Reducing Hospital Readmissions and Length of Stay in Advanced Illness Patients

Reducing Hospital Readmissions and Length
of Stay in Advanced Illness Patients

CE Provider Information
VITAS®
Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through:
VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved by: Florida Board of Nursing/Florida Board of
Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling.
VITAS®
Healthcare programs in California/Connecticut/Delaware/ Illinois/Northern/Virginia/Ohio/Pennsylvania/Washington DC/Wisconsin
are provided CE credit for their Social Workers through VITAS Healthcare Corporation, provider #1222, is approved as a provider for
social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org, through the Approved Continuing
Education (ACE) program. VITAS Healthcare maintains responsibility for the program. ASWB Approval Period: (06/06/2021-06/06/2024).
Social Workers participating in these courses will receive 1 clinical continuing education clock hour. {Counselors/MFT/IMFT are not
eligible in Ohio}. VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards
(ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and
provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education
credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2021-06/06/2024. Social workers
completing this course receive 1.0 continuing education credits.
VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board
of Registered Nursing, Provider Number 10517, expiring 01/31/2025.
Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH:
No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois.

Goal
Discuss hospital readmissions in today’s ever-changing
healthcare environment and how hospice can have
an impact.
3

Objectives
• Describe HRRP (Hospital Readmission Reduction
Program) within the context of healthcare reform
• Identify what constitutes a hospital readmission
• Appreciate the definition of a hospital readmission
and the conditions that risk penalties
• Recognize the role of hospice in helping prevent
hospital readmissions
4

Top Causes of Death for Those Age 65+ 2020
Curtin, et al. (2023). Deaths: Leading Causes for 2020. National vital statistics reports: from the Centers for Disease Control and Prevention, National Center for Health Statistics,
National Vital Statistics System 72.13 (2023): 1-115.
Cancer, 17.6%
COVID-19,
11.3%
Stroke, 5.5%
Alzheimer
disease, 5.3%
CLRD, 5.1%
Diabete
s, 2.9%
Uninentional injuries, 2.5%
Kidney disease, 1.7%
Influenza and
pneumonia, 1.7%
Other, 24.3%
Heart disease, 22.2%

Place of Death US
Teno, et al. (2018). Site of death, place of care, and health care transitions among US Medicare beneficiaries, 2000-2015. JAMA, 320(3), 264-271.

Healthcare Spending in the US by Type of Service 2022
Centers for Medicare & Medicaid Services (2023) National Health Expenditure Data Historical. Available at:
https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/historical
Hospital Care , 30%
Physician and clinical services, 20%
Retail prescription drugs, 9%
Other health, residential, and
personal care services, 6%
Dental services, 4%
Nursing care facilites and continuing
care retirement communities, 4%
Home health care, 3%
Other professional services, 3%
Other non-durable medical products, 3% Durable medical equipment, 2%
$4.5 trillion

Healthcare Spending by Source of Funds 2019
Centers for Medicare & Medicaid Services (2023) National Health Expenditure Data Historical. Available at: https://www.cms.gov/data-research/statistics-trends-and-reports/national-
health-expenditure-data/historical
Private health insurance, 29%
Medicare , 21%
Medicaid, 18%
Private health insurance, 29%
Out of pocket, 11%
$4.5 trillion

Healthcare Spending as Percent of Gross Domestic Product (GDP)
Wagner, et al. (2023) How does health spending in the U.S. compare to other countries? Peterson Center on Healthcare & Kaiser Family Foundation. Available at https://www.healthsystemtracker.org/chart-
collection/health-spending-u-s-compare-countries/)
Health spending as a share of GDP in the U.S. declined in 2021 as the economy improved spending grew more slowly

Medicare Payment Advisory Commission. Report to the Congress: Medicare and the Health Care Delivery System. June 2023.
Available at: https://www.medpac.gov/document/july-2023-data-book-health-care-spending-and-the-medicare-program/
Healthcare Spending Has Grown As a Share of the Country’s GDP

Baby Boomer Impact
King. Et al. (2013). The status of baby boomers' health in the United States: the healthiest generation?. JAMA Internal Medicine, 173(5), 385-386.
• More than 11,200 will turn 65 every day from 2024
through 2027.
• By 2035, there will be 78 million people 65 years and
older, compared to 76.4 million children under the
age of 18
– Patient access will become an issue
– Hospitals will need to address chronic care
needs, because aging Baby Boomers are
living longer but have higher rates of
chronic disease and more disability

Factors Contributing to Healthcare Waste
Shrank, et al. (2019). Waste in the US health care system: estimated costs and potential for savings. JAMA, 322(15), 1501-1509.
• Waste accounts for about 25% of US healthcare spending
• Estimates range from $760 billion to $935 billion
– The annual cost of waste from failure
of care coordination is estimated
at $27.2 billion–$78.2 billion
– The annual cost of waste from overtreatment
or low-value care is estimated at
$75.7–$101.2 billion

