April 25, 2014 T. Hanh Trinh, MD Associate Medical Director

1. April 25, 2014 T. Hanh Trinh, MD Associate Medical Director How Patients Arrive at Your Door: Palliative Medicine vs Hospice vs Aggressive End of Life Therapies

2. Objectives At the conclusion of this activity, participants will be able to: • Develop techniques to help patients and their families to validate their decisions at the end of life • Identify the dynamics that brought the patient to their current situation • Provide guidance for patients and their families as the patients' medical conditions decline.

3. Challenging Situation • A 60 yo patient with a CVA is referred to hospice, but the patient/family desire that he gets stronger. • You ask how they arrived at hospice, and they said they didn't get to talk to the doctor, and the next thing they knew, the patient was transferred to hospice. You ask what their goals are and find that they want to try physical and occupational therapy to build up the patient's strength. • Despite efforts of several members of the hospice team, the patient and family are dissatisfied with the care, and they revoke hospice to go back to the hospital.

4. The Big Picture Palliative Medicine • Symptom management • Spiritual support • Advanced Directives • Building a Legacy Aggressive End of Life Therapies • Dialysis • Transfusions • AICD/LVAD • Chemotherapy/XRT • Placement of • Trach • G-tube Hospice Prognosis of 6 months or less

5. Aggressive End of Life Therapies • Dialysis • Transfusions • AICD/LVAD • Chemotherapy/XRT • Placement of • Tracheostomy • G-tube

6. Who Makes the Decision? • Ultimately – it should be the patients/families • Physician's order • That attending physician may desire to participate in the care • Case manager • Overwhelming numbers of organizations • May have a “short” list of organizations that are provided to the patients/families • Requirements of the receiving institutions • SNF, LTAC, nursing home, hospice

7. How Do Patients/Families Choose Their Locations? • Hurdle: Getting patients/families the information they need to make informed decisions. • Patients/families will often go along with the physician's recommendations to continue or the discontinue therapies. • Guilt: They do not want to give up too early. • Family dynamics • Medical decision maker may be ready for comfort measures, but others may influence for further work-up and aggressive treatments. • Cultural influences • Patients and families want to make sure they are doing the right thing.

8. How Do Physicians Make Recommendations? • Based on the discussion with the patients/families • Based on physician's own values/ethical principles • Based on recommendations of other physicians/clinicians • Continuation of care at the receiving institution • Same physician may have privileges at both • Requirements of the receiving institutions • The patient ran out of Medicare days for SNF • The hospital physician recommended LTAC, but patient has Medicaid, so they could not go.

9. Where are the Possible Locations?From Hospital to... • Aggressive End of Life Therapies • Palliative Medicine • Hospital • LTAC • SNF • Home/Nursing Home/ALF • Hospice • Inpatient • Home/Nursing Home/ALF

10. Aggressive End of Life Therapies • Dialysis • Transfusions • AICD/LVAD • Chemotherapy/XRT • Placement of • Tracheostomy • G-tube

11. Palliative Medicine • Symptom management • Spiritual support • Advanced Directives • Building a Legacy

12. Where Is Palliative Medicine? • Hospital • Consult services • Units • LTAC • SNF • Home/Nursing Home/ALF

13. What is a Long Term Acute Care Hospital (LTCH)? • Step down from hospital • 24-hour facility • Average length of stay of 25 days or more • Based on diagnosis-related groups (DRG) • Can be admitted to LTCH from: • Hospital • Direct from home, if Medicare • Requires inpatient hospital work-up, if insurance

14. Requirements for Long Term Acute Care (LTCH) • Patient must have a skilled nursing need • IV antibiotics (3 or more) • Wound care • Ventilator weaning • TPN • Low-Intensity Rehabilitation • Patient must be insured by • Medicare • Private insurance • No Medicaid • No uninsured

15. Long Term Acute Care (LTCH) • Attending physicians see patients daily • A physician in-house at all times • May have multiple specialists • Pulmonary, Renal, Infectious disease, etc. • Respiratory therapist 24-hours • Lower intensity therapy • Physical therapy, Occupational therapy, Speech therapy

