Exploring Hospice Care | VITAS Healthcare

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

1. Exploring Hospice Care The Who, What, Where, Why and How of End-of-Life Care

2. Care at the End of Life Statistics show that while most people hope to die at home, approximately 50% of the general population dies in an acute care hospital setting. The chances, however, improve with hospice— which allows three out of four hospice patients to die in their home Journal of Oncology Practice, 2008

3. How We Die… Misleading Information <10% suddenly, unexpected event, MI, accident, etc. >90% protracted life-threatening illness Predictable steady decline with a relatively short “ terminal ” phase ( e.g cancer) Slow decline punctuated by periodic crises ( e.g CHF, emphysema, Alzheimer ’s)

4. How We Die: Facts & Figures Only 25 percent of Americans actually die at home. Source: Centers for Disease Control (2005) More than 80 percent of patients with chronic diseases say they want to avoid hospitalization and intensive care when they are dying – however – Hospitalizations during the last six months of life are rising: from 1,302 hospital admissions per 1,000 Medicare recipients in 1996 to 1,442 in 2005. Source: Dartmouth Atlas of Health Care (2005) Even when patients have an advance directive, physicians are often unaware of their patients' preferences. One large-scale study found that only 25 percent of physicians knew that their patients had advance directives on file. Source: Critical Care Journal (2007)

5. Goal To educate healthcare professionals about the benefits of hospice, in order to provide timely, quality end-of-life care for terminally ill patients and their families

6. Objectives List two myths about hospice care Identify the difference between palliative and curative care Explain services provided under the hospice benefit List four eligibility criteria for hospice services Describe how hospice is structured to meet the needs of terminally ill patients and their families

7. Your Thoughts? Many people already know something about hospice… What are your perceptions and/or experiences?

8. Hospice Origins The origin of the word hospice was used to describe a “ shelter or haven for the weary traveler ” The term “ hospice ” has come to be associated with support and care Shelter from discomfort is provided to enable dying patients to approach death in a peaceful way

9. History of Hospice 1905 St. Joseph ’s, London 1967 St. Christopher ’s, London 1969 Elisabeth Kubler -Ross ( On Death and Dying ) 1974 New Haven Hospice of CT 1978 National Hospice Organization — now called the National Hospice & Palliative Care Organization (NHPCO) 1979 First state hospice licensure law 1982 Congress enacts Medicare hospice benefit

10. Hospice Facts Question #1 What are some of the most common misconceptions you ’ ve heard from providers and families about hospice?

11. Hospice Misconceptions Hospice is a place Someone dies right away Hospice is for those who are in their last days of life Hospice/palliative care means “ doing nothing ” All treatments are discontinued

12. What is Hospice? Affirms life Regards dying as a normal process Focus is on the patient ’ s physical, spiritual, emotional and social needs Neither hastens nor postpones death Expert medical care, pain management and emotional/spiritual support The belief that each person has the right to die pain-free and with dignity

13. Hospice Interdisciplinary Team Photo retrieved May 2, 2013 from:http :// www.hospicebr.org /s3web/1001964/Images/1001964interdisciplinaryteamdiagram.jpg The plan of care is determined by the patient & caregiver Hospice care is focused on their needs and quality of life

14. Palliative Care Palliative care means patient- and family-centered care that optimizes quality of life by anticipating, preventing and treating suffering Palliative care should be given throughout the continuum of illness and involve management of physical, intellectual, emotional, social and spiritual needs and facilitate patient autonomy, access to information and choice 73 FR 32204, June 5, 2008 Medicare Hospice Conditions of Participation – Final RuleV Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.

15. Hospice. A Type of Palliative Care The aggressive treatment of physical, social and emotional pain & symptoms at the end of life An active treatment plan, not intended to cure the disease Palliative treatment focuses on enhancing a patient ’s comfort and overall quality of life Palliative care redirects energy Patient and family drive the plan of care and decide what is important to accomplish Focus can be on physical, psychosocial or spiritual – or all three

16. Palliative Care Improves Quality and Reduces Costs Hospice programs demonstrate high patient satisfaction and quality of care for terminally ill patients A 2012 study found that 96% of physicians supported palliative care Research out of Mount Sinai’s Icahn School of Medicine, published in the March 2013 issue of Health Affairs, found that hospice enrollment saves money for Medicare and improves care quality for Medicare beneficiaries across a number of different lengths of service.