Costs at End of Life
Jha, A. K. (2018). End-of-life care, not end-of-life spending. JAMA, 320(7), 631-632.
Trella Health (2020). Quantifying Hospice’s End-of-Life Impact. Available at: https://www.trellahealth.com/portfolio_page/quantifying-hospices-end-of-life-impact/
• More than 90 million Americans
live with at least 1 chronic illness
• 7 out of 10 Americans die from
chronic disease
– Patients with multiple chronic
diseases can spend upwards
of $57K per year on
their healthcare
• One quarter of Medicare spending
goes toward care for people during
their last year of life
• Patients who do not elect their
hospice benefit may incur as much
as $27,455 in additional healthcare
costs, compared with patients who
received hospice care in their last
months of life

Changing Healthcare Environment
CHANGES
CHANGES
CHANGES
CHANGES

CMS Value-Based Program Timeline
Centers for Medicare & Medicaid Services. Value-Based Programs. Retrieved from https://www.cms.gov/Medicare/
Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs
Value-Based Programs
Legislation
ACA: Affordable Care Act
MACRA: Medicare Access and CHIP
Reauthorization Act of 2015
PAMA: Protecting Access to Medicare Act
Program
APMs: Alternative Payment Models
ESRD-QIP: End-Stage Renal Disease Quality Incentive Program
HACRP: Hospital-Acquired Condition Reduction Program
HRRP: Hospital Readmissions Reduction Program
2008 2010 2012 2014 2015 2018 2019 2023
Legislation
Passed
MIPPA ACA PAMA MACRA
Program
Implemented
ESRD-QIP
HVBP
HRRP
HAC VM SNF-VBP
APMs
MIPS
HHVPP
Program (cont.)
HVBP: Hospital Value-Based Purchasing Program
MIPS: Merit-Based Incentive Payment System
VM: Value Modifier or Physician Value-Based Modifier (PVBM)
SVFVBP: Skilled Nursing Facility Value-Based Purchasing Program
HHVPP: Home Health Value-Based Purchasing

The Value Equation
1
Kohn L. T., Corrigan J., & Donaldson M. S. (2000). To Err is Human: Building a Safer Health System (Vol. 6). Washington, DC: The National Academies Press.
2MEDICINE, I. R. O. E. B. (2011). Learning What Works Best: The Nation's Need for Evidence on Comparative Effectiveness in Health Care: AN ISSUE OVERVIEW.
In Learning What Works: Infrastructure Required for Comparative Effectiveness Research: Workshop Summary. The National Academies Press.
Numerator problems
• 100,000 deaths/year from medical errors1
• Millions more harmed by overuse,
underuse, and misuse
• Fragmentation
• Medical practice based on evidence
< 50% of the time2
• Healthcare spending as % of GDP
Value of
Healthcare
Quality
Cost
=

Value of
Healthcare
Quality
Cost
=
The Value Equation
1
McGough, et al. (2023). Kaiser Family Foundation Health Tracker. Available at: https://www.healthsystemtracker.org/chart-collection/how-much-is-health-spending-expected-to grow/#Annual%20change%20in%
20per%20capita%20health%20spending,%201970s%20%E2%80%93%202021;%20projected%202022%20%E2%80%93%202031
2Merelli, A. US health insurance prices went up nearly 30% over the past year. Quartz. https://qz.com/health-insurance-prices-went-up-nearly-30-over-the-pas-1849655576
3Centers for Medicare & Medicaid Services (2023) National Health Expenditure Data Historical. Available at: https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/historical
Denominator problems
With utilization continuing to return to pre-pandemic levels and price inflation in the health sector, per person
health spending is projected to rebound to an annual rate of 4.8% per capita on average from 2022 to 2031,
which is slightly above pre-pandemic growth rates (average of 3.9% from 2014 to 2019)1
• Insurance premiums increased
by > 200% in the last 10 years2
• US spending 17.3% GDP in 20223
• Healthcare spending is the #1 threat to
the American economy and way of life

Hospice Impact on CMS Quality for a Hospital
CMS, FAQ for the Risk-Standardized Outcomes & Payment Measures Public Reporting Year 2019 (July 1, 2019 - June 30, 2020). VITAS Proprietary Case Study
Hospice
Enrollment
Mortality
Hospital
Readmission
ICU and
Hospital Bed
Availability
Medicare
Per-Beneficiary
Spend
12 Months
Before
First Day
of Index
Admission
After the
First Day of
Index
Admission
No
Hospice
Day 30
12 Months Before the
Index Admission
Risk-Adjustment Look-Back Period Outcome Timeframe
Index Admission
(Day 0)
Patient
Dies
Medicare Hospice
Medicare Hospice
No Hospice
Medicare Hospice Patient
Dies
Patient
Dies
Patient
Dies

Hospital Readmission Reduction Program (HRRP)
The MedPAC Blog. (2018). The Hospital Readmissions Reduction Program has succeeded for beneficiaries and the Medicare program.
Retrieved from: http://www.medpac.gov/-blog-/the-hospital-readmissions-reduction-program-(hrrp)-has-succeeded-for-beneficiaries-and-the-
medicare-program/2018/06/15/the-hospital-readmissions-reduction-program-has-succeeded-for-beneficiaries-and-the-medicare-program
• Part of the Affordable Care Act (ACA)
• Intended to drive meaningful
reductions in all-cause readmissions
by aligning payment with outcome
• Ultimate objectives:
– Improve care transitions
– Relieve Medicare beneficiaries
of the burden of returning to
the hospital
– Relieve taxpayers of the cost
of readmissions