16. What is a Skilled Nursing Facility (SNF)? • Step down from hospital and LTCH • 24-hour facility • Located within a nursing home facility or hospital • Requires a 3-day inpatient hospitalization within the last 30 days prior to admission • Requires a pre-certification for Medicare patients

17. How is Cost for Skilled Nursing Facility (SNF) covered? • 1st 20 days paid 100% • Day 21-100 $147 copay • Discharged after 100th day • Requires 60 day wellness break, then patient can restart the 1st 20 days paid 100%, then Day 21-100 has a $147 copay, etc.

18. What are Medical Requirements for Skilled Nursing Facility (SNF)? • IV antibiotics (1-2 antibiotics, up to 3) • Wound care • Intense physical therapy • Physical therapy, occupational therapy, speech therapy • Up to 3 hours a day, up to 6 days a week • May require minimum nutritional intake • Placement of G-tube • TPN

19. Home • Pro's • Comfort of familiar surroundings • Access to patient's family and belongings • Con's • May require 24 hour caregiver • May be unsafe, after certain point in patient's decline • Concerns about end of life in the home

20. Nursing Home • 24 hour nursing care • Some nursing home may have policies requiring nutritional intake • G-tubes • Few can support tracheostomies • Financially draining • Medicaid nursing homes

21. Where are the Possible Locations?From Hospital to... • Aggressive End of Life Therapies • Palliative Medicine • Hospital • LTAC • SNF • Home/Nursing Home/ALF • Hospice • Inpatient • Home/Nursing Home/ALF

22. Medicare Hospice Benefit • 4 Levels of Hospice Care • Home Level of Care • Inpatient • Respite • Crisis Care

23. Common Misconceptions About Hospice • Misconception: As a result of solely the medications in hospice, patients sleep more. • Patients sleep more due to a combination of both the disease and medications, but the medications are meant for comfort, in the smallest dose necessary for symptom management. • Hospice tapers back medications to those that are necessary for comfort. • If the patient desires to continue some medications, it is possible to do so, but hospice may not be able to pay for these medications, because they are not part of the plan of care.

24. Common Misconceptions About Hospice • Misconception: Hospice hastens death. • The goal on hospice is to improve the quality of life. • Study supports that coming to hospice enables patients to live longer with higher quality of life. • Connor et al. Journal of Pain and Symptom Management. March 2007. 33(3): 238-246.

25. Common Misconceptions About Hospice • Misconception: Because patients are reaching the end of life, they will not receive the same quality of care. • Patients receive monitoring by the hospice team members, including nurses, aides, chaplains, social workers, and volunteers. • The support provides patients and families the comfort of having a higher level of monitoring and just as high, often higher quality of care.

26. Patient and Family Concerns • Desire to minimize symptoms that can arise from rapid medication changes • Desire to have patient be as alert as possible, since family may value patient's ability to communicate with them • Desire to understand the indications and administration of the medications

27. Medicare Hospice Benefit • 4 Levels of Hospice Care • Home Level of Care • Inpatient • Respite • Crisis Care

28. Medicare Hospice Benefit • Home Level of Care • Nurse visits 1-2 times a week • Aide visits 2-3 times a week • Chaplain, social worker, volunteer • Physician oversight • Nurse on-call available 24 hours a day • Durable medical equipment • Medications related to the hospice diagnosis

29. Medicare Hospice Benefit • Inpatient Level of Care • Nurse monitoring 24 hours a day • RN on site • Aide visits • Chaplain, social worker, volunteer • Physician oversight • Durable medical equipment • Medications related to the hospice diagnosis

30. Medicare Hospice Benefit • Respite • For family's benefit • Up to 5 days at a time • Nurse visits 1-2 times a week • Aide visits 2-3 times a week • Chaplain, social worker, volunteer • Physician oversight • Nurse on-call available 24 hours a day • Durable medical equipment • Medications related to the hospice diagnosis

