Don’t deny the eco­nom­ics

Hospice and pal­lia­tive care are best for chronic ill­ness, con­trol­ling costs

Modern Healthcare - - OPINIONS COMMENTARY - Sally Adelus Sally Adelus is pres­i­dent and CEO of Hospice of the Val­ley, San Jose, Calif.

While change has been an ev­er­p­re­sent force in our na­tion’s health­care sys­tem, what we are see­ing now is a mon­u­men­tal trans­for­ma­tion in the way care will be pro­vided in the fu­ture. It’s an is­sue that is be­ing dis­cussed far and wide, from con­ver­sa­tions around the din­ner ta­ble to elec­tion-year speeches of can­di­dates and even among the jus­tices on the U.S. Supreme Court.

The essence of health­care re­form, of­ten dubbed Oba­macare, can be bro­ken down into three broad ar­eas—ex­pand­ing cov­er­age, con­trol­ling costs and im­prov­ing the de­liv­ery of care. One as­pect of our health­care sys­tem that has been un­der the prover­bial microscope is the man­age­ment of pa­tients with chronic ill­nesses. In­cluded in health re­form leg­is­la­tion are pro­posed penal­ties for hos­pi­tals that read­mit pa­tients with cer­tain chronic con­di­tions within 30 days.

Re­gard­less of the de­ci­sions, sig­nif­i­cant change must hap­pen in the way we care for pa­tients with chronic con­di­tions to best meet their needs and sup­port their care­givers. Sta­tis­tics from the Dart­mouth At­las of Health Care il­lus­trate the need. Ap­prox­i­mately 90 mil­lion Amer­i­cans live with at least one chronic dis­ease. In New York City, the av­er­age per­son with a se­ri­ous ill­ness re­ceives care from 12 spe­cial­ists, with no one co­or­di­nat­ing care.

To bet­ter man­age pa­tients with chronic con­di­tions and re­duce mul­ti­ple hos­pi­tal­iza­tions and un­nec­es­sary vis­its to the ER, we must el­e­vate hospice and pal­lia­tive care within the over­all con­tin­uum of care. Along with ex­per­tise in pain and symp­tom man­age­ment for the pa­tient and emo­tional and spir­i­tual sup­port for the en­tire fam­ily, there is so much more to hospice and pal­lia­tive care. Hall­marks of hospice and pal­lia­tive care in­clude as­sis­tance nav­i­gat­ing our com­plex health­care sys­tem, help iden­ti­fy­ing re­sources in the community, guid­ance on treat­ment choices and care co­or­di­na­tion. The doc­tors, nurses and other spe­cial­ists who com­pose the team work with a pa­tient’s other doc­tors to pro­vide an ex­tra layer of sup­port.

As it stands now, our health­care sys­tem em­braces a dif­fer­ent per­spec­tive. Dr. Ira By­ock, di­rec­tor of pal­lia­tive medicine at Dart­mouth-Hitch­cock Med­i­cal Cen­ter in Le­banon, N.H., and pro­fes­sor of anes­the­si­ol­ogy and community and fam­ily medicine at

Now is the time for a rad­i­cal shift in the way we think about the con­tin­uum of care.

Dart­mouth Med­i­cal School, said, “We have a dis­ease-treat­ment sys­tem rather than a health­care sys­tem car­ing for hu­man be­ings.”

Our health­care sys­tem views hospice as if it’s a sep­a­rate en­tity, not an im­por­tant part of the care con­tin­uum. The phe­nom­e­nal ad­vances in med­i­cal tech­nol­ogy, treat­ments and med­i­ca­tions help pa­tients of all ages fight against heart and vas­cu­lar con­di­tions, can­cers and an ar­ray of de­bil­i­tat­ing con­di­tions. When one treat­ment fails, we try the next op­tion and then the next. This process con­tin­ues un­til there are no other op­tions. It’s at this point that pa­tients may come to hospice. More of­ten than not, pa­tients are re­ferred too late and are not given the chance to re­ceive the full range of ben­e­fits hospice pro­vides. In 2010, more than onethird of pa­tients re­ferred to hospice care died within seven days of ad­mis­sion.

Pal­lia­tive care, which can be pro­vided while a pa­tient seeks cu­ra­tive treat­ment, rarely is in­tro­duced by physi­cians or other mem­bers of a pa­tient’s health­care team. Re­search has shown that some physi­cians equate pal­lia­tive care with end-of-life care. As a re­sult, pa­tients don’t know the types of com­fort care and sup­port they could re­ceive to en­hance their qual­ity of life while they seek to cure their ill­ness. If the de­ci­sion is made to forgo cu­ra­tive care, pa­tients can tran­si­tion to hospice care to re­ceive sup­port, based on their goals, to en­hance qual­ity of life.

Aside from the ob­vi­ous ben­e­fit of pro­vid­ing care and sup­port from a team of health­care pro­fes­sion­als ded­i­cated to pain and symp­tom con­trol and emo­tional and spir­i­tual sup­port, you can’t deny the eco­nom­ics. A study con­ducted by Duke Univer­sity found that “hospice re­duced Medi­care spend­ing by an av­er­age of $2,309 per per­son com­pared to nor­mal care that of­ten in­cludes hos­pi­tal­iza­tion.” In ad­di­tion, the study found that longer use of hospice—months ver­sus days or even weeks— max­i­mized sav­ings to Medi­care.

Health­care ex­penses are re­duced be­cause of the man­ner in which hospice care is de­liv­ered, of­ten pro­vided where the pa­tient lives, whether that is a pri­vate res­i­dence, as­sist­edliv­ing fa­cil­ity or nurs­ing home. Nurses are avail­able 24 hours a day to an­swer ques­tions and co­or­di­nate care should a pa­tient’s con­di­tion change, which re­duces the need for vis­its to an emer­gency room. Study af­ter study has shown the ma­jor­ity of Amer­i­cans want to re­ceive end-of-life care at home. Yet, ac­cord­ing to the Cen­ters for Dis­ease Con­trol and Preven­tion, nearly half of all Amer­i­cans die in a hospi­tal.

Hospice and pal­lia­tive care are proven mod­els to man­age costs of care most ef­fi­ciently dur­ing a se­ri­ous ill­ness and at end of life. This is the time for a rad­i­cal shift in the way we think about the con­tin­uum of care. Rather than hospice and pal­lia­tive care be­ing con­sid­ered op­tions when “noth­ing more can be done,” these spe­cial­ized ar­eas of care and sup­port must be bet­ter in­te­grated throughout the care con­tin­uum. Do­ing so will bet­ter meet pa­tients’ needs, re­duce the mul­ti­ple hos­pi­tal­iza­tions and un­nec­es­sary vis­its to the emer­gency room, and thus con­trol costs of health­care.

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