Components of Readmission Measure
Component Description
Target Population Medicare fee for service age 65 and older discharged from acute care or VA
hospital with an index condition. Beginning in FY 2019, the 21st-Century Cures
Act requires CMS to assess a hospital’s performance relative to other hospitals
with a similar proportion of patients who are dually eligible for Medicare and
full-benefit Medicaid
Definition Patient is discharged from the applicable hospital to a non-acute care
setting and is admitted to the same or another acute-care hospital for
any reason
Exclusions Planned readmission within 30 days
Applicable Data Three years of discharge data calculates excess readmissions
Risk Adjustment
Patient-related factors that may impact readmissions including age, gender,
comorbidity and disease severity. Patient data for risk is obtained from claims
for 12 months prior to and including index admission

HRRP Penalties and Conditions
Program Year 1 2 3 4 5 6
Fiscal Year 2013 2014 2015 2016 2017 2018
Dates of
Performance
Measurement
8-Jun to
11-Jul
9-Jun to
12-Jul
10-Jun to
13-Jul
11-Jun to
14-Jul
12-Jun to
15-Jiul
13-Jun to
16-Jul
Conditions for
Original
Hospitalization
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
Chronic
Obstructive
Pulmonary
Disease (COPD)
Hip/Knee
Arthroplasty
(THA/TKA)
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
Chronic
Obstructive
Pulmonary
Disease (COPD)
Hip/Knee
Arthroplasty
(THA/TKA)
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
[Expanded]
Chronic
Obstructive
Pulmonary
Disease (COPD)
Hip/Knee
Arthroplasty
(THA/TKA)
Coronary Artery
Bypass Grafting
(CABG)
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
[Expanded]
Chronic
Obstructive
Pulmonary
Disease (COPD)
Hip/Knee
Arthroplasty
(THA/TKA)
Coronary Artery
Bypass Grafting
(CABG)
Maximum Penalty 1% 2% 3% 3% 3% 3%

What Counts as a Readmission?
When a patient with AMI, COPD, pneumonia, or heart failure is readmitted to a hospital
within 30 days of the initial hospitalization, it is considered a readmission.
Counts as a readmission for Hospital
A – patient discharged with HF and
readmitted within 30 days
A even if patient readmitted to a
different hospital
A when patient is readmitted from a
PAC provider
Counts as only one readmission for
Hospital A, even if patient readmitted
more than once during the 30-day period
Scenario 1
Scenario 2
Scenario 3
Scenario 4
Each of these scenarios would count as ONE readmission for Hospital A
Hospital A
Heart Failure
Home
Hospital A
UTI
Home
Hospital A
Heart Failure
Home
Hospital B
UTI
Home
Hospital A
Heart Failure
SNF
Hospital A
UTI
SNF
Hospital A
Heart Failure
SNF
Hospital A
UTI
SNF
Hospital B
Pneumonia
0 days 30 days

Zuckerman et al. (2016). Readmissions, observation, and the hospital readmissions reduction program.
New England Journal of Medicine, 374(16), 1543-1551.
Readmission Rates for Targeted and Nontargeted
Conditions Within 30 Days After Discharge

HRRP: Penalties
Advisory Board. Sept. 28, 2023. More hospitals brace for readmission penalties in 2024. Available at: https://www.advisory.com/daily-briefing/2023/09/18/readmission-penalties
• CMS found that 2,273 hospitals
face HRRP penalties for FY 2023,
the lowest number of hospitals
penalized in almost 10 years.
• However, this trend is likely to
be reversed for FY 2024. 70.1%
of hospitals of hospitals will
receive penalties of less than
1% of their readmissions
• 7.5% of hospitals will receive
penalties of 1% or more
in 2024
• 22.4% of hospitals won’t
receive penalties

Hospitals Punished for Multiple Readmissions in Multiple Years
Rau, J. 10 Years of Hospital Readmissions Penalties, Kaiser Family Foundation, published Nov. 4, 2021. Available at :
https://www.kff.org/health-reform/slide/10-years-of-hospital-readmissions-penalties/,
396 366
238
184
128 109 83 72 56
219
0
400
800
1,200
10 years 9 years 8 years 7 years 6 years 5 years 4 years 3 years 2 years 1 year 0 years

Readmission Patient Profile
• Readmitted patients have 2-3 times
longer length of stay in the ICU than
non-readmitted patients
• Readmitted patients have 2-10 times
higher risk of death than patients who
are not readmitted
• ICU re-admissions are associated with
dramatically higher hospital mortality
30-day hospital readmissions among Medicare beneficiaries
age 65 and older per 1,000 beneficiaries
All hospital admissions among patients who were readmitted within 30 days of an
acute hospital stay for any cause. Presented as a rate of readmissions per
1,000 fee-for-service Medicare beneficiaries age 65 and older.
Commonwealth Fund. Available at: Hospital 30-day readmissions age 65 and older, per 1,000 Medicare beneficiaries. Available at:
https://www.commonwealthfund.org/datacenter/hospital-30-day-readmissions-age-65-and-older-1000-medicare-beneficiaries
America's Health Rankings analysis of The Dartmouth Atlas of Health Care, United Health Foundation, AmericasHealthRankings.org, Accessed 2020.
30
32
34
36
38
40
42
44
46
48
Rate
Years

