#ALFA2014

END-OF-LIFE CARE TRENDS AND INNOVATIVE MODELS

Presented by: Susan Enguidanos, PhD, MPH USC Davis School of Gerontology Co-Facilitated by: Randy A. Platt, SVP of Operations Silverado Hospice & At Home

#ALFA2014

Agenda

• What is important for individuals at end of life? • Current experience of Dying • Introduction to Palliative Care • Two Models of palliative care Hospital-based Home-based

• Impact of palliative care on 30-day hospital readmissions • A discussion of Hospice and Palliative care in the Assisted

Living Environment

#ALFA2014

Group Exercise

• What is important to people at end of life? • Where do people want to spend their time at end of life? • Is your Community the “home” your resident and their

family expect? • Are you prepared to have care discussions, to include the

resident and family’s end of life goals? • Are your associates, nurses and medical directors

prepared to have the Palliative or hospice care discussion?

#ALFA2014

Background: Patient & Family Need

Current dying experience is far from one that is desired by most Americans

• Majority of Americans prefer to die at home (Hays et al., 2001; Gallup, 2000) •33.5% die at home (2009; Teno et al., 2013)

• Patients continue to die in pain (Meier, 2006) • Health care providers do not know code status

preferred by their patients • 46% of Do Not Resuscitate orders written within 2

days of death

#ALFA2014

Impact on Costs of Care

5% of people 65 & up die each year

28.30%

25.10%

23.00%24.00%25.00%26.00%27.00%28.00%29.00%

1978 2006

Percent of Total Medicare Spending

(Riley & Lubitz, 2010)

#ALFA2014

65+ Medicare Beneficiaries Hospital Use

64.5 63.7 62.6 62.5

18.5 16.1 16.5 16.7

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

1978 1988 1997 2006

Decedents INPSurvivors INP

(Riley & Lubitz, 2010)

#ALFA2014

65+ Medicare Beneficiaries Multiple Hospitalizations

(Riley & Lubitz, 2010)

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65+ Medicare Beneficiaries ICU Use

(Riley & Lubitz, 2010)

#ALFA2014

Rise in Aggressive Care?

0

5

10

15

20

25

30

ICU 30 days 3 or > INP 90days

Transition 3days

24

10 10

26

11 12

29

11 14

2000

2005

2009

Teno et al., 2013

#ALFA2014

Hospice Care

• What is hospice care? • Do you know someone who has had hospice

care? • What was it like?

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Hospice Enrollment Trends (NHPCO, 2011, 2012)

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What is Palliative Care?

• Type of care for seriously ill patients that is focused on quality of life: • Pain & Symptom control • Optimizing functioning • Helps patients and families make important decisions • Provides psychological & spiritual support

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Goal of Palliative Care

“…to prevent and relieve suffering & to support the best possible quality of life for patients & their families, regardless of the stage of the disease or the need for other therapies.”

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Core Components of Palliative Care

• Interdisciplinary team: physician, nurse, social worker, chaplain • Physical, medical, psychological, social & spiritual

support • Patient & family education & training

• Develop plan of care • Train patients and families on how to manage

symptoms • Coordinated, patient-centered care • Pain & symptom management

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Hospice Palliative care

Curative / remissive therapy

Presentation Death

Adapted from Lynn and Adamson, 2003

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Palliative Care vs. Hospice

Physicians not required to give a 6 month prognosis Patients do not have to forego curative care Palliative care physician coordinates care to

prevent service fragmentation

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Organ Failure Trajectory

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Palliative Care Models

Hospital-based Palliative Care Programs

Home-based Palliative Care

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Inpatient Palliative Care Consultation Teams

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Hospital-based Palliative Care

• Consultative IPC service involves family meeting with patients/family

#ALFA2014

Clinical Impact of IPC

• LOS 30% • Pain by 86% • Dyspnea by 64%

(Ciemins, Blum, Nunley, Lasher, Newman, 2007)

#ALFA2014

Fewer ICU Admissions at Readmission

0

5

10

15

20

2521

12

Usual Care IPC

(Gade, Venohr, Connor et al., 2008)

#ALFA2014

Lower Costs of Care

(Gade, Venohr, Connor et al., 2008)

