guidelines to assist with prognostication Uses Medicare Hospice benefit True interdisciplinary care Hospice will not cover treatment intended to cure Emotional shift Care goals shift
    27. 27.  Routine Respite Continuous care General inpatient (GIP)
    28. 28.  Per diem daily rate All patient care/medication/DME related to hospice diagnosis included Minimum requirement is RN, Chaplain, SW and volunteer Patient can see designated attending and/or hospice medical director
    29. 29.  Primary Care Nurse  Volunteers *Attending Physician  Medications ◦ Patient’s choice ◦ For symptom relief Hospice Physician  Medical Equipment *Hospice Aide and Supplies Social Worker  Bereavement Services Spiritual Care Coordinator ◦ For one year following a patient’s death
    30. 30.  Treatment choices that are meant to cure illness or prolong life rather than provide symptom control or pain relief Long-term room and Board Care in an emergency room, inpatient facility care, or ambulance transportation, unless it’s either arranged by your hospice team or is unrelated to your terminal illness
    31. 31. Medicare Part A HospitalSkilled Nursing Facility Home Health Care Hospice
    32. 32. HOSPICE MYTHS“Hospice is only for patients who are very close to death, I’m not sure you qualify”
    33. 33.  Do patients have to be DNR to be on hospice? Do patients have to stop their medications? Do you have to turn off Pacemakers and ICDs? Do patients on hospice die sooner? Does hospice provide 24-7 custodial care? Do patienst have to have 24 hour caregiver? Does a physician have to see the patient before hospice admission?
    34. 34. .
    35. 35.  1 in 5 deaths in US occurs in NH 1/3 of NH admissions die within 1 year 2/3 die within 2 years THAT’S A 60% DEATH RATE OVER 2 YEARS Morley JE, J Am Med Dir Assoc 2010 In 2008, about ¼ of all hospice care delivered in NH Rodin MB. J Am Med Dir Assoc 2011
    36. 36.  The long-term resident who develops a rapid decline/terminal illness The long-term resident with advancing dementia* The short-term patient who doesn’t respond to therapy/interventions The patient coming from the hospital actively dying Maybe all residents?
    37. 37.  Monitoring of quality of life required (MDS) ◦ Pain, depression, delirium, pressure ulcers ◦ Care plans must be created and followed Inter-disciplinary team approach mirrors hospice Degree of expertise of Medical Director varies ◦ Overlap of interests in NH and palliative care ◦ “Certified Medical Director” status Palliative medicine consults
    38. 38.  Any “Nursing Home” location ◦ Per diem is the same regardless of where “home” is Give up Medicare Part A enrollment ◦ Terminal diagnosis ◦ Other diagnoses? Contract required between hospice agency and facility ◦ Hospice pays facility
    39. 39.  Hospice covers cost of meds and DME ◦ Related to terminal illness Hospice is responsible for plan-of-care Medicaid/Medicare Dual Eligible ◦ Process can vary state by state ◦ Possible disincentives for facilities to enroll in hospice
    40. 40.  Pearls ◦ Need 24-hour RN for Inpatient Hospice Status ◦ Can have Medicare A status AND Hospice if patient needs SNF for non-terminal diagnosis  Room and Board  Ex: CHF and hip fx ◦ Both Medicare Nursing Home and Hospice Regulations Apply  Ex: NH certification visits/Hospice face-to-face visits  Ex: weight monitoring
    41. 41.  Additional support to healthcare team ◦ Hospice RN focuses on quality of life issues exclusively  Provides support to facility nurse ◦ Hospice RN and MD/NP with expertise in symptom management  available 24 hours a day ◦ May decrease likelihood of burdensome transition (Gozalo et al, NEJM 365:13, 2011)
    42. 42.  Most NH don’t have ◦ Chaplain or bereavement services ◦ Massage or Aromatherapy* ◦ Music Thanatologist* Most NH have limited ◦ Volunteers/One-to-one activities ◦ Staff = limited TIME Most NH Do have ◦ Support for family while resident living ◦ Social worker on staff ◦ PT/OT
    43. 43.  Other residents may benefit when hospice in building ◦ Education to facility staff – annual in-services required ◦ “Spill-over” effect (Miller SC. J Pall Med 1998) ◦ Change in philosophy of the staff
    44. 44.  End-of-life care can “skill” for Medicare Part A ◦ Room and Board = $$$ Medicaid Disincentive Patient/Family ambivalence Lack of education of NH healthcare providers and nurses (Parker-Oliver D, J Am Med Dir Assoc 2002)
    45. 45.  Communication and Collaboration ◦ Hospice staff “come in here and write notes and leave without talking to anyone” Parker-Oliver D. J Am Med Dir Assoc 2002
    46. 46.  Communication and Collaboration ◦ Consistent staffing by the hospice in facility ◦ Hospice involved in care-plan meetings ◦ Facility staff engaging with hospice team ◦ Social events to build rapport ◦ Investment by the DONs of both companies Professionalism Integrity
    47. 47. Ronica Symes LCSWPalliative Care Social Worker
    48. 48.  Brief overview of the Veterans Affairs Salt Lake City Health Care System (VASLCHCS) ◦ Eligibility ◦ Enrollment ◦ Financial benefits ◦ Patient Aligned Care Teams (PACT) SLCVA Palliative Care Services VASLCHCS Resources and Benefits
    49. 49.  George E. Wahlen Department of Veterans Affairs Medical Center
    50. 50.  Based on: ◦ Type and time of service ◦ Injuries occurred ◦ Finances
    51. 51.  Veterans can enroll by ◦ Presenting to the Enrollment office, ◦ Online at, or ◦ Call 1-877-222-VETS (8387) Documents ◦ 10-10EZ ◦ DD214 (discharge papers) Priority groups determine copayments for medical treatment and medications.