Reasons for Readmission
Jencks S. F., Williams M. V., & Coleman E. A. (2009). Rehospitalizations among patients in the
Medicare fee-for-service program. New England Journal of Medicine, 360(14), 1418-1428.
• Failure in discharge planning
• Insufficient outpatient and
community care/lack of care coordination
• Severe progressive illness

Readmission: Severe Progressive Illness
Freund, et al. (2012). Hospice Eligibility in Patients Who Died in a Tertiary Care Center. Journal of Hospital Medicine, 7(3), 218-223.
• University of Iowa Retrospective Chart Review
• Penultimate admission within 12 months
of death
– 84% (175/209) of patients were within
6 months of their actual deaths
• Documentation of hospice discussion
– Terminal admission: 23%
– Penultimate admission: 14%

Hospice and Hospital Readmission Prevention

Advanced Illness Continuum
Timelier
Hospice
Access
Increased
Value
• Wishes and values
• Advance directive
• MOLST/POLST
• Goals of care
1. Advance Care
Planning
• Extra layer of support
• Symptom management
• Goal-concordant care
• Care transitions
2. Palliative
Care
Medicare Care Choices
Open
Access
3 Pathways to Hospice
Hospice
Death
• Care not consistent with wishes and values
• Greater healthcare utilization
• Less hospice use and shorter length of stay
• Higher healthcare cost
3. Traditional
Care
Hospice
Death
Decreased
Value

Advance Care Planning (ACP)
Conversations should occur throughout the natural history of serious illness.
Index presentation and hospitalization
introduce natural disease history and
concept of advance care planning
Acute exacerbations, including ED visits
and hospitalizations; ongoing disease
education and help to complete an ACP
Annual
Wellness Visit
Assists in timely
transition to hospice
Quality
of
Life

Supports the
Triple Aim
Increased Satisfaction With Care on CAHPS
Greater Goal-Concordant Care
Fewer Hospitalizations
Fewer ICU Days
Fewer ED Visits
Lower Healthcare Cost
Greater Hospice Utilization
Die in Location of Choice:
Home
Advance Care Planning Evidence Base
1
Patel M., et al. Effect of a Lay Health Worker Intervention on Goals-of-Care Documentation and on Health Care Use, Costs, and Satisfaction Among Patients With Cancer:
A Randomized Clinical Trial. JAMA Oncolology, 4(10):1359-1366.
2El-Jawahri et al. (2016). Randomized, Controlled Trial of an Advance Care Planning Video Decision Support Tool for Patients With Advanced Heart Failure. Circulation, 134(1):52-60.

Hospice Enrollment and Hospital Readmissions
Holden et al.. (2015). Hospice Enrollment, Local Hospice Utilization Patterns, and Rehospitalization in Medicare Patients. Journal of Palliative Medicine, 18(7), 601-612.
Kaplan-Meier survival curves
for hospice enrollees and
non-enrollees demonstrating the
proportion of patients remaining
out of the hospital in the 30-day
post-discharge period.

0.00
0.10
0.20
0.30
0.40
0.50
In-hospital deaths ICU admissions 30-day hospital
readmissions
Incremental
reduction
in
various
outcomes
(proportion)
53-105 days 15-30 days 8-14 days 1-7 days
Hospice enrollment:
Hospice Use Decreases Acute-Care Utilization
Kelly, A. (2013). Hospice Enrollment Saves Money and Improves Quality. Health Affairs, 32 (3):552–561.
0
2
4
6
8
10
Hospital Days ICU days
Hospital
and
ICU
days
avoided
53-105 days 15-30 days 8-14 days 1-7 days
Hospice enrollment:

Hospice and Medicare Cost Savings
NORC at the University of Chicago (2023). Value of Hospice in Medicare. Available at: https://www.nhpco.org/wp-content/uploads/Value_Hospice_in_Medicare.pdf

Adjusted Healthcare Expenditures at the End of Life for Individuals
Enrolled With Hospice and Non-Hospice Control, 2002-2018
Aldridge, et al. "Association Between Hospice Enrollment and Total Health Care Costs for Insurers and Families, 2002-2018."
JAMA Health Forum. Vol. 3. No. 2. American Medical Association, 2022.
Adjusted mean, $
Characteristic Hospice group
Propensity score
weighted controls
Difference P value
Total expenditures
Last 3 da
2473 5285 -2831 <.001
Last wkb
2106 8911 -6806 <.001
last 2 wks
c
4083 12869 -8785 <.001
last mod
8558 20305 -11747 <.001
Last 3 mos
e
20908 31816 -10908 <.001
Last 6 mosf
43679 43357 322 0.93
Family out of pocket
last 3 da
67 139 -71 <.001
Last wk
b
46 262 -216 <.001
last 2 wksc
159 424 -265 <.001
Last mo
d
241 912 -670 <.001
Last 3 mose
2412 1763 649 .41
Last 6 mos
f
4096 2988 1109 .55
a
Hospice enrollment in the last
week of life and comparison
group (n = 3781)
b
Hospice enrollment 8-14 days
before death and comparison
group (n = 3242)
c
group (n = 3223)
d
group (n = 3202)
e
group (n = 2832)
f
Hospice enrollment >182 days
group (n = 2551)