$0

$5,000

$10,000

$15,000

$20,000

$25,000$21,252

$14,486 Usual CareIPC

Lowered cost by $4855

#ALFA2014

Home-based Palliative Care

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Home-based Palliative Care (HBPC)

• Eligibility • Diagnosis of congestive heart failure (CHF), chronic

obstructive pulmonary disease (COPD), or cancer • Life expectancy about 1 year

• Primary care physician “would not be surprised” if the patient died in the next year

• Palliative Care • Home visits provided by interdisciplinary team • Access to all usual medical care services

#ALFA2014

Satisfactory Scores by Study Group

10

15

20

25

30

35

40

45

Usual Care Palliative Care

39.35 40.89 40.88 43.56

Sati

sfac

tion

wit

h C

are

Enrollment

90 Days Follow-up

Brumley, Enguidanos, Jamison et al., 2007 p=.02

#ALFA2014

Acute Care Service Use (n=297)

Brumley, Enguidanos, Jamison et al., 2007

0%

10%

20%

30%

40%

50%

60%

*ED *Hospital

20%

36% 32%

58% Pe

rcen

t Usi

ng

Palliative

Usual Care

#ALFA2014

Unadjusted Medical Service Use (n=297)

Brumley, Enguidanos, Jamison et al., 2007

0

5

10

15

20

25

30

*ED *Hospital SNF *MD Office *HomeVisits

0.29 2.2 1.77

4.42

30

0.67

7.34

3.18

9.11 12.39

Mea

n N

umbe

r of

Day

s/V

isits

Palliative Usual Care

* P<.01

#ALFA2014

Site of Death (n=217)

0%

10%

20%

30%

40%

50%

60%

70%

80%

Home Hospital SNF InPt.Hospice

71%

9% 11% 9%

51%

24% 14%

11%

Palliative Care Usual Care

• Studies show that most people prefer to die at home*

• Patients enrolled in the Palliative Care program were significantly more likely to die at home (71% vs. 51%: p=.001)

P=.013 *(Townsend, Frank, Fermont, et al., 1990; Karlsen & Addington-Hall, 1998; Hays et al., 2001)

#ALFA2014

Total Service Costs

$0

$5,000

$10,000

$15,000

$20,000

$25,000

All Costs

$12,670

$20,221

Palliative

Usual Care• Adjusted costs of care

for those in PC were 32.6% less than those receiving UC

• Saves $7,551

p<.001

#ALFA2014

30-Day Readmission among Seriously Ill Older Adults: Why Do

They Come Back?

#ALFA2014

AIMS

• Determine rate of and factors associated with 30 day readmissions among Inpatient Palliative Care (IPC) patients

• Characterize patient and family perspectives on 30-day readmissions • aligned with desired plan of care? • avoidable?

Enguidanos, Vesper, & Lorenz (2012). 30 day readmissions among Seriously Ill Older Adults. Journal of Palliative Medicine, 1-6.

#ALFA2014

Readmission Rates Among IPC Patients

• Among IPC patients discharged, overall readmission rate = 10% • Overall hospital readmission = 15%

• Reduced readmission by 1/3

#ALFA2014

Type of Care at Discharge (n=408)

58.8%

14.7%

3.7%

14.2%8.6%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Hospice Home-based PC

Home Health Nursing Facility

Home-No Care

(Enguidanos et al., 2012)

#ALFA2014

Readmission Rate by Post Discharge Service Use

(Enguidanos et al., 2012)

58.8%

14.7%

3.7%

14.2% 8.6%

4.6% 8.3%

13.3%

24.1% 25.7%

0%

10%

20%

30%

40%

50%

60%

70%

Hospice Home-basedPC

Home Health Nursing Facility Home-No Care

Care at D/C

% Readmitted

#ALFA2014

Predictors of 30-Day Readmit

Examined age, gender, ethnicity, marital status, pain, diagnosis, # chronic conditions, anxiety, ADs, and their association with 30 day readmit

No Advance Directive 2.7x’s more likely

Added discharge disposition to the model

Nursing Facility 5x’s & Home (no care) 3.7x’s more

likely Enguidanos, Vesper, & Lorenz (2012). 30 day readmissions among Seriously Ill Older Adults. Journal of Palliative Medicine, 1-6.