    52. 52.  Service-Connection Disability Compensation VA Pensions Aide & Attendance
    53. 53.  Integrated palliative care model Interdisciplinary Team including ◦ Palliative Care Medical Director, +2 physician, 2 Nurse Practitioners, Social Worker, Chaplain, Psychologist, and Administrative Support. Palliative Care Consultation in the hospital Palliative Care Clinic (outpatient) Hospice and Palliative Care Committee Inpatient Palliative /Hospice Care Room Supportive care in collaboration with veterans primary care team and specialty care team(s).
    54. 54.  Palliative care rooms provide a private place of solace and introspection to both the patient and family while also meeting any required medical needs. The medical team in consultation with the Palliative Care Consult Team will frequently review the patient’s status and recommend continued care in the palliative care room or transfer to home or a community facility.
    55. 55. Resources and Benefits  VHASLCHCS ook/2012_Federal_benefits_ebook_final.pdf
    56. 56.  Home Health ◦ PT, OT, ST, RN, infusion services ◦ All enrolled veterans are eligible for n-home skilled nursing care services. ◦ The VA will pay for care with one of our contracted hospice agencies if a veterans insurance will not cover the services or the veteran does not have insurance. ◦ Copayments may apply
    57. 57.  Homemaker/Home Health Aide ◦ Homemaker  Veterans at risk of nursing home placement  2 hours 1xweek + based on needs assessment ◦ Home Health Aide  Veterans at risk of nursing home placement  1 hour 3xweek + based on needs Home OT Consult ◦ Lives in Salt Lake valley ◦ Frequent falls, difficulty with ADLs or IADLs, cognitive impairment raising safety issues, known safety hazards, need home safety evaluation
    58. 58.  Hospice ◦ All enrolled veterans are eligible for hospice care services. ◦ The VA will pay for care with one of our contracted hospice agencies if a veterans insurance will not cover the services or the veteran does not have insurance. ◦ VA paid hospice services include the same benefits as Medicare paid hospice services.
    59. 59.  GHELP ◦ Geriatric High Risk Evaluation and Liaison to Primary Care Program ◦ Prevent unnecessary and inappropriate nursing home placements, emergency room visits, re- hospitalizations, and unscheduled outpatient clinic visits Home Based Primary Care (HBPC)
    60. 60.  VA pays for a skilled nursing facility at a contracted facility. 70% service connected veterans or 60% service connected with unemployability are eligible for an indefinite contract. Enrolled veterans with no private insurance are eligible for a 31 Day VA Contract for rehabilitation. Exceptions can be made based on the situation and need.
    61. 61.  Medical Foster Home ◦ Skilled Nursing Home alternative. Community Residential Care ◦ Assisted Living equivalent. ◦ Sponsor families or homes in the community.
    62. 62.  All enrolled veterans are eligible for an End of Life Contract Criteria ◦ Prognosis is weeks to months/6 months ◦ Veteran agreeable to hospice services SNF: VA pays for room and board at a contracted facility Hospice: Medicare/Private/VA pay for hospice services
    63. 63.  Respite ◦ Up to 30 days of respite per calendar year. ◦ VA Contracted Nursing Home, Homemaker/Home Health Aide, and/or Contracted Adult Day Care. Caregiver Support Group Caregiver Program ◦ ◦ 1-855-260-3274 ◦ Enhanced benefits for all enrolled veterans and caregivers. ◦ Comprehensive assistance for Family Caregivers for eligible veterans who were disabled in the line of duty since Sept. 11, 2001
    64. 64.  Reviews VA Death Benefits ◦ Burial flag ◦ Grave marker ◦ US President Memorial Certificate ◦ Burial at any military, veteran or national cemetery
    65. 65.  High quality, temporary lodging to families of active duty military personnel and m Veterans who are undergoing medical treatment at the VASLCHCS  20 private suites  Common areas include: kitchen, laundry facilities, spacious dining room and an inviting living room with a library and toys for children