Case of AF
• 76 y/o, 6-year history of HF, relatively stable until past 6 months
secondary to ischemic cardiomyopathy
–Presents to ED with third
exacerbation in 6 months
–Recent EF 23%
–Long-standing ACE inhibitor,
B-blocker and diuretic
• Admitted to hospital with HF exacerbation, unclear reason
–ICD placed several years ago
–Dopplers negative DVT,
CXR HF
–PMH: s/p CVA, HTN,
DJD, hard of hearing

Case of AF (cont.)
• Admitted to hospitalist service
– IV diuresis
– Optimization of BP medications
– Education about HF
• Patient had cut back on diuretics
due to functional urinary incontinence
• Start consideration of discharge process
• Prior to admission, ambulates with
assistance, shortness of breath
w/minimal exertion

Heart Failure Trajectory
Function
Death
Low
Multiple hospitalizations Death after exacerbation
High
NYHA Class III/IV
Hospice Eligible
NYHA Symptoms:
Shortness of breath
Fatigue
Chest pain
Palpitations

Hospitalizations and End of Life
Dunlay, et al. (2015). Care in the Last Year of Life for Community Patients with Heart Failure. Circulation: Heart Failure, 8(3):489-96
• 80% HF patients hospitalized
last 6 months of life
• 28% died in the hospital
• Mean number hospitalizations
last 6 months 2.5-3.6;
LOS 11-13 days
0
50
100
150
200
250
300
350
331-365 301-330 271-300 241-270 211-240 181-210 151-180 121-150 91-120 61-90 31-60 0-30
Number
of
Hospitalizations
Days Prior to Death
Hospitalizations Days in Hospital

HF and Hospice
Patient is:
• Optimally treated
• Not a candidate/pursuing
surgical options
NYHA Class IV:
• Symptoms at rest
• Physical activity causes
further discomfort
Functional status and symptom burden are strongest indicators of hospice eligibility
NYHA Class III:
• Symptoms during
less than ordinary activity
• Significant comorbidities
Symptoms include:
• Fatigue
• Dyspnea
• Angina
• Palpitations
Or

HF Functional Status and Survival
PPS
Level
Ambulation Activity and Evidence of Disease Self-Care Intake Conscious Level
100% Full
Normal activity and work
No evidence of disease
Full Normal Full
90% Full Normal activity and work Some evidence of disease Full Normal Full
80% Full Normal activity with effort Some evidence of disease Full Normal or reduced Full
70% Reduced
Unable to perform normal job/work
Significant disease
Full
Normal or reduced Full
60% Reduced Unable to perform hobby/housework Significant disease
Occasional assistance
necessary
Normal or reduced Full or Confusion
50% Mainly Sit/Lie Unable to do any work Extensive disease
Considerable
assistance required
Normal or reduced Full or Confusion
40% Mainly in Bed Unable to do most activity Extensive disease Mainly assistance Normal or reduced
Full or Drowsy
+/- Confusion
30% Totally Bedbound Unable to do any activity Extensive disease Total Care Normal or reduced Full or Drowsy
20% Totally Bedbound Unable to do any activity Extensive disease Total Care Minimal to sips
Full or Drowsy
+/- Confusion
10% Totally Bedbound Unable to do any activity Extensive disease Total Care Mouth care only
Drowsy or Coma
+/- Confusion
0% Death — — — —

HF Functional Status and Survival (cont.)
Creber, et al. (2019). Use of the Palliative Performance Scale to estimate survival among home hospice patients with heart Failure. ESC: Heart Failure: 6:371-378
Patients with a PPS score of ≤50 or lower are generally hospice-eligible; some patients
with a higher PPS may also be eligible.

0%
5%
10%
15%
20%
25%
30%
35%
40%
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Inpatient Emergency Room Home Hospice Nursing Home/LTAC
HF Location of Death 2006-2015
Al-Kindi, et al. (2017). Where Patients With Heart Failure Die: Trends in Location of Death of Patients With Heart Failure in the United States.
Journal of Cardiac Failure, (9):713-714.
Year of death
Percentage
all
HF
deaths
Hospital 32.3%
Home 24.4%
2015 Location of Death
Nursing Home/LTAC 28.8%
Hospice 5%
ED/Outpatient 4.9%
Other/Unknown 4.2%

Heart Failure Symptom Burdens
Allen et al. (2012). Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation, 125(15), 1928-1952.
Outcome
Heart Failure
EF < 30%
Heart Failure
>30%
Advanced
Cancer
Number of Physical
Symptoms
9.4 (1.1) 8.7 (1.2) 8.7 (1.5)
Depression Score 3.6 (0.6) 4.3 (0.6) 3.2 (0.8)
Spiritual Well-Being 35.2 (1.8) 36.3 (1.9) 39.1 (2.3)
No significant difference between any of the groups

Main Symptoms Presented in HF Patients
46
Lee, et al. (2022) End-of-life care for end-stage heart failure patients. Korean Circulation Journal ,52.9, 659:679.

