The goal of this webinar was to help healthcare professionals improve care coordination for patients with advanced illness and to reduce hospital readmissions and length of stay.

1. Reducing Hospital Readmissions
and Length of Stay in Advanced
Illness Patients

2. CE Provider
Information
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: (03/03/22 - 023/03/23).

3. 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.
CE Provider
Information
(Cont.)

4. CE Provider
Information
(Cont.)
ACE provider approval period: 06/06/2018 –
06/06/2021. 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 03/03/2023.
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

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

6. • 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
Objectives

7. Heart disease
25.1
Cancer
20.6
CLRD
6.3
Stroke 6.1
Alzheimer disease 5.7
Diabetes 2.9
Unintentional Injuries 2.9
Kidney disease 2.0
Influenza and pneumonia 1.9
Parkinson disease 1.6
Other
24.9
Ages 65 and Over
National Vital Statistics Reports Volume 70, Number 9 Jul6 26, 2021
Deaths: Leading Causes for 2019 by Melonie Heron, Ph.D., Division of Vital Statistics
Top Causes of Death for Those Age
65+ 2019

8. Teno J. M., Gozalo P., Trivedi A. N., Bunker J., Lima J., Ogarek J., & Mor V. (2018). Site of death, place of care, and health care transitions among US Medicare beneficiaries, 2000-2015. JAMA, 320(3), 264-271.
Place of Death US

9. Hospital Care
$1,192.00, 25.1%
Physician
services
$565.50,
20.6%
Clinical
services
$206.60,
6.3%
Home health care $113.50, 6.1%
Nursing care facilities $172.70,
5.7%
Prescription drugs
$369.70, 2.9%
Other personal health care
$587.10, 2.9%
Government administration
$48.90, 2.0%
Net cost of health insurance
$239.90, 1.9%
Government public health activities
$97.80, 1.6%
Investment
$201.70,
24.9%
Source: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-
Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. Tables 6, 7, 9, 10, and 16 in NHE Tables
Healthcare Spending in the US 2019

10. Hospital care
$1,108.30,
31.5%
Home health care
$115.8, 20.6%
Nursing home care $168.30,
16.2%
Prescription Drugs
$392.40, 6.1%
Other personal health care
$567.40, 5.7%
Program administration and net cost of
private health insurance $315.90, 2.9%
Government public health activities
$100.30, 2.9%
Source: preliminary Altarum estimates as of February 2021. Data was obtained through direct correspondence with Altarum and analysis of data is printed with
permission. For details about Altarum 2020 health spending data see https://altarum.org/publications/february-2021-health-sector-economic-indicators-briefs
Healthcare Spending in the US 2020

11. Healthcare Spending as Percent of
Gross Domestic Product (GDP)
Schneider E. C., Sarnak D. O., Squires D., Shah A., & Doty M. M. (2017). Mirror, mirror: how the US health care system compares internationally at a time of radical change. The Commonwealth Fund.
0
2
4
6
8
10
12
14
16
18
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014
United States (16.6%) Switzerland (11.4%) Sweden (11.2%) France (11.1%)
Germany (11.0%) Netherlands (10.9%) Canada (10.0%) United Kingdom (9.9%)
New Zealand (9.4%) Norway (9.3%) Australia (9.0%)
1980 - 2014
GDP data (2014)

12. Medicare Payment Advisory Commission. Report to the Congress: Medicare and the Health Care Delivery System. June 2019.
Available at: http://medpac.gov/docs/default-source/reports/jun19_medpac_reporttocongress_sec.pdf?sfvrsn=0
Future US Healthcare Spending Projections
Health care spending growth rates have begun to gradually increase following recent slowdown

13. Baby
Boomer
Impact
• 10,000 Baby Boomers reach the age of 65
daily, that’s 7 new Boomers each minute1
• By 2035, there will be 78 million people 65
years and older, compared to 76.4 million
children under the age of 182
– 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
1Gibson W.E. (2018). Age 65+ Adults Are Projected to Outnumber Children by 2030.
Retrieved from https://www.aarp.org/home-family/friends-family/info-2018/census-baby-boomers-fd.html
2King D. E., Matheson E., Chirina S., Shankar A., & Broman-Fulks J. (2013). The status of baby boomers' health
in the United States: the healthiest generation?. JAMA Internal Medicine, 173(5), 385-386.

14. Song Z., & Ferris T. G. (2018). Baby Boomers and beds: a demographic challenge for the ages. Journal of General Internal Medicine, 33(3), 367-369.
Population 65 Years and Older and
Hospital Beds in US

15. Factors
Contributing
to Healthcare
Waste
• 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
Shrank W. H., Rogstad T. L., & Parekh N. (2019). Waste in the US health care system:
estimated costs and potential for savings. JAMA, 322(15), 1501-1509.

