Hospice can help reduce hospital readmissions and lengths of stay for patients with serious illnesses like heart failure. By providing comprehensive care, including nursing support 24 hours a day, palliative care physician support, medications, equipment, and targeted programs for conditions like CHF, hospice can help meet patient goals of comfort and avoiding inappropriate hospitalizations. For the patient with heart failure described in the case study, hospice could help prevent readmissions and allow the patient to focus on quality of life rather than further medical interventions by providing end-of-life care in their home.
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.
The goal of this webinar is to help hospice and healthcare professionals understand the history, philosophy and practice of hospice care and palliative care, including common myths and misconceptions, common diagnoses for hospice referrals, identification of hospice-eligible patients, reimbursement for hospice services, and the benefits of advance care planning and early referrals.
This webinar provides resources and guidance on effective conversations with patients and families about their goals, wishes, and values for end-of-life care.
The who, what, where, why and how of end-of-life care. A continuing education webinar presented by VITAS Healthcare on March 15, 2018. For more information or future webinars, please visit: https://www.vitas.com/partners/continuing-education
The goal of this webinar is to help healthcare professionals improve care coordination for patients with advanced illness and to reduce hospital readmissions and length of stay (LOS).
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The goal of this webinar was to educate physicians and healthcare professionals about hospice eligibility and benefits for patients with advanced cardiac disease (ACD).
The goal of this webinar is to help healthcare professionals improve care coordination for patients with advanced illness and to reduce hospital readmissions and length of stay (LOS).
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.
The goal of this webinar is to help hospice and healthcare professionals understand the history, philosophy and practice of hospice care and palliative care, including common myths and misconceptions, common diagnoses for hospice referrals, identification of hospice-eligible patients, reimbursement for hospice services, and the benefits of advance care planning and early referrals.
This webinar provides resources and guidance on effective conversations with patients and families about their goals, wishes, and values for end-of-life care.
The who, what, where, why and how of end-of-life care. A continuing education webinar presented by VITAS Healthcare on March 15, 2018. For more information or future webinars, please visit: https://www.vitas.com/partners/continuing-education
The goal of this webinar is to help healthcare professionals improve care coordination for patients with advanced illness and to reduce hospital readmissions and length of stay (LOS).
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This webinar leverages evidence-based data to help physicians and healthcare professionals differentiate delirium, terminal restlessness and dementia-related agitation in patients as they near the end of life.
The goal of this webinar was to educate physicians and healthcare professionals about hospice eligibility and benefits for patients with advanced cardiac disease (ACD).
The goal of this webinar is to help healthcare professionals improve care coordination for patients with advanced illness and to reduce hospital readmissions and length of stay (LOS).
The goal of this webinar was to educate healthcare professionals about the differences between palliative and curative care while exploring the history and philosophy of the hospice movement.
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Written by Adele Allison, National Director of Government Affairs, SuccessEHS.
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Dr John Wren
Principal Researcher Advisor
New Zealand Accident Compensation Corporation
PO Box 242, Wellington, New Zealand
john.wren@acc.co.nz
(P23, Thursday 27, Civic Room 3, 1.30)
The goal of this webinar was to educate healthcare professionals about the differences between palliative and curative care while exploring the history and philosophy of the hospice movement.
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The initial presentation of the Economics of Language Access. For an updated version with new research please do not hesitate to contact Douglas Green through the website. Thank you.
Focusing on Pharmacist-Led Programs to Improve Medication Management Produces...Heidi Yanoski
This MBA Thesis presentation looks at pharmacist-led programs that not only improve patient outcomes, but help save millions by preventing medication errors, thirty-day hospital readmissions, and medication-induced morbidity and mortality.
Written by Adele Allison, National Director of Government Affairs, SuccessEHS.
The shape of the U.S. health care industry is changing every day, and this presentation sheds light on some interesting statistics including Primary Care Providers, The American Patient, Health Care and the U.S. Economy and more.
