Home to Roost Role of Hospice and Palliative Care In Helping Folks Age and Die at Home Greg Phelps MD MPH FAAHPM Chief Medical Officer Alleo Health/Hospice of Chattanooga Thursday, November 21, 2019 1:45 -2:45 Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
The Issues US vs the OECD Silos of Health Care • US Healthcare is disjointed, siloed, segmented with perverse incentives • Cost double ($10,224) average of OECD ($5280) • 18% of GDP • Worst in mortality in OECD • Worst in Maternal Mortality • 37th over all • 11K Baby Boomers hit 65 DAILY • Fastest Growing population is >85 Source Kaiser Foundation Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
Endangered Species?? 10 Hospitals in TN since 2012 Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
Health Care Challenges • Readmission penalties now up to 3% of Medicare for hospitals. Roughly 2,599 hospitals (>1/2) $566Million last year • Readmission Penalties for SNF (73% penalized in first year) • Readmission Penalties for Home Health which is cheaper but has 5.6% Higher rate of re-admissions than SNF. Jordan Rau, Medicare Eases Up on Readmissions Penalties for Hospitals Serving the Poor; NPR/Kaiser Health News. Sept 26 th , 2018 Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
Medicare Advantage Plans (MA) ~ 40% reduction in revenues “I’d rather take Medicaid than MA” “Medicare Advantage Plans use Significantly less PAC” Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
Rural Health an Uphill Fight in a Headwind • Rural Americans — who make up at least 15 to 20% of the U.S. population — face inequities that result in worse health care than that of urban and suburban residents • “When you don’t get your health care taken care of, you wind up with disease presentations that are much farther along. People with cancer show up with metastatic cancer, people with diabetes show up with end- organ damage” • Joseph Florence, MD, professor of family medicine and director of rural programs at Eastern Tennessee State University Quillen College of Medicine Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
Risk Factors for People in the Rural South • Older than the population as a whole • Poorer, lower education and income • Greater distance to health care • More likely to have risk factors such as smoking, obesity, opioid use • Lower rates of insurance • Greater prevalence of top five fatal illnesses • Higher infant mortality • Lower access to primary care 55.1/100,00 vs 79.3/100,00 urban • Death Rate 830.5/100,000 vs 704.3/100,000 urban Robin Warshaw, Health Disparities Affect Millions in Rural US Communities, AAMC News Oct 31, 2017 Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
Doing the same thing over and over and expecting different results is the definition of Insanity On average, patients make 29 visits to the doctor’s office in their last six months. In their last month alone, half of Medicare patients go to an emergency department, one- third are admitted to an I.C.U., and one-fifth will have surgery — even though 80 percent of patients say they hope to avoid hospitalization and intensive care at the end of life. Medicare spending for patients in the last year of life (5% of Medicare) is six times what it is for other patients, and accounts for a quarter of the total Medicare budget — a proportion that has remained essentially unchanged for the past three decades. It’s not clear all that care improves how long or how well people live. Patients receiving aggressive medical care at the end of life don’t seem to live any longer , and some work suggests a less aggressive approach buys more time. Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
Two interventions have been show to slow the Insanity • Palliative Care Services: Specialists in Hospice and Palliative Medicine that focus On the “Three Cs” - Comfort, Communication and Coordination • Advanced Care Planning: Patients who engage in advance care planning are less likely to die in the hospital or to receive futile intensive care. Family members have fewer concerns and experience less emotional trauma if they have the opportunity to talk about their loved one’s wishes. And earlier access to palliative care has consistently been linked to fewer symptoms, less distress, better quality of life — and sometimes longer lives. Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
The Hasting Center Guidelines for Decisions on Life Sustaining Treatment and Care Near the End of Life • ….patients will benefit from health care leaders who see end of life care as part of health care rather than a failure of health care… (p 23) • “There are powerful incentives for hospitals to define care in terms of reimbursable treatment interventions and diagnostic testing to prioritize quantity over quality and set lower value on …services that are non-income generating. These incentives have a large role in shaping the delivery of end-of- life care.” (p29) Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
Hippocrates "To impose treatment on the patient overmastered by disease is to display an ignorance akin to madness.” Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
Getting to What Matters “I learned a lot of things in medical school but mortality wasn’t one of them… our textbooks had almost nothing on aging or frailty or dying.” Also see: “Letting Go What Medicine Should Do When it Can’t Save Your life” By Atul Gawande, MD New Yorker, Aug 10 th 2010 Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
There is Never, Ever “Nothing Else We Can Do…Ever!” “Cure Sometimes, Treat often, Comfort Always.” Hippocrates Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
How Do I Sleep at Night? A True Story….. • Better quality of care • Better communication • Less suffering • Lower costs • Fewer re-admissions Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
Palliative Care …is specialized medical care for people with serious illnesses . This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness – whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient’s other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment. Three Cs - Comfort, Communication, Coordination Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
A New Paradigm If we keep doing what we’re doing, we’ll keep getting what we’re getting Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
Curative and Palliative Models Curative Palliative • • Primary Goal is cure Primary Goal is relieving suffering • • Object of treatment is the disease Object of treatment is the patient and family • • Symptoms treated primarily as clues to Distressing symptoms are entities diagnosis themselves • • Primary value placed on measurable data Subjective and measurable data valued such as labs and tests • This model values patient experience as an • This model tends to devalue data that is illness subjective, immeasurable or unverifiable • Therapy indicated if it controls symptoms for • Therapy indicated if it eradicates disease or relieves suffering slows progression. • Patient is viewed as complex being with • Patient’s body differentiated from mind. physical emotional social and spiritual dimensions • Patient viewed as collection of parts so there • is little need to get to know the whole Treatment congruent with values and beliefs person. and concerns of patient and family • • Death is the ultimate failure Enabling a patient to live fully and comfortably until he or she dies is a success Unipac 1: Characteristics of Curative vs Palliative Care Models Page 8. 2003 Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
The Difference Between Hospice and Palliative Care Hospice is an insurance benefit, Palliative Care is a treatment philosophy Palliative Care : Can be engaged in life threatening illness much earlier in acute care when curative treatment still on-going. Hospice: A 1982 Medicare benefit. For Palliative Care Hospice last six months of life. Usually home or residential based. Used when curative care is no longer pursued. Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
Smaller Rural Hospitals Less Likely To Have PC services Center for the Advancement of Palliative Care- CAPC.org Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
Tennessee ranks B- at 61.7% of Hospitals with Palliative Care Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
Everyone is entitled to SOME Palliative Care G r i e f c a r e Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM
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