31. Medicare Hospice Benefit • Crisis Care or Continuous Care • Crisis Care Nurse up to 24 hours a day • Nurse visits 1-2 times a week • Aide visits 2-3 times a week • Chaplain, social worker, volunteer • Physician oversight • Nurse on-call available 24 hours a day • Durable medical equipment • Medications related to the hospice diagnosis

32. What Some Hospices Can Provide • Parenteral fluids • Parenteral medications for comfort • Some in inpatient setting vs home setting

33. Patients May Have, But Hospice May Neither Provide Nor Manage • TPN • Intrathecal pump • Pacemaker • AICD: recommend discontinuing since this is no longer beneficial

34. Medicare Hospice Benefit • 4 Levels of Hospice Care • Home Level of Care • Inpatient • Respite • Crisis Care

35. How is the Decision Made About What Happens to the Patient? • Who makes the decisions? • Where are the possible locations? • When is the time to move? • What pressures are there?

36. When Is It Time to Move? • After hospitalization • Traumatic event • Functional decline • Medical intervention changes • Change in family support • When the patient is ready

37. Why Do We Say “Yes” to Admitting a Patient, When Our Gut Says “No”? • Patients/families are not ready to move, but external factors come into play. • Numbers of days Medicare reimburses according to DRG's runs out • If a patient remains or dies in the hospital, it contributes to hospital morbidity and mortality. • If a patient is re-admitted within 3 days of discharge, the hospital is obligated to absorb costs for that re-admission. (Hospitals don't like that.) • Pressures on the Admissions Departments to grow and increase numbers of patients

38. Result of Moving Before the Patients/Families are Ready • Patients/families may struggle with the patients' decline • Concern that there wasn't enough done yet • Symptoms can not be effectively controlled due to patients'/families' concerns about over-medication • Dissatisfaction with the care provided • Complicated bereavement

39. What Are the Key Questions? • What do the patients/families desire? • Will benefits outweigh the risks? • If you can not provide the services that the patients/families desire, how can you help them get where they need to go?

40. Facilitate the Needs of Patients/Families • Providing patients/families with the information they need to make an informed decision. • Support their decision • Follow Medicare guidelines

41. Favorable Encounter • A 60 yo patient with a CVA is referred to hospice, but the patient/family desire that he gets stronger. • You ask how they arrived at hospice, and they said they didn't get to talk to the doctor, and the next thing they knew, the patient was transferred to hospice. You ask what their goals are and find that they want to try physical, occupational, and speech therapy to build up the patient's strength. • The social worker contacts a SNF near the family's home to evaluate the patient, and it turns out that he is eligible. • The patient and family appear relieved that he can have a trial of therapy. They revoke hospice to pursue SNF. • 1 week later, they are referred back to you, but this time, they are more comfortable with the patient coming onto hospice. • The patient passes away peacefully with the family's support.

42. Summary At the conclusion of this activity, participants will be able to: • Develop techniques to help patients and their families to validate their decisions at the end of life • Identify the dynamics that brought the patient to their current situation • Provide guidance for patients and their families as the patients' medical conditions decline.

43. References Long Term Acute Care Hospitals http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/LongTermCareHospitalPPS/index.html?redirect=/longtermcarehospitalpps/02a_rtireports.asp . Accessed March 10, 2014. Medicare Hospice Benefits. http://www.medicare.gov/publications/pubs/pdf/02154.pdf Accessed March 12, 2014. NHPCO Facts and Figures: Hospice Care in America: http://www.nhpco.org/files/public/Statistics_Research/2013Facts_Figures.pdf. Accessed March 1, 2014. Palmetto GBA Hospice Rate Calculator. http://www.palmettogba.com/palmetto/calculators/hospicerate.nsf/calculator?OpenForm&Seq=3#_RefreshKW_Input2 . Accessed March 1, 2014. CMS Readmissions Reduction Program. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html Accessed March 3, 2014. Skilled Nursing Facilities http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ge101c05.pdf. Accessed March 11, 2014. Vignoroli et al. Journal of Palliative Medicine. February 2012. 15(2): 186-191.