Dr John Wren
Principal Researcher Advisor
New Zealand Accident Compensation Corporation
PO Box 242, Wellington, New Zealand
john.wren@acc.co.nz
(P23, Thursday 27, Civic Room 3, 1.30)
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The goal of this webinar was to educate healthcare professionals about the differences between palliative and curative care while exploring the history and philosophy of the hospice movement.
The goal of this webinar was to educate healthcare professionals about the differences between palliative and curative care while exploring the history and philosophy of the hospice movement.
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For more information contact: Slideshare@marcusevans.com
Presentation delivered by Donna Medina, Regional Director,OSF Hospice and Homecare Foundation at the marcus evans Home Care Leadership Summit held on July 13 & 14 2015 in Palm Beach FL.
The goal of this webinar was to help hospice and healthcare professionals understand the ethics and application of artificial nutrition and hydration (ANH) for patients near the end of life.
When Decision-Making Is Imperative: Advance Care Planning for Busy Practice S...VITAS Healthcare
Complex, chronically ill patients present an opportunity to discuss and implement hospice and palliative care. Many elderly patients who present to the ED and other busy practice settings are hospice-eligible because of functional decline and multi-morbidity. Key tools can quickly facilitate goals-of-care (GOC) conversations, advance care planning, and hospice referrals amid time constraints and high-acuity challenges.
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This webinar helps physicians conduct a systematic evaluation for behavioral changes
in persons with dementia. It offers approaches for developing a comprehensive care plan for
disruptive behaviors. These methods incorporate caregiver education and non-pharmacologic
interventions followed by pharmacologic management.
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This presentation details how to conduct a comprehensive pain assessment, considerations when prescribing analgesics, and when opioids may be appropriate.
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Supported by evidence-based data, this webinar helped physicians and healthcare professionals gain greater understanding of the multifaceted applications of pain management in the context of palliative hospice care.
The goal of this webinar was to educate healthcare professionals about advance directives and advance care planning,
including the types and purposes of legal documents that govern patients’ decisions and
preferences.
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 (LOS).
The goal of this webinar was to educate physicians and healthcare professionals about hospice eligibility and the benefits of hospice for patients with advanced cardiac disease (ACD).
The goal of this webinar was to equip healthcare professionals with an understanding of military veterans’ unique medical, emotional, and spiritual needs as they near the end of life.
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The goal of this webinar was to educate physicians and healthcare professionals about the medical management of advanced lung disease (ALD), the value of advance care planning (ACP) and the benefits of hospice for end-of-life patients.
The clinical case study of a patient with advanced COPD who has multiple comorbid conditions and develops sepsis provideD the backdrop for two potential clinical pathways—sepsis and post-sepsis syndrome.
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Supported by evidence-based data, this webinar helped physicians and healthcare professionals gain greater understanding of the multifaceted applications of pain management in the context of palliative hospice care.
The goal of this webinar was to help hospice and healthcare professionals understand the ethics and application of artificial nutrition and hydration (ANH) for patients near the end of life.
Key tools can quickly facilitate goals-of-care (GOC) conversations, advance care planning, and hospice referrals amid the ED’s time constraints and high-acuity challenges.
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This webinar helps physicians conduct a systematic evaluation for behavioral changes in persons with dementia. It offers approaches for developing a comprehensive care plan for disruptive behaviors.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
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QA Paediatric dentistry department, Hospital Melaka 2020Azreen Aj
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Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
2. Objectives
• Discuss the intent of the Hospital
Readmission Reduction Program
• Identify three components of readmission
measures
• Verbalize an understanding of preventable
hospital readmissions
• Appreciate the role of hospice in reducing
hospital readmissions
3. How People Die
• <10% die suddenly of an unexpected event:
MI, accident, etc.
• >90% die of a life-limiting condition, typically
over a 5-15 year period
– Predictable steady decline with a relatively
short “terminal” phase (cancer)
– Slow decline punctuated by periodic crises
(CHF, COPD, dementia)
4. What Do Patients With
Serious Illnesses Want?