17. Palliative Care Improves Quality and Reduces Costs Medicare costs for hospice patients were lower than non-hospice Medicare beneficiaries with similar diagnoses and patient profiles Hospice enrollment is associated with fewer 30-day hospital readmissions and in-hospital deaths Hospice enrollment is associated with significantly fewer hospital and ICU days

18. Palliative Care Improves Quality and Reduces Costs (Cont.) However 42% of MDs expressed concern that emphasizing palliative care could interfere with treatment aimed at extending lives 25% of MDs were reluctant to recommend because patients may perceive they are not doing everything possible to extend their lives

19. Curative vs. Palliative Care Curative Treatment Disease driven Doctor in charge Disease process is primary focus Few choices Palliative Care Symptom driven Patient is in charge Disease process is secondary to person Many choices Comfort & quality of life

20. What Do Patients With Serious Illness 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 Hospice Management Advisor, 2011

21. Hospice Facts Question #2 What percentage of Medicare patients started a new course of chemotherapy within two weeks of their death?

22. How Long Should Aggressive Treatment Continue? More than 20% of Medicare patients who have advanced cancer start a new chemotherapy regimen two weeks before they die Only 37% of MDs told patients how long they had to live, even when patients asked for the information Patients frequently learn more about their prognosis from other patients in the waiting room than from their doctors, authors say Journal of the American Medical Association (2008).

23. Hospice Facts Question #3 What percentage of hospice admissions were of a minority race?

24. Hospice Facts – 2015 (NHPCO) Answer : Only 13.2% of hospice admissions were of a minority race in 2015 This is down from 17.2% between 2010 and 2011 Race Percentage Caucasian 86.8% African American 8.2% Hispanic 2.0% Asian 1.2% Other 1.0% Native American 0.4% Unknown 0.3% NHPCO Facts and Figures 2016

25. Example African-Americans ’ underutilization of hospice services Stronger preference for “aggressive care” Lack of knowledge about hospice Religious/hope factors Mistrust of healthcare system National Hospice and Palliative Care Organization, 2012

26. Hospice use among minorities Racial and ethnic minorities continue to enroll in hospice at lower rates than whites Racial and ethnic minorities receiving end-of-life care were less likely to have advanced care planning documentation in place, even after enrolling in hospice Only one in five patients are of a minority race Cancer diagnoses account for less than half of all hospice admissions (27.7%) 1/3 of all deaths in the US were under the care of a hospice program (1.65 million) 44.6% of all deaths in the US were under the care of a hospice program “ The greatest challenge is having honest conversations with patients and their families so we can bring the appropriate resources to bear.” National Hospice and Palliative Care Organization, 2016 Medicare Hospice Payment Reform: A Review of the Literature, 2015 Update

27. Hospice Facts Question #4 What is the average length of service for hospice patients?

28. Answer The average length of service (ALOS) for Medicare patients is 69.5 days However, the median length of service in 2015 was only 23 days This means that half of hospice patients received care for just over three weeks and half received care for more than three weeks National Hospice and Palliative Care Organization, 2016

29. Hospice Facts Question #5 What percentage of patients died or were discharged in seven days or less of service?

30. Answer 30% of hospice patients were enrolled in seven days or less in 2015 National Hospice and Palliative Care Organization, 2016

31. Hospice Facts Question #6 How many patients died or were discharged 180 days or more after admission to hospice?

32. Answer: 11.5% of patients died or were discharged 180 days or more after hospice admission National Hospice and Palliative Care Organization, 2013

33. Short and Long Lengths of Hospice Services Experts agree that hospice patients gain the full benefit of hospice when provided for at least three months National Hospice and Palliative Care Organization, 2016 Figure 3. Proportion of Patients By Days of Care In 2015

34. Hospice Reduces Medicare Healthcare Costs Hospice services save money for Medicare and bring quality care to patients with life-limiting illness and their families Duke University : Hospice reduced Medicare costs by an average of $2,309 per hospice patient Reduced costs for seven out of 10 hospice recipients if hospice has been used for a longer period of time Taylor DH Jr , Ostermann J, Van Houtven CH, Tulsky JA, Steinhauser K. What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Soc Sci Med. 2007 Oct;65(7):1466-78.