Pharmacologic Interventions for Heart Failure
47
Class Name Indication Adverse Effects Comments
Aldosterone Blocker Spironolactone NYHA III or IV
• Hyperkalemia
• Renal dysfunction
Monitor hyperkalemia
ACEi
Enalapril
Lisinopril
Ramipril
HF Stage B-D
• Hyperkalemia
• Hypotension Angioedema
• Cough First line for HFrEF
Beta-Blockers
Carvedilol
Metoprolol
• Fatigue
• Hypotension
• Depressed mood
ARBs
Losartan
Valsartan
Candesartan
• Hyperkalemia
• Hypotension
Substitution for ACE
inhibitors, not with ACEI
Diuretics
Furosemide
Metolazone
Thiazides
Volume overload
• Frequent urination
• Increase thirst
IV or Sub Q admin
Cardiac Glycosides Digoxin
Arrhythmias;
symptomatic
HF after 1st line
• Cardiac arrhythmias
• Vision changes (green)
• Dizziness, Nausea
• Delirium
Second line for HFrEF
Narrow treatment window
Many contraindications

Pharmacologic Interventions for Heart Failure
48
Class Name Indication Adverse Effects Comments
Mineralocorticoid Receptor
Antagonist
Spironolactone
Eplerenone
NYHA II-IV
• Hyperkalemia
Monitor potassium,
renal function
ARNi
Entresto
(Sacubitril-Valsartan)
NYHA II or III
• Hyperkalemia
• Dizziness, Fatigue
First-line;
not to be used
with ACEI
Soluble Guanylate
Cyclase Stimulator
Vericiguat
Certain pts w/worsening
HFrEF symptoms
despite GDMT
• Hypotension
• Anemia
Second line
for HFrEF
SA Node Funny Current
Inhibitor
Corlanor/Ivabradine
NYHA II or III HFrEF
• Bradycardia
• Increased BP
• Atrial fibrillation
SA node modulator;
many contraindications
SGLT2 Inhibitor
Farxiga/Dapagliflozin
and others)
NYHA III or IV HF
+/- T2DM
• Renal impairment
• UTIs Caution in older adults
Pulmonary HTN
medications
Prostacyclins
Endothelin antagonists
PDE-5 Inhibitors
Pulmonary HTN; improve
exercise ability; slow
progression of PAH
• Anemia
• Respiratory tract infection
• Headache
• Edema
• Nausea
Inhibit vasoconstriction
and/or promotes
vasodilation in
pulmonary circulation
IV, SQ, inhaled, PO

HF and Hospice Reduce Hospital Readmissions
Kheirbek, et al. (2015). Discharge Hospice Referral and Lower 30-Day All-Cause Readmission in Medicare Beneficiaries Hospitalized for Heart Failure.
Circulation: Heart Failure, 8(4):733-40.
Approximately 10%
of HF patients who
were admitted to the
hospital and died
within the next 6
months were
referred to hospice.
Hospice-eligible HF
patients who enroll
were 88% less likely
to be re-hospitalized
compared to non-
enrollees.

Case of AF (cont.)
• Family meeting with patient and
daughter, who want to try skilled
rehabilitation to strengthen patient
• Open conversation with
patient and daughter
– Overall poor prognosis
– Recommend hospice services
to best meet patient goals
– Continue to provide
state-of-the-art HF care
– Open to informational
visit prior to transfer

Allen et al. (2012). Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation, 125(15), 1928-1952.
• No hospital
• Minimal tests
Outcomes Relevant
to Individual Patient
• Improve shortness of breath
• Continue to live at home
• Live as long as
possible
Survival
Costs/Burden
Direct Medical Costs
Indirect Costs
Lost Opportunities
Caregiver Burden
Quality of Life
Symptoms
Physical Function
Mental
Emotional
Social
Important Elements of Shared Decision-Making
for Goals-of-Care Conversations

Case of AF (cont.)
• At NH, patient participates in PT/OT and
builds up some strength and endurance
– Able to get out of seated position and
ambulate with quad cane
– Still short of breath with minimal
exertion or at rest
• End of week 1, appears a little confused,
blood work and urine sent for analysis
– At night, develops confusion and agitation
– Sent back to hospital
– Admitted with UTI and delirium

Service Comparison
53
VITAS Palliative Care Home Health
Eligibility Requirements
Prognosis required: ≤ 6 months
if the illness runs its usual course
Prognosis varies by program,
usually life-defining illness
Prognosis not required
Skilled need not required Skilled need not required Skilled need required
Plan of Care Quality of life and defined goals Quality of life and defined goals Restorative care
Length of Care Unlimited Variable Limited, with requirements
Homebound Not required Not required Required, with exceptions
Targeted Disease-Specific Program ✓ Variable Variable
Medications Included ✓ X X
Equipment Included ✓ X X
After-Hours Staff Availability ✓ X X
RT/PT/OT/Speech ✓ X ✓
Nurse Visit Frequency Unlimited Variable Limited, based on diagnosis
Palliative Care Physician Support ✓ Variable X
Levels of Care 4 1 1
Bereavement Support ✓ X X

