The Current Paradigm
Traditional Medicare/Medicaid hospice benefit provides reimbursement
for care to patients with a life limiting illness.
- Most patients wait until the last weeks of life to enroll in hospice
- Most physicians wait until they have exhausted all other options
- In other hospice programs, most patients never see a physician after enrolling in hospice
- Patients fear they will not receive enough medical care under hospice
- Nevertheless, patients are, for the most part, very satisfied with their hospice experience
- For some patients, however, "It's not hospice; it’s last rites."
- Patients must choose between aggressive care or end of life care.
- Each institution does it differently, however:
- This makes it difficult to evaluate in a standardized fashion
- Nevertheless, this system gets good grades and raises the bar for the American health care system
Methodology
Open Access
- A paradigm shift
- Each institution does it differently
- Hospice of Palm Beach County is a non-profit institution with an average daily census (ADC) of 1,100 patients
- Economy of scales
- Ability to spread risk
- Strong support from Board of Directors
Complex Case Management: The Palliative Care Fund
Complex Case Management is our means to provide palliative care to patients not willing to let go. Implemented 2005, funds were set aside as Palliative Care Fund:
- It allowed us to admit patients who were within the six month "terminal" umbrella but were receiving disease modifying therapy
- Treatment may alter prognosis but not outcome
- We were able to provide high level care to indigent patients who would otherwise receive no care
How we got here
- Institutional "Paradigm Shift"
- Staff, who were used to a more traditional approach to hospice care, had to be re-educated
- Strong internal education program
- Hired full-time physicians to serve as team Medical Directors
- 19 FTE
- 11 PTE and Independent Contractors
- Encouraged doctors to teach and do clinical research
- Encouraged doctors to pursue Board Certification
How do we decide?
- What did we promise at enrollment?
- We never want to bait and switch
- Is the treatment related to the terminal diagnosis?
- Does it work?
- What do the physicians involved say?
- What does the medical literature say?
- What is the palliative goal?
- Symptom control
- Improved quality of life
- More time; non-curative
- Family palliation – is patient in agreement?
- Cost is only evaluated after these questions are answered
How do we evaluate?
- Has treatment helped?
- Is treatment burdensome?
- Will another less burdensome intervention provide comfort?
- Does patient and family understand benefits and burdens?
- Team members monitor and educate patient and family on an on-going basis
- Document care plan issues in order to ensure consistency of message by all members of team
- Team members monitor and educate patient and family on an on-going basis
Results
Palliative Care Fund Use
| 2005-2006 | $ 965,000 |
| 2006-2007 | $ 1,370,056 |
| 2007-2008 | $ 1,498,731 |
| 2008-2009 | Anticipate a 10% increase from 2007-2008 |
Patients Served
Admissions 2007-2008:
Over 6,039- Number of patients receiving complex palliation: 591(9.7%)
- 40% were younger than 65
- 25% African-American and Latino
- 6% Indigent
- Average cost of complex palliative care per patient:
$2,536
Conclusion
Open Access is not the cure-all but, until Medicare and Medicaid change their reimbursement structure, it is a Sanctuary for a segment of the population who are already facing very difficult choices.
Challenges and opportunities include:
- Patients and physicians perceive us as a "payer"
- Sometimes refer non-terminally ill patients
- Very delicate balance between what "we" think is appropriate and what treating physician sometimes recommends
- Threat of revocation
- Community physicians lump us in with other institutions that are not involved in Complex Case Management
- Rising cost of medications
- ESA's single costliest item
- Intervention to educate team doctors in proper prescription
- ESA's single costliest item
- Oncologists see most chemo as palliative
- Team physicians are uncomfortable with being perceived as "questioning" referring colleagues.
- While they are experts in Palliative Medicine, they are not Oncologists, pulmonologists, cardiologists, etc..
- Do not want to be seen as doing UR
- Do not wish to bite the hand that feeds them