16. • 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
Jha, A. K. (2018). End-of-life care, not end-of-life spending. JAMA, 320(7), 631-632.
Costs at
End of Life

17. Changing Healthcare Environment
CHANGES
CHANGES
CHANGES
CHANGES

18. 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
CMS Value-Based Program Timeline
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
Legislation
Passed
MIPPA ACA PAMA MACRA
Program
Implemented
ESRD-QIP
HVBP
HRRP
HAC VM SNF-VBP
APMs
MIPS
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

19. Value of Healthcare = Quality
Cost
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
1Kohn 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.
2
MEDICINE, 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.
The Value
Equation

20. 1
Kaiser Family Foundation. Employer Health Benefits 2019 Annual Survey. Retrieved from http://files.kff.org/attachment/Report-Employer-Health-Benefits-Annual-Survey-2019
2Centers for Medicare and Medicaid Services. National Health Expenditures 2018 Highlights. Retrieved from https://www.cms.gov/files/document/highlights.pdf
The Value
Equation
Value of Healthcare = Quality
Cost
Denominator problems
• Insurance premiums increased
by >200% in the last 10 years1
• US spending 17% GDP2
• Healthcare spending is the
#1 threat to the American
economy and way of life

21. 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
Risk-adjustment look
back period
Outcome
timeframe
Index Admission
(day 0) Day 30
12 months before the
index admission
Patient
dies
Patient
dies
Patient
dies
Patient
dies
Medicare
Hospice
Medicare
Hospice
Medicare
Hospice
No Hospice
Hospice Impact on CMS Quality
for a Hospital

22. Hospital
Readmission
Reduction
Program
(HRRP)
• 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
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

23. 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

24. Catalyst, N. E. J. M. (2018). Hospital Readmissions Reduction Program (HRRP). NEJM Catalyst.
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%

25. 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
Counts as a readmission for Hospital A even
if patient readmitted to a different hospital
Counts as a readmission for 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

26. Zuckerman R. B., Sheingold S. H., Orav E. J., Ruhter J., & Epstein A. M. (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

27. • 2021 penalties based on discharges
July 2017–Dec 2019
• 82% of the 3,046 hospitals CMS
evaluated were assessed a penalty
• CMS will cut payments to the penalized hospitals
by as much as 3% for each Medicare patient stay
during fiscal year 2022 (Oct 2021- Sept 2022)
– The average penalty is a .64% payment
reduction for each Medicare patient
stay 10/21 – 9/22
– 39 hospitals received the maximum
3% penalty for fiscal year 2022
• The penalties are projected to save Medicare an
estimated $521 million over the next fiscal year
HRRP: 2021
Penalties
Rau, Jordan. (2019 Medicare Punishes 2,499 Hospitals for High Readmissions. Kaiser Health News.
Retrieved from https://khn.org/news/article/hospital-readmission-rates-medicare-penalties/ /

28. Rau, J. 10 Years of Hospital Readmissions Penalties, Kaiser Family Foundation, ublished Nov. 4, 2021. Available at :
https://www.kff.org/health-reform/slide/10-years-of-hospital-readmissions-penalties/,
Hospitals Punished for Multiple
Readmissions in Multiple Years
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

29. Readmission
Patient
Profile
• 15% of Medicare enrollees age 65+
were readmitted within 30 days of
hospital discharge in 2019
• 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
America's Health Rankings analysis of The Dartmouth Atlas of Health Care, United Health Foundation, AmericasHealthRankings.org, Accessed 2020.

30. Reasons for
Readmission
• Failure in discharge planning
• Insufficient outpatient and
community care
• Severe progressive illness
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.

31. • 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%
Freund K., Weckmann M. T., Casarett D. J., Swanson K., Brooks M. K., & Broderick A. (2012). Hospice Eligibility
in Patients Who Died in a Tertiary Care Center. Journal of Hospital Medicine, 7(3), 218-223.
Readmission:
Severe
Progressive
Illness

32. Hospice and Hospital Readmission
Prevention

33. 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

34. 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

35. 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
1Patel 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.
Advance Care Planning Evidence Base

36. Holden T. R., Smith M. A., Bartels C. M., Campbell T. C., Yu M., & Kind A. J. (2015). Hospice Enrollment,
Local Hospice Utilization Patterns, and Rehospitalization in Medicare Patients. Journal of Palliative Medicine, 18(7), 601-612.
Hospice Enrollment and Hospital
Readmissions
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.