• Pain and symptom control
• Avoid inappropriate prolongation of the dying process
• Achieve a sense of control
• Relieve burdens on family
• Strengthen relationships with loved ones
Singer et al, JAMA 1999
5. Outcome Hospice Nursing
Home
Home
Health
Hospital
Not Enough Help with
Pain, %
18.3 31.8 42.6 19.3
Not Enough Help
Emotional Support, %
34.6 56.2 70 51.7
Not always Treated
with Respect, %
3.8 31.8 15.5 20.4
Enough Information
Dying, %
29.2 44.3 31.5 50
Quality Care
Excellent, %
70.7 41.6 46.5 46.8
Last Place of Care Experience
Teno et al. Family Perspectives on End of Life Care. JAMA 2004
6. Where do patients spend their
last days?
Without Hospice
Hospital
Home
Nursing Facility
7
56
19
16
20
With Hospice
Hospital
Home
Nursing Facility
Hospice Unit
Residential Care Facility
7. Medicare Hospice Utilization
NHPCO Facts and Figures: Hospice Care in America. Alexandria, VA:
National Hospice and Palliative Care Organization, October, 2012.
8. Healthcare Spending in the U.S.
• Continues to far exceed other industrialized countries
• Accounts for $2.64 trillion ($8,650 per person a year)
– 17.7% of the nation’s total economic output and
nearly twice that of 34 countries
• It is estimated by 2020, that will increase
to $13,710 or $4.6 trillion
9. International Comparison of Spending on Health, 1980–2009
* PPP=Purchasing Power Parity.
Data: OECD Health Data 2011 (database), version 6/2011.
Average spending on health
per capita ($US PPP*)
Total expenditures on health
as percent of GDP
9
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
United States
Canada
Germany
France
Australia
United Kingdom
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
United States
France
Germany
Canada
United Kingdom
Australia
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
EFFICIENCY
11. Impact of Baby Boomers
• 2.8 million boomers qualified for Medicare in 2011
• Through 2030, about 10,000 Baby Boomers a day
will reach the age of 65
• Medicare beneficiaries: 47 million today; 80 million
by 2030
– Patient access will become an issue
– Hospitals will need to address chronic
care needs
12. Readmission Patient Profile
• 1 in 5 Medicare patients re-admit within 30 days
• 1 in 3 Medicare patients re-admit within 90 days
• 30 day re-admissions cost Medicare $12-$15 billion
– 3/4 would not return to the hospital if they had a
follow-up plan
– 1/3 of patients can not explain their medications
– 1/2 cannot state their diagnosis
14. Lack of Care Coordination
Contributing To Waste
• $25-$50 billion annually
• Eliminating estimated avoidable emergency
department visits—$21.4 billion annually
• Cost for “avoidable” hospitalizations of nursing
home residents—$7.5 billion annually
• Cost of Medicare unplanned readmissions—
$17.4 billion
IOM Report
15. Costs at the End of Life
• Last two years of life, patients with chronic illness
account for approximately 32% of total healthcare
spending
• Sickest 5% of population accounts for almost half
of all health care expenses
• Hospital & physician bills during last two months
of patients’ lives cost Medicare $50 billion
• Hospitals have long argued ALOS figures are
skewed by patients no longer responsive to
curative treatments
16. Readmission Patient Profile
• Hospital death rates are 2-10 times higher for
re-admitted patients
• Re-admitted patients frequently require ICU
admission
• Re-admitted ICU patients length of stay (LOS)
is twice as long as non-readmitted patients
• ICU re-admits are associated with dramatically
higher hospital mortality
20. How They Think About it in
Washington: The Value
Equation
Value of health care = Quality
Cost
Numerator problems
– 100,000 deaths/year from medical errors
– Millions more harmed by overuse, underuse and misuse
– Fragmentation
– Medical practice based on evidence <50% of the time
– U.S. ranks 40th in quality worldwide
21. How They Think About it in
Washington: The Value
Equation (Cont.)