35. Patients on Hospice Live Longer Recent study of 4,493 patients with CHF or cancer of breast, colon, lung, prostate or pancreas Mean survival was 29 days longer with hospice care than those who did not choose hospice Connor ST, Pyenson B, Fitch K, Spence C, Iwasaki K. Comparing hospice and non-hospice patient survival among patients who die within a three-year window. Journal of Pain and Symptom Management. 2007 Mar; 33(3):238–46

36. Question Break

37. Medicare Hospice Benefit Part A Medicare Benefit Terminal illness Certified by two physicians Comfort and caring, not cure Covers 100% of costs related to the terminal prognosis Unlimited election periods if criteria met for recertification (prognosis less than 6 months or less if the illness runs its normal course)

38. Hospice Certification and Recertification Divided into distinct periods Two benefit periods of 90 days each Followed by unlimited number 60 day benefit periods Prior to the start of any new benefit period the hospice team is required to recertify the patient ’s terminal prognosis

39. Medicare Hospice Benefit: Service Components Medical direction and physician participation in the development of the plan of care Expert pain and symptom management 24/7 Medications, DME, medical supplies related to terminal prognosis Dietary counseling, speech, physical and occupational therapy as indicated for palliation Education/support of family/caregivers Bereavement services for up to 13 months

40. Presenting the Hospice Benefit What challenges do you face when you present hospice as an option? Have there been difficult responses with the member or their family? Has the physician explained the terminal illness before you talk to the member?

41. Hospice Interdisciplinary Team Attending physician Hospice physician Nurse (RN & LPN) Social worker Chaplain/clergy Hospice aide Trained volunteer

42. When is it Time to Consider Hospice? Would I be surprised if this patient died in the next six months?

43. Eligibility Criteria: General Patient preferences Patient ’s personal goals palliation over life Burden of treatment vs. potential benefit Changes in functional status Unable to do IADLs and some difficulty in self-care that is progressive (non-cancer patients) Unintentional weight loss > 10% of normal body weight in 6 months Body Mass Index (BMI) < 22 kg/m2 Kinzbrunner , Barry 20 Common Problems in End-of-Life Care ( Ch 1) New York, McGraw Hill, 2011

44. A Little More on Weight Loss and Poor Prognosis Two studies demonstrate the importance of weight loss as a key determinant of poor prognosis First study looked at 24 of 153 LTC residents who lost 5% weight in 1 month They were 5 times more likely to die in the ensuing year Another prospective evaluation looked at 91 patients in an outpatient setting with 5 % weight loss in last 6 months 35% had no identifiable cause Those with 25% of weight loss patients had died over the ensuing year

45. General Criteria: Clinical Progression of Disease Increased utilization of health care resources Multiple hospitalizations ED visits Other health care services Disease progression Serial physician assessments Laboratory or diagnostic studies Changes in MDS in LTC facilities Decline identified by home health care provider Kinzbrunner , Barry 20 Common Problems in End-of-Life Care ( Ch 1) New York, McGraw Hill, 2011

46. End-of-Life Symptoms Pain Shortness of breath Delirium Nausea and vomiting Fatigue or poor energy, spending more time in bed Swallowing difficulty Increasing falls Withdrawn Increasing confused Progressive decline despite use of curative medical therapies

47. Terminal Diagnosis: Examples Cancer End stage non-cancer diseases: Alzheimer ’s disease/dementia Heart disease Lung/respiratory disease Kidney disease Liver disease Stroke AIDS-related diseases