0
1
2
3
4
5
6
7
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Days Following Hospital Discharge
Heart failure hospitalization
Heart Failure and Hospital Readmission
Dharmarajan, et al. (2013). Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA, 309(4), 355-363.
31.7% of 30-day readmissions (Day 0 – Day 7)
61.0% of 30-day readmissions (Day 0 - Day 15)
0 10 20 30 40 50
Readmission diagnosis Heart failure Heart Failure
Renal disorders
Pneumonia
Arrhythmias
Septicema/shock
Cardiorespiratory failure
Chronic obstructive pulmonary disease
Chronic angina and coronary artery disease
Acute myocardial infarction
Complications of care
30-Day Readmissions, %
Heart Failure Hospitalization
0-30 0-15
0-7 0-3
Cumulative periods
after discharge, d
13.4 % of 30-day readmissions (Day 0 – Day 3)

Case of AF (cont.)
• Hospital plan of care:
– Antibiotics
– Gentle hydration
– Safe and supportive environment
• Cognition improves within 2 days and
PT evaluation recommends skilled
• Family elects to return to skilled
facility for PT

• Participates in PT/OT and continues
to improve endurance and strength
• Discharge planning initiated with
discussions of home health or hospice
– NYHA Class III or IV
– Daughter wants PT in home
for a couple of sessions when
patient transitions
– Home health aides to help
bathe patient
Case of AF (cont.)

Service Comparison
Service VITAS Home Health
Palliative Care
Physician Support
Yes No
Nurse Frequency
of Visits
Unlimited based
on patient need
Diagnosis
driven
RT/PT/OT/Speech Yes Yes
Equipment Included Yes No
After Hours Staff
Availability
Yes No
Levels of Care 4 Levels Home
Care Plan Review Weekly Variable
Targeted Disease-
Specific Program
Yes Variable
Bereavement Support Yes No
Service VITAS Home Health
Eligibility • Physician-certified prognosis
<6 months, if disease runs
normal course
• Hospice prognosis must be
re-certified periodically
• Patient agrees to palliative,
not curative, plan of care
• Plan of care determined by
initial and ongoing doctor/team
assessment, combined
with patient/family wishes
• Not required to be homebound
• Must require skilled level
of care and a specific plan
of care confirming need,
frequency and duration
of visits
• Skilled nursing care need
must be re-certified periodically
• As skilled needs change,
approved services change
• Must be homebound,
except for short durations
Length
of Care
Unlimited number of visits based
on patient need, if prognosis
remains 6 months or less
• Limited number of visits
• Must document progress within
the length of service allowed
Medications
Included
VITAS provides Rx and OTC
medications related to hospice
diagnosis at no charge to the patient
Medications are not covered
under the Medicare Home Health
Benefit

0
10
20
30
40
50
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Adjusted
Prevalence
of
SNF
Admission
(%)
Year of Death
65 - < 75yr 75 - < 85yr ≥ 85yr
SNF Use by Older Adults in Last 6 Months of Life
Aragon, et al. (2012). Use of the Medicare Posthospitalization Skilled Nursing Benefit in the Last 6 Months of Life. Archives of Internal Medicine, 172(20), 1573-1579.
Only 1.5% enrolled in hospice at discharge

Case of AF (cont.)
• Daughter elects home health,
as SNF believes hospice
would not cover PT
• Patient makes a smooth
transition home
• Two weeks later, on Sunday,
patient develops acute shortness
of breath
– Calls home health service
– Answering service
recommends going to ED
– HF exacerbation requires
IV diuresis and initiation
of inotropes
• In ED, daughter asks what
can be done to keep mom
out of the hospital

Therapy Indication Benefits Burdens Other
ICD Detects fatal
arrhythmia and restores
sinus
EF<35% Over
1 year survival
Survival
No QOL/function
improvements
Pain, trauma,
PTSD, anxiety,
device issues
Life expectancy
over 1 year and
good function
CRT Pacemaker
RV plus lateral LV
so beat synchrony
NYHA III/IV
Ambulatory EF<35% and
QRS>120
Improved survival
with ICD, symptoms,
exercise, and QOL.
Fewer hospitalizations
Surgery- and
device-related
complications
20–30% no benefit,
mortality benefit
by 3 months
LVAD Channel ejects
blood LV to circulation
Bridge or Destination
therapy systolic
dysfunction
Improved survival, exercise,
QOL
Bleeding, infection, and
thromboembolic events
2-year
survival 58%
Cardiac
Inotropes
Decompensated
HF without adequate
response diuresis
Increased QOL and ability
to transition home
Continuous infusion,
defibrillator shocks
Hospice-eligible
Advanced Therapies in HF