Value of health care = Quality
Cost
Denominator problems
• Insurance premiums increased by >200% in the
last 10 years.
• U.S. spending 17% GDP, >$8400/person/year
• Nearing 35% of total state spending
• Health care spending is the #1 threat to the
American economy and way of life.
22.
23. 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
• Outcome measure: Hospital specific, risk standardized,
all cause 30-day excess readmission ratio following index
hospitalizations for AMI, heart failure or pneumonia
• 2013: 1% reduction in Medicare base reimbursement for
inpatient services for all DRGs
• 2014: 2% and 2015: 3%
Source: Kocher R, Adashi E. Hospital readmissions and the affordable care
act. Paying for coordinated quality care. JAMA 306:1794-1795, 2011.
30. Reasons for Readmission
• Failure in discharge planning
• Insufficient outpatient and community care
• Severe progressive illness
Source: Jencks S, et al: Rehospitalizations among patients in the
Medicare fee-for-service program. NEJM 360:1418-1428, 2009.
32. Coordinated Approach
Hospitalist
• Communicate PCP on
admission
• Involve PCP early in
discharge planning
• Notification of discharge
• Discharge summary
• Follow-up appointments
• Prescriptions at pharmacy
• Self-management
Primary Care
• Call within 72 hours D/C
• Ensure follow-up
• Coordinate care
• Repeat until stable
• Access for patients with new
symptoms
• Track readmission rates
• Track and review frequently
admitted patients
Teng N. Jour Gen Hosp Med 2013
33. Readmission Impacts
on Hospitals
• Adversely affects hospital LOS and mortality rates
– Stay longer
– More likely to die
• Negatively impacts hospital “Core Measure” outcomes
• Utilization challenges for managing LOS and DRGs
• Increased ED volume and extended patient wait times
• Reduced patient and family satisfaction
• Hospice appropriate patients occupy hospital beds
34. Hospice/Palliative Care
Interface
Integrating Palliative Care and Hospice
Modified From Emanuel, von Gunten, Ferris. Plenary 3:EPEC series and reproduced in
Kinzbrunner. Palliative Care Perspectives, Chapter 1 in Kuebler, Davis, Moore Palliative
Practices, An Interdisciplinary Approach, 2005, p. 22.
Hospice
Curative / disease modifying
therapy
Time course of illness Last months
of life
Palliative care
Family
Bereavemen
t care
35. Hospice Care
• Interdisciplinary team-oriented
approach to end-of-life (EOL) care
– Patient-family center of care
– Goals of care/shared
decision making
• Aggressive care at the EOL—
medical care, pain and symptom
management and emotional and
spiritual support
• Provided in any setting
36. Medicare Hospice Benefit
Basic Hospice Benefit
• Prognosis of six months or less if the terminal illness
runs its normal course as determined by the patient’s
attending physician and the hospice medical director
• Patients elect hospice via informed consent
• Hospice reimbursed a flat per diem based on one of
four levels of care:
1. Routine home care
• Includes patients living in LTC or ALF
2. Continuous home care
3. General inpatient care
4. Respite inpatient care
37. Readmission: Hospice
Can Help
Medicare Hospice Benefit
• Comprehensive Part A benefit
• Focus is on care in the patient’s primary place of
residence
– Private home, ALF, nursing home
• “General inpatient” level of care for patients who
require “hospitalization” or “readmission”
• “Continuous care” enables patients who would
otherwise “require” an acute care (re)admission to
remain at home
38. VITAS Care Transition Pathway 2012
Hospital
(ED/CC/Telemetry/Med-Surg)
IPU GIP or Home
ICC ICC
Home Home
Visit VisitICC ICCTelecare Telecare
Visit
Frequenc
y
Virtual
ED
Mobile
Intensive
Palliative
Care
Visit
Frequenc
y
Virtual
ED
Mobile
Intensive
Palliative
Care
Patient
ED
39. Readmission: Hospice
Can Help (Cont.)