48. Medicare Hospice Benefit Four Levels of Care Routine Home Care Continuous Care Inpatient Care Respite Care

49. Hospice: Routine Home Care Most frequently delivered level of care Proactive plan of care Frequency of visits by the care team is determined by the needs of the patient

50. Hospice: Continuous Care Goal: To avoid a hospitalization Indicated during a period of crisis Patient desires to stay at home, but requires more intensive medical care Minimum of eight hours of care per day; > 50% must be provided by a nurse Reimbursement is hourly — based on the number of actual hours of care Examples: Uncontrolled pain, dyspnea, bleeding, change in level of consciousness, nausea/vomiting

51. Hospice: General Inpatient Care Goal: acute symptom management when issues cannot be controlled in the home setting Pain, nausea/vomiting, agitation, seizure, dyspnea , bleeding, wound care, etc Care may be provided in: Free-standing units Leased wing of hospital/LTC facility Contract beds Requires RN coverage 24hr a day

52. Hospice: Respite Care Goal: Short-term inpatient care provided to relieve the patient ’ s caregiver Must be provided by a hospice, hospital, skilled nursing facility or intermediate care facility staffed with a 24-hour RN Respite care may be provided only on an occasional basis and may not be reimbursed for more than five consecutive days at a time

53. The Value of Hospice Think about which hospice benefit is most important to your members? Care delivered in their home Management of pain and symptoms Ability to stay at home and out of the hospital or nursing home Coverage of medications and medical needs related to the terminal condition Additional caregiver support Spiritual care

54. Hospice Facts Question #7 True or False? A DNR must be signed before a patient can be admitted to hospice

55. Answer False However, the hospice team will educate, provide counseling and clarify end-of-life decisions with the patient and family

56. Considerations when choosing a quality hospice provider Rapid response time; same day admission Direct access to clinicians 24/7 Ability to accept complicated cases & access to an ethics committee Routine care staffing and frequency of visits

57. Considerations when choosing a quality hospice provider (Cont.) Continuous care staffing Death attendance Bereavement counseling/support groups Quality and process improvement systems Robust clinical system and outcome reporting

58. Hospice Facts Question #8 What are the potential physician barriers to referral to palliative care and hospice?

59. Answer: A lack of physician comfort with EOL conversations, including the fear of depriving patients of hope Fear or concern of “failing” patient Misperceptions about hospice Uncertainty about prognosis including a lack of familiarity with various prognostic tools

60. How Can You Make a Difference? Become an advocate for quality end-of-life care Consider your own beliefs about advanced illness and death Carry the tools that help you identify a terminal illness (consider more training in end-of-life care, disease trajectories and prognostic indicators, care planning/goals of care conversations, etc.) Evaluate the patient ’ s understanding of their condition Suggest an order evaluation for hospice care in your treatment options when speaking with the patient ’ s physician Ask yourself—what does the patient want and am I an advocate for his/her wishes?

61. For Additional Information: NHPCO National Hospice & Palliative Care Organization www.nhpco.org

62. For Additional Information: www.caringinfo.org Caring Connections is a national consumer and community engagement initiative to improve care at the end of life, supported by a grant from The Robert Wood Johnson Foundation State-specific documents for advance care planning are available