37. 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:
Kelly, A. (2013). Hospice Enrollment Saves Money and Improves Quality. Health Affairs, 32 (3):552–561.
Hospice Use Decreases
Acute-Care Utilization
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:

38. Kelly, A. (2013). Hospice Enrollment Saves Money and Improves Quality. Health Affairs, 32 (3):552–561.
Hospice and Medicare Cost Savings
0
2,000
4,000
6,000
8,000
53-105 days 15-30 days 8-14 days 1-7 days
Total
Medicare
savings
(s)
Hospice enrollment range

39. 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 Healthcare Expenditures at the End of
Life for Individuals Enrolled With Hospice and
Non-Hospice Control, 2002-2018
Adjusted mean, $
Characteristic Hospice group
Propensity score
weighted controls
Difference P value
Total expenditures
Last 3 d
a
2473 5285 -2831 <.001
Last wk
b
2106 8911 -6806 <.001
last 2 wks
c
4083 12869 -8785 <.001
last mo
d
8558 20305 -11747 <.001
Last 3 mose
20908 31816 -10908 <.001
Last 6 mos
f
43679 43357 322 0.93
Family out of pocket
last 3 d
a
67 139 -71 <.001
Last wkb
46 262 -216 <.001
last 2 wks
c
159 424 -265 <.001
Last mo
d
241 912 -670 <.001
Last 3 mos
e
2412 1763 649 .41
Last 6 mosf
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
Hospice enrollment 15-28 days
before death and comparison
group (n = 3223)
d
Hospice enrollment 29-91 days
before death and comparison
group (n = 3202)
e
Hospice enrollment 92-182 days
before death and comparison
group (n = 2832)
f
Hospice enrollment >182 days
before death and comparison
group (n = 2551)

40. • 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
– ICD placed several years ago
– Dopplers negative DVT, CXR HF
– PMH: s/p CVA, HTN, DJD, hard
of hearing
• Admitted to hospital with HF
exacerbation, unclear reason
Case of AF

41. • 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
Case of AF
(cont.)

42. 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

43. Dunlay S., Redfield M., Jiang R., Weston S., Roger V. (2015). Care in the Last Year of Life for Community Patients with Heart Failure. Circulation: Heart Failure, 8(3):489-96
Hospitalizations and End of Life
• 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

44. • Symptoms w/ minimal exertion or rest
(NYHA Class III/IV) despite standard
of care
• Inability to tolerate standard of care
medical therapies
• Recent history of cardiac arrest or
recurrent syncope
• Inotropic support required and not
LVAD/transplant candidate
• Oxygen requirement secondary to
poor cardiac function
• ED visits and hospitalizations from
HF exacerbations
HF and
Hospice

45. HF Functional Status and Survival
PPS
Level
Ambulation Activity & 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 — — — —

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

47. 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
Al-Kindi S., Koniaris C., Olivera G., Robinson M. (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.
HF Location of Death 2006-2015
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%

48. Allen et al. (2012). Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation, 125(15), 1928-1952.
Heart Failure Symptom Burdens
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

49. Most
Common
HF Symptoms
>50%
• Lack of energy
• Pain
• Feeling drowsy
• Dry mouth
• Shortness of breath
• Depression
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.

50. Class Examples Indication Adverse Effect Other Comment
ACE Inhibitor
Enalapril
Lisinopril
HF stage B-D
Hyperkalemia, Dec Cr,
low BP, cough, angioedema
First-line for
systolic HF
ARBs
Candesartan
losartan valsartan
HF stage B-D
Hyperkalemia, renal
dysfunction, hypotension
No not add to ACE
inhibitors
Beta blockers
carvedilol
metoprolol
HF stage B-D
Fatigue, hypotension,
depressed mood
First-line for systolic HF
Aldosterone blocker spironolactone
NYHA
III or IV
Hyperkalemia, renal dysfunction Monitor hyperkalemia
Loop diuretics
furosemide
bumetanide
Volume overload
Renal dysfunction, frequent
urination, increased thirst
IV or subq admin
Cardiac glycosides digoxin
Symptomatic HF
after 1st line
Cardiac arrhythmias, nausea,
VH, delirium
Monitor toxicity closely
Al-Kindi S., Koniaris C., Olivera G., Robinson M. (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.
Pharmacologic Treatment for HF

51. 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.
HF and Hospice Reduce Hospital
Readmissions
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.

52. • 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
Case of AF
(cont.)

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

54. • 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
Case of AF
(cont.)

55. 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
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
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.
Cumulative periods
after discharge, d
13.4 % of 30-day readmissions (Day 0 – Day 3)

56. • 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
Case of AF
(cont.)

57. • 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.)

58. 58
Service Comparison
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

59. 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
Only 1.5% enrolled in hospice at discharge

60. • 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
Case of AF
(cont.)

61. 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

62. 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

63. Nizamic T., Murad M., Allen L., McIlvennan C., Wordingham S., Matlock D., Dunlay S. (2018). Ambulatory Inotrope
Infusions in Advanced Heart Failure: A Systematic Review and Meta-Analysis. JACC: Heart Failure, 6(9):757-767.
Inotropes
Outcomes
• 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

64. Acute
Decompensated
HF and SQ
Furosemide
• 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
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.

65. • 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®
Case of AF
(cont.)

66. • 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”
Summary

67. 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.
Al-Kindi S., Koniaris C., Olivera G., Robinson M. (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.
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.
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.
Catalyst, N. E. J. M. (2018). Hospital Readmissions Reduction Program
(HRRP). NEJM Catalyst.
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73. This document contains confidential and proprietary business information and 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.