Kelly, A. Hospice enrollment saves money and
improves quality. Health Affairs 2013
40. Readmission: Hospice
Can Help (Cont.)
• Nursing home residents on hospice were less likely
to be hospitalized than residents not on hospice (OR
0.47; 95% CI: 0.45-0.5) 1
• Nursing home residents who had a “hospice
informational visit” had fewer acute care admissions
(mean 0.28 vs. 0.49; p = .03) and fewer acute care
days (mean 1.2 vs. 3.0; p = .03) than those who
did not 2
1Gozalo P, Miller S. Hospice enrollment and evaluation of the
causal effect on hospitalization of dying nursing home patients.
Health Svcs Res 42:587-610, 2007.
2Casarett D, et al. Improving the use of hospice services in
nursing homes. A randomized trial. JAMA 294:211-217, 2005.
41. Readmission: Hospice
Can Help (Cont.)
• University of Iowa, Retrospective Chart Review
• Penultimate admission within 12 months of death
– 60% (125/209) of patients met NHPCO guidelines
for hospice
– 84% (175/209) of patients were within six mo. of their
actual deaths
– Only 59% (103/175) of patients who died within six mo.
of the admission met NHPCO guidelines
• Documentation of hospice discussion
– Terminal admission: 23%
– Penultimate admission: 14%
Source: K Freund et al. Hospice eligibility in patients who died
in a tertiary care center. J of Hospital Med 7:218-223, 2012.
42. Case of AF
• 84 y/o with six-year history of CHF; relatively stable
until past six months
– Presents to ED with third exacerbation in three
months
– Recent EF 55% with diastolic dysfunction
– Long-standing ace inhibitor, b-blocker
and diuretic
– Dopplers negative DVT, CXR CHF
– PMH- s/p CVA, HTN, DJD, hard of hearing
• Admitted to hospital with CHF exacerbation
unclear reason
43. Case of AF (Cont.)
• Admitted to hospitalist service
– IV diuresis
– Optimization of BP medications
– Education about CHF
• 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 minimal exertion
44. Hospice Guidelines
• NYHA Class IV : Symptomatic at rest
– Despite maximal therapies and/or therapies are
not tolerated or refused
• NYHA Class III : Symptoms with minimal exertion
– multiple co-morbidities, renal disease, pulmonary
disease, syncope, arrhythmia
46. Hospice Triggers
• Frequent readmissions to the hospital
• Ongoing symptoms despite optimal treatment
• Declining functional status
• Use of ionotropes
• Declining renal function
• ICD fires despite medical therapies
• Patient goals focus on quality of life
• Would we be surprised if this patient died in
the next 6-12 months?
HFSA 2010 Guideline Executive Summary.
Journal of Cardiac Failure 2010; 16 (6)
47. Elements Important To Goals
of Care Conversations
Shared Decision-Making
Allen L A et al. Circulation 2012;125:1928-1952
• No more hospitals
• Minimal tests
• Improve shortness
of breath
• Continue to live
at home
• Keep alive as long
as possible
49. Burden Heart Failure
–Symptoms
Outcome Heart Failure
EF< or = 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
Bekelman DB et al Journal of General
Internal Medicine 2009
50. Burden Heart Failure
—Symptoms (Cont.)