63. For Additional Information: Duke University Institute http:// www.iceol.duke.edu /

64. Questions, Comments?

65. References Adams, C. (2010). Dying with dignity in America: The transformational leadership of Florence Wald. Journal of Professional Nursing , 26 (2), 125-132. doi:10.1016/j.profnurs.2009.12.009 Brumley , R., Enguidanos , S., Jamison, P., Seitz, R., Morgenstern, N., Saito, S., & ... Gonzalez, J. (2007). Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. Journal of The American Geriatrics Society , 55 (7), 993-1000. doi:10.1111/j.1532-5415.2007.01234. Buck, J. (2011). Policy and the reformation of hospice: lessons from the past for the future of palliative care. Journal of Hospice & Palliative Nursing , 13 (6S), S35-43. doi:10.1097/NJH.0b013e3182331160 Campbell, C., Williams, I., & Orr, T. (2010). Factors that impact end-of-life decision making in African Americans with advanced cancer. Journal of Hospice & Palliative Nursing , 12 (4), 214-224. doi:10.1097/NJH.0b013e3181de1174 Casarett DJ, Quill TE. “I’m not ready for hospice”: strategies for timely and effective hospice discussions. Ann Intern Med. 2007;146(6):443-449. Christakis NA, Lamont EB. Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study. BMJ. 2000;320(7233):469-472. Connor, S., Pyenson , B., Fitch, K., Spence, C., & Iwasaki, K. (2007). Comparing hospice and non-hospice patient survival among patients who die within a three-year window. Journal of Pain & Symptom Management 33 (3), 238-246. Consider palliative care, hospice as options. (2012). Hospital Case Management , 20 (12), 175-177. Epstein, A. S., Volandes , A. E., & O'Reilly, E. M. (2011). Building on individual, State, and Federal initiatives foradvance care planning, an integral component of palliative and end-of-life cancer care. Journal of Oncology Practice,7 (6), 355-359. doi:10.1200/JOP.2011.000355

66. References (Cont.) Fletcher, D., & Panke , J. (2012). Improving Value in Healthcare: Opportunities and Challenges for Palliative CareProfessionals in the Age of Health Reform. Journal of Hospice & Palliative Nursing , 14 (7), 452-461. Howell, D., & Lutz, S. (2008). Hospice referral: An important responsibility of the oncologist. Journal of OncologyPractice , 4 (6), 303-304. Institute of Medicine. (2013). Committed on Transforming End-of-Life Care. Retrieved from http:// www.institute+of+medicine+report+on+end+of+life+care&rls =com.microsoft%3Aen-us&oe=UTF-8&startIndex=& startPage =1&oq=Institute+of+Medicine%2C+End&gs_l=heirloom- serp.1.7.0l2j0i22i30l7.5015.7703.0.12859.8.7.1.0.0.0.187.781.1j5.6.0...0.0...1ac.1.12.heirloom-serp.ucG-nWk-CRQ Jencks, S., Williams, M., & Coleman, E. (2009). Re-hospitalizations among patients in the Medicare fee-for- serviceprogram . New England Journal of Medicine , 360 (14), 1418-1428. doi:10.1056/NEJMsa0803563 Kinzbrunner , M., & Policzer , M. (2011). End-of-life care . (2nd ed.). New York, NY: McGraw Hill Medical Mack, J., Cronin, A., Keating, N., Taback , N., Huskamp , H., Malin , J., & ... Weeks, J. (2012). Associations between end-of-life discussion characteristics and care received near death: A prospective cohort study. Journal of ClinicalOncology , 30 (35), 4387-4395. doi:10.1200/JCO.2012.43.6055 Murray, M., Fiset , V., Young, S., & Kryworuchko , J. (2009). Where the dying live: A systematic review of determinants of place of end-of-life cancer care. Oncology Nursing Forum , 36 (1), 69-77. doi:10.1188/09.ONF.69-77

67. NHPCO Facts and Figures: Hospice Care in America . (2011). Alexandria, VA: National Hospice and Palliative Care Organization, 2012. Last accessed May 3, 2013.  Rogers, T. (2009). Hospice myths: what is hospice really about?. Pennsylvania Nurse , 64 (4), 4-8. Smedley , B., Stith , A., & Nelson, A. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care . Washington, D.C: The National Academies Press. Taylor, D., Ostermann , J., Van Houtven , C., Tulsky , J., & Steinhauser , K. (2007). What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Social Science & Medicine , 65 (7), 1466-1478. VITAS (2013). VITAS: About us. Retrieved from: http://www.vitas.com/Aboutus.aspx Wu, H., & Volker, D. L. (2012). Humanistic nursing theory: Application to hospice and palliative care. Journal of Advanced Nursing , 68 (2), 471-479. doi:10.1111/j.1365-2648.2011.05770.x References (Cont.)