#ALFA2014

Qualitative Interviews

Interviews with IPC CHF & CA patients/caregivers

following 30 day hospital readmission to determine

patient/caregiver perspective

(n=7)

#ALFA2014

Themes

• Three themes identified: 1. Lack of Support &

Purpose 2. Rehospitalization as

appropriate care 3. Lack of access to

care/information

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Theme: Lack of Support & Purpose

• Lack of support & purpose • Living alone and lack of support • “I wasn’t cooking for myself, I

wasn’t doing anything…I just wasn’t eating”

• “It’s just a matter of me …motivating me”

• “If there was something I could look forward to…”

#ALFA2014

Theme: Appropriate Care

Hospital care most appropriate for medical condition “ I get to retaining the fluids again and then

right back to where we were [hospital]” Preference for aggressive care

“ I ain’t going nowhere, and I’m fighting”

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Theme: Lack of Access to Care/Information • “I should be comfortable. I shouldn’t have to go,

‘Oh, I got pain I need pain meds.’ I shouldn’t be going after pain medication…I was told I should come back to the ER to get my pain medicine.”

• “Sometimes I have questions” • “I could have REALLY used a • hospital bed” • Inability to physically transport spouse to

specialist appt.

#ALFA2014

Theme: Lack of Access to Care/Information

“We need to look at my overall picture…I have a number of problems that I need to resolve both medical and …psychological. There’s some psychological problems, there’s some financial problems…when I go home, ok, I’m faced with a whole group of problems that I have to resolve which is enough to give a person a heart attack to begin with, and every day that I’m out, it gets worse.”

#ALFA2014

1. 2010 National Survey of Residential Care Facilities The NSRCF was conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS). The survey

methodology and data dictionary are available from the NCHS website. (http://www.cdc.gov/nchs/nsrcf/nsrcf_questionnaires.htm).

Silverado Communities Clinical Outcomes CLINICAL OUTCOMES: COMMUNITIES

SILVERADO SKILLED NURSING COMPANY-WIDE FACILITIES (non-

Silverado) ¹ASSISTED LIVING

% TRANSFERS TO ER/URGENT CARE 2.2% 8.0% 34.6% % of HOSPITAL READMISSIONS WITHIN 30 DAYS 0.3% 16.9% % of ACUTE HOSPITALIZATIONS 3.6% 20.0% 23.9% % of DEATHS RECEIVING HOSPICE SERVICE 89.4% 33.1%

1. 2010 National Survey of Residential Care Facilities The NSRCF was conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS). The survey methodology and data dictionary are available from the NCHS website. (http://www.cdc.gov/nchs/nsrcf/nsrcf_questionnaires.htm).

#ALFA2014

Silverado Hospice Clinical Outcomes

CLINICAL OUTCOMES: HOSPICE SILVERADO NATIONAL

COMPANY-WIDE (Year ending, 2013)

Average (Year ending, 2012 NHPCO)

HOSPITAL READMISSION RATE WITHIN 30 DAYS (CMS) 2.7% 5.4% REVOCATION RATE (NHPCO) 6.3% 14.4% CONVERSION RATE 77.0% 75.0%

Silverado Hospice has earned The Joint Commission’s Gold Seal of Approval

#ALFA2014

Group Exercise

• What are the benefits of palliative care? • How can palliative care and hospice care be

better integrated into assisted living facilities? • What is the potential business case for

integrating palliative care and hospice care into existing care services?

#ALFA2014

How to reach us….

Susan Enguidanos, PhD, MPH USC Davis School of Gerontology enguidan@usc.edu Randy A. Platt, Senior Vice President of Operations Silverado At Home and Hospice rplatt@Silveradocare.com 949-240-7200

#ALFA2014

END-OF-LIFE CARE TRENDS AND INNOVATIVE MODELS

Presented by: Susan Enguidanos, PhD, MPH USC Davis School of Gerontology Co-Facilitated by: Randy A. Platt, SVP of Operations Silverado Hospice & At Home