Heart Failure Most Common Symptoms (>50%)
Bekelman DB et al Journal of General
Internal Medicine 2009
• Lack of energy
• Pain
• Feeling drowsy
• Dry mouth
• Shortness of breath
• Depression
51. Comprehensive Services
Service VITAS Home Health
Nurse 24 hours day Yes Variable
Nurse frequency of visits Unlimited Diagnosis
Driven
Palliative Care Physician Support Yes No
Medications Included Yes No
Equipment Included Yes No
Levels of Care Home
Inpatient
Respite
Continuous
Home
Home
Bereavement Support Yes No
Primary Care/Specialty visits Yes Yes
Targeted CHF program Yes Variable
Care Plan Review Weekly Variable
53. Case of AF (Cont.)
• Family meeting with patient and daughter. They
want to try skilled rehabilitation to get stronger
• Open conversation with patient and daughter
– Overall poor prognosis
– Recommend hospice services to best meet
patient goals
– Continue to provide state-of-art CHF care
– Open to informational visit prior to transfer
54. Case of AF (Cont.)
• At NH patient participates in PT/OT and builds
up some strength and endurance
– Ambulate with quad cane
• Still short of breath minimal exertion
• Approaching end of stay and develops acute
shortness of breath and back to the hospital
– Cut back on diuretic dose due to ongoing
functional urinary incontinence
56. Reason for Hospital Admission
from Nursing Home
Krueger K et al. Nursing Research and Proactive 2011
57. Case of AF (Cont.)
• Admitted to the hospital with CHF
• Diuresis
• Goals of care conversation and amenable
to hospice
• Elects hospice benefit
58. Case of AF (Cont.)
• At home on hospice and remains
relatively stable for two months
• Middle of night patient develops
acute shortness of breath
• Calls hospice—nurse to arrive in
1-2 hours
• Daughter brings mom to ED
60. VITAS Care Transition Pathway 2012
Hospital
(ED/CC/Telemetry/Med-Surg)
IPU GIP or Home
ICC ICC
Home Home
Visit VisitICC ICCTelecare Telecare
Visit
Frequenc
y
Virtual
ED
Mobile
Intensive
Palliative
Care
Visit
Frequenc
y
Virtual
ED
Mobile
Intensive
Palliative
Care
Patient
ED
61. Case AF (Cont.)
• Elects to go home with continuous care
• Sub Q furosemide initiated for fluid overload
• Overall stabilization within five days
• Routine home level of care re-initiated
62. AF Visit Summary
Patient Profile
• 84 y/o female w/heart
disease unspecified
(ICD-9 429.9)
• Home hospice elected
• LOS 92 days
VITAS Services Received
• Seven Physician Visits
• 42 RN Visits
• Two Social Worker Visits
• 35 CNA Visits
• Continuous Care:
Five days
• HME-Elect bedzO2,
w/C, etc.
64. References
• Casserett D, et al. (2005) Improving the use of hospice services in
nursing homes. A randomized trial. JAMA 294:211-217.
• Freund, K. et al. (2012) Hospice eligibility in patients who died in a
tertiary care center. J of Hospital Med 7:218-223.
• Gade G, et al. (2008) Impact of an inpatient palliative care team: A
randomized control trial. J Pall Med 11(2):180-190.
• Gozalo P, & Miller S. (2007) Hospice enrollment and evaluation of the
causal effect on hospitalization of dying nursing home patients. Health
Svcs Res 42:587-610.
• Jencks S, et al: (2009) Rehospitalizations among patients in the
Medicare fee-for-service program. NEJM 360:1418-1428.
65. References (Cont.)
• Kocher R, & Adashi E. (2011) Hospital readmissions and the
affordable care act. Paying for coordinated quality care. JAMA
306:1794-1795.
• Nelson C, et al. (2011) Inpatient palliative care consults and the
probability of hospital readmission. Permanente J 15:48-51.
• Pantilat: Role of Palliative Care in Readmission Reduction. (2012)
Retrieved from:
http://www.avoidreadmissions.com/wwwroot/userfiles/documents/76/pr
esentation-3.pdf.
• U.S. Department of Health and Human Services – January 2012
• Wright JB, & Kinzbrunner B. (2011): How to assist patients and
families in accessing end-of life care. Chapter 2 in Kinzbrunner BM,
Policzer JS (eds): End-of-Life Care: A Practical Guide. New York:
McGraw Hill, p. 37.