Man­ag­ing care be­tween home and hospice

Modern Healthcare - - NEWS - By Steven Ross John­son

They call it the gray zone—the grad­ual de­te­ri­o­ra­tion of health ex­pe­ri­enced by many frail and chron­i­cally ill el­derly peo­ple, the con­di­tion that lies be­tween treat­able dis­ease and ter­mi­nal ill­ness.

More than a decade ago, Sut­ter Health rec­og­nized that ag­gres­sively treat­ing such pa­tients as their ill­nesses pro­gressed raised trou­bling qual­ity-oflife and cost is­sues.

“There was this fre­quency with which pa­tients with ad­vanc­ing ill­ness would come back to the emer­gency depart­ment or hos­pi­tal for symp­toms that seemed like they should be able to man­age at home,” Sut­ter Health Chief Hospice Ex­ec­u­tive Betsy Gor­net said.

Such pa­tients rep­re­sent a dis­pro­por­tion­ate share of Medi­care spend­ing.

El­derly pa­tients with four or more chronic con­di­tions rep­re­sented about 14% of Medi­care ben­e­fi­cia­ries in 2010, but ac­counted for 70% of the 1.9 mil­lion hos­pi­tal read­mis­sions, ac­cord­ing to a 2012 CMS re­port. Nearly two-thirds of pa­tients did not re­ceive any home health­care vis­its that year, and hospice care re­mained un­der­uti­lized.

But when should providers switch from treat­ment to hospice, or even be­gin to dial back on the tests, drugs and pro­ce­dures they pre­scribe for the frail el­derly?

“This pop­u­la­tion is in the gray zone be­tween treat­able and ter­mi­nal, and that gray zone is ex­pand­ing re­ally rapidly,” said Dr. Brad Stu­art, for­mer se­nior med­i­cal di­rec­tor of Sut­ter Vis­it­ing Nurse As­so­ci­a­tion and Hospice.

“In that gray zone, it’s of­ten not ap­pro­pri­ate to just stop treat­ment and go straight to hospice,” he said. “But at the same time, it’s also not ap­pro­pri­ate to just throw the whole nine yards of treat­ment at every­body ev­ery time, which is what we tend to do in tra­di­tional care.”

Stu­art was in­stru­men­tal in help­ing Sut­ter de­velop its Ad­vanced Ill­ness Man­age­ment (AIM) pro­gram, an in­te­grated de­liv­ery model that ad­vises pa­tients and their fam­i­lies on how to make the tran­si­tion to hospice while still de­liv­er­ing de­sired health­care ser­vices in a home set­ting.

The pro­gram be­gins with a team of staffers con­sist­ing of home health and hospice nurses, physi­cians and so­cial work­ers ask­ing pa­tients about their treat­ment.

Those tar­geted for en­try into the pro­gram are usu­ally chron­i­cally ill pa­tients who have the pos­si­bil­ity of dy­ing within a year and have yet not cho­sen to en­ter hospice.

Once pa­tients have been iden­ti­fied, AIM staff works on a plan for the next steps in man­ag­ing their care. AIM’s goal is to co­or­di­nate care for th­ese pa­tients be­fore they reach the ter­mi­nal stage to smooth the tran­si­tion into hospice.

Even­tu­ally, the fo­cus of treat­ment shifts from ad­min­is­ter­ing acute pro­ce­dures to pro­vid­ing more pal­lia­tive care. AIM staff also helps pa­tients de­velop ad­vance di­rec­tives. As pa­tients get sicker, the team helps them move into hospice.

Sut­ter ex­panded the pi­lot after early re­sults showed the rate at which AIM pa­tients en­tered hospice was 47% com­pared with 20% among non-AIM pa­tients, ac­cord­ing to a 2006 study pub­lished in the Jour­nal of Pal­lia­tive Medicine. A few years later, Sut­ter be­gan in­vest­ing $ 21.4 mil­lion into a sys­tem- wide roll­out of AIM, which was helped along with a $13 mil­lion grant in 2012 from the CMS In­no­va­tion Cen­ter. The AIM model now serves 79% of Sut­ter’s ser­vice ter­ri­tory: The pro­gram is in 14 out of 19 coun­ties treat­ing an av­er­age of 1,200 pa­tients a day.

The pro­gram faces chal­lenges, how­ever. The cur­rent fee-for-ser­vice pay­ment model used by pri­vate and pub­lic pay­ers does not re­im­burse for all of the ser­vices AIM pro­vides.

For ex­am­ple, while the Medi­care­cer­ti­fied home health­care ser­vice is re­im­bursed, any tran­si­tional care pro­vided to a pa­tient to en­able en­ter­ing hospice is not re­im­bursed.

It also sharply re­duces rev­enue by re­duc­ing hos­pi­tal ad­mis­sions, which has turned AIM into a money-loser for the sys­tem.

“The rate of the spread of the pro­gram will be in di­rect pro­por­tion to the rate that our sys­tem con­verts from fee-for-ser­vice to­ward ac­count­able care,” Stu­art said. “The quicker that tran­si­tion hap­pens, the quicker this (kind of) pro­gram will grow,” he said.

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