The Social Context. If you are young and thin, you will be happy and live forever! (Assuming you have an iphone )

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Cooper Linton, MSHA, MBA VP Marketing and Business Development

Improving Care Transitions

through Better Use of Palliative

Care Resources

The Social Context

Forget the 2.3 kids and the white, picket

fence, the REAL American Dream is…

If you are young and thin, you will be happy and live forever!

(Assuming you have an iPhone…)

Death is just as natural as


(Well it sure doesn t feel like it…)

•  This morning, after losing a courageous 9-month battle with pregnancy, Suzy delivered a baby.

•  We used to die at home with our loved ones with pastors and friends as the midwives of death. According to surveys, we overwhelmingly still want to.

•  But we don t. Most of us die in a healthcare facility.


How do you think you will die?

Facts from 2.5 Million U.S. Death (2010 Statistics)

•  Bear Attack (1) •  Shark Attack (2) •  Hit by Lightning (62) •  Electrocution (500) •  Airplane Crash (941) •  Hit by a Car (1,100) •  Firearm Discharge (1,150) •  Choking (3,200)

How Do Most




> 90% from Predictable Chronic Illness

(about 38% will get Hospice care)

aka Brain Failure


The Boring Stuff

aka Origins of the Word

§  Palliate: to relieve or lessen without curing; to mitigate or alleviate

§  Pallium: a cloak: In palliative medicine, we intend to cloak the patient in comfort.

Palliative Care

(more boring stuff)

Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with

life-threatening illness, through the prevention

and relief of suffering by means of early

identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

World Health Organization (emphasis added)

We Need to Separate

Palliative Care from Hospice

•  All hospice is palliative care. •  Not all palliative care is hospice

or leads to hospice. •  Palliative care is a valuable

resource for managing patient care and outcome with or without hospice services.


End-of-Life Care is

Not Just Hospice

§  Not every terminal patient wants or qualifies for hospice

§  We have to broaden our discuss beyond that less than 6 months thing

§  Some patients want curative care to the end §  Hospice usually interrupts Medicare skilled

days in a SNF

§  Palliative care can help patients navigate changes in their disease trajectory

Palliative Care vs. Hospice

Palliative Care

•  Palliative care can be concurrent with curative care

•  Patient doesn t have to be dying

•  Paid under Medicare Part B; 20% co-pay •  Best quality of life


•  Comfort care only

•  Patient MUST be terminal & accepts mortality •  Paid under Medicare

Part A; 100% •  Best quality of living

and dying

Example Components of

Continuum of Care

•  Home Health Care: Medicare-certified home health to help manage transitions •  Physician Practice Palliative Care:

medical practice sometimes with mobile staff

•  Hospice: Medicare-certified hospice offering a full palliative spectrum of care


Example of Palliative Care Continuum

The Who and Where

of Palliative Care

Who •  Physicians and Nurse Practitioners (billable) •  Social worker

(usually not billable)

•  Registered Nurse (not billable) Where •  Hospitals •  Skilled Facilities •  Assisted Living Facilities •  Private residences

Primary Reasons WHY We Get

Palliative Care Referrals

1)  Pain & Symptom Management (36%) 2)  End-of-Life Decision Making (34%)

3)  Goals of Care (21%)

4)  Patient/Family Support ( 7%)

§  Family conflicts about medical decision-making §  Assistance with advance care planning

§  Patient has a terminal diagnosis and is not ready for hospice §  Assistance with complex medical decision-making §  Continuing palliative care which was started in the hospital


What Happens During a

Palliative Care Consultation?

§  Comprehensive assessment and development of plan to manage physical symptoms

§  Assistance to identify personal goals and to process related decisions

§  Assessment of psychological and spiritual needs §  Assessment of support systems

§  Assessment and communication of estimated


§  Coordination with other medical providers

Some Key Decision Points

in Palliative Care

§  The balance between quality and quantity of life §  Symptom management and therapeutics §  Help determine appropriateness of diagnostic


§  Assist with determining appropriateness of: §  Nutritional/Fluid intervention and feeding tubes §  Antibiotics, radiation or chemotherapy therapy §  Transfusions and use of biologicals

§  Withholding or withdrawal of life support §  CPR/DNR/AND/MOST

§  Assessment of when Hospice is appropriate

The Benefits to the Patient

and their Family

For patients & families, palliative care is a key to: §  Relieve symptom distress – less stress on pt/family §  Navigate a complex and confusing medical system §  Understand the plan of care

§  Help coordinate care options

§  Allow simultaneous palliation of suffering along with continued disease modifying treatments (no requirement to give up curative care)

§  Provide practical and emotional support for exhausted family caregivers including bereavement care.


The Benefits to Clinicians

For clinicians, palliative care is a key tool to: §  Save time by helping to handle repeated, intensive

patient-family communications, coordination of care across settings, comprehensive discharge planning

§  Bedside management of pain and distress of highly symptomatic and complex cases, 24/7, thus supporting the treatment plan of the primary physician

§  Promote patient and family satisfaction with the reduction in patient suffering and hence the clinician s quality of care

Nut and Bolts of Palliative Care

Can be used with Medicare Home Health and SNF Skilled Days with no interruption of care or payment!!! §  Paid under Medicare Part B (80/20)

§  It s like consulting any other subspecialty, e.g., cardiology, podiatry

§  Billing and payments through the physician practice §  No contract is necessary in ALFs or SNFs §  Can accompany curative therapeutic efforts §  Patient may move from palliative care to full hospice

care at appropriate time

Transitional Risk Points for Care

•  Changes in:

–  The Who of Care (changes in medical staff)

–  The What of Care (levels and/or types of care)

–  The Where of Care (changes in setting of care)


Changes in the Who of Care

•  Palliative care physicians can help pass the baton between providers.

•  PCP to hospitalist

•  Hospitalist to rehab/SNF Medical Director

•  Rounding physician at ALF •  Return to PCP

Changes in What Type of Care

•  Palliative care can help clarify the goals involving different types of care.

•  Intensive care •  Medical Surgical

•  Medicare skilled rehab days •  SNF long term care days •  Home health

Changes in the Where of Care

•  Palliative care can help bridge the transitions between locations of care. •  Hospital to home

•  Hospital to Rehab/SNF •  Rehab/SNF to ALF •  SNF to home health


Palliative Care Should

Adapt to Settings of Care

•  Hospitals

•  Nursing Homes (SNFs)

•  Assisted Living Facilities (ALFs) •  Private home

In Hospitals

•  Less pain/symptom management •  More goal setting and decision making •  Compassionate truth telling

In Nursing Homes

•  More pain and symptom management •  More coordination of care

•  Advanced care planning

•  MDS scores can be used to trigger palliative care consults


Residential Palliative Care

•  Assisted living setting or private home •  Usually dealing with patient s PCP and

community specialist

•  Navigation of family dynamics

•  Home health OBQI scores can be used to trigger palliative care consults •  ALFs: Important to understand issues

related to adult care home regs

Palliative Home Health

•  Some home health programs have a bridge program. (Where does the bridge go to?) As an example, 50% of our home health patients are also in our palliative care program

•  These tend to be nursing heavy with therapies available

•  We utilize a hospice on-call model to avoid unnecessary hospitalizations.

It won t keep you young, thin,

and beautiful, but it can help

•  With transition points in care delivery •  Reduce emergent care

•  Avoid unnecessary re-hospitalizations •  Achieve patient-defined goals.