Candidate’s Home Inotropic Therapy
• Inotrope provides some symptomatic relief
– Less shortness of breath, more
awake, more able to concentrate
• Maintenance phase and dose, no
active titration
– No previous hypersensitivity
to the agent
• More permanent central
venous access
• Agreeable to hospice plan of care
– No monitors, not a bridge
to transplant or LVAD
– Typically discharged on
continuous care for transition
– Do not have to deactivate ICD

Inotropes Outcomes
Nizamic, et al. (2018). Ambulatory Inotrope Infusions in Advanced Heart Failure: A Systematic Review and Meta-Analysis. JACC: Heart Failure, 6(9):757-767.
• Inotropes can be used for symptom control
in patients with advanced HF who are not
candidates for MCS or transplant
– Improved NYHA class
(mean difference 0.6 95% CI 0.2–1.0)
– No association with mortality
(0.68 95% CI 0.40–1.17)
– No association with hospital
readmission p>0.10
– ICD shock 2.4 95% CI (2.1–2.8)
• Hospice will cover, since its goal is
improved symptom management
• Overall improvements in survival
over time likely secondary to the
incorporation of improved medical
management and ICD

Afari, et al. (2019). Subcutaneous Furosemide for the Treatment of Heart Failure: a State-of-the-Art Review. Heart Failure Reviews, 24(3):309-313.
• Subcutaneous Lasix may
eliminate the need for an IV
for patients at home
• Similar outcomes between
subq and IV
–Similar diuresis
–No difference in re-hospitalizations
• Dosing has been done in hospice
as a continuous infusion as well
as intermittent
• Limited data in severely obese and
end-stage kidney disease patients
• Local side effects can occur:
stinging, burning, swelling
Acute Decompensated HF and SQ Furosemide

Case of AF (cont.)
• Elects hospice benefit
• Inpatient hospice, contract bed
or continuous care at home?
–Continuous care
• Diuresis with subcutaneous
furosemide
• Continuation of inotrope
• CHF exacerbation improved;
4 days later, transitions to routine
home care
• Physical therapy assessment initiated
• Dies 5 months later at home with
one additional episode of acute
exacerbation HF on Intensive
Comfort Care®

Summary
• Advanced illness is a common
contributor to hospital readmission
• Hospice helps prevent
hospital readmissions
• Hospice factors associated with
lower hospital readmissions:
– After-hours care
– Availability of continuous care
– Visit frequency
– “Open access”

References
Advisory Board. Sept. 28, 2023. More hospitals brace for readmission penalties in 2024. Avaialable at: https://www.advisory.com/daily-
briefing/2023/09/18/readmission-penalties
Afari M., Aoun J., Share S., Tsao L. (2019). Subcutaneous Furosemide for the Treatment of Heart Failure: a State-of-the Art Review.
Heart Failure Reviews, 24(3):309-313.
Aldridge, et al. “Association Between Hospice Enrollment and Total Health Care Costs for Insurers and Families, 2002-2018.”
JAMA Health Forum. Vol. 3. No. 2. American Medical Association, 2022.
Allen L. A., Stevenson L. W., Grady K. L., Goldstein N. E., Matlock D. D., Arnold R. M., ... & Havranek, E. P. (2012). Decision
making in advanced heart failure: a scientific statement from the American Heart Association. Circulation, 125(15), 1928-1952.
America’s Health Rankings analysis of The Dartmouth Atlas of Health Care, United Health Foundation, AmericasHealthRankings.org,
Accessed 2020.
Aragon, K., et al. (2012). Use of the Medicare Post-hospitalization Skilled Nursing Benefit in the Last 6 Months of Life. Archives of
Internal Medicine, 172(20), 1573-1579.
Blinderman, C. D., Homel, P., Billings, J. A., Portenoy, R. K., & Tennstedt, S. L. (2008). Symptom distress and quality of life in
patients with advanced congestive heart failure. Journal of Pain and Symptom Management, 35(6), 594-603.
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References
Advisory Board. Sept. 28, 2023. More hospitals brace for readmission penalties in 2024. Available at: https://www.advisory.com/daily-
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Centers for Medicare & Medicaid Services (2023) National Health Expenditure Data Historical. Available at:
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Curtin, et al. (2023). Deaths: Leading Causes for 2020. National vital statistics reports: from the Centers for Disease Control and
Prevention, National Center for Health Statistics, National Vital Statistics System 72.13 (2023): 1-115.
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Dharmarajan et al. (2013). Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial
infarction, or pneumonia. JAMA, 309(4), 355-363.
Dunlay S., Redfield M. Jiang R., Weston S., Roger V. (2015). Care in the Last Year of Life for Community Patients with Heart Failure.
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El-Jawahri et al. (2016). Randomized, Controlled Trial of an Advance Care Planning Video Decision Support Tool for Patients
With Advanced Heart Failure. Circulation, 134(1):52-60.
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Died in a Tertiary Care Center. Journal of Hospital Medicine, 7(3), 218-223.
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may not be further distributed in any way, including but not limited to email. This
presentation is designed for clinicians. While it cannot replace professional clinical
judgment, it is to guide clinicians and healthcare professionals in reducing hospital
readmissions and length of stay in advanced illness patients. It is provided for
general educational and informational purposes only, without a guarantee of
the correctness or completeness of the material presented.

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