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Enhancing Access, Quality, and Equity for Persons With Advanced Illness
- 1. Enhancing Access, Quality,and Equity for Persons With Advanced Illness
- 2. CME Provider Information SatisfactoryCompletion Learners must complete an evaluation form to receive a certificate of completion. You must participate in the entire activity as partial credit is not available. If you are seeking continuing education credit for a specialty not listed below, it is your responsibility to contact your licensing/certification board to determine course eligibility for your licensing/ certification requirement. Physicians In support of improving patient care, this activity has been planned and implemented by Amedco LLC and VITAS® Healthcare. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Credit Designation Statement – Amedco LLC designates this live activity for a maximum of 1.5 AMA PRA Category 1 CreditsTM . Physicians should claim only the credit commensurate with the extent of their participation in the activity. 2
- 3. CE Provider Information VITASHealthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through: VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved by: Florida Board of Nursing/Florida Board of Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy and Mental Health Counseling. VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists through: VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number: 139000207/RT CE Provider Number: 195000028/Approved by the Illinois Division of Profession Regulation for: Licensed Nursing Home Administrators and Illinois Respiratory Care Practitioners. VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2021-06/06/2024. Social workers completing this course receive 1.5 continuing education credits. VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of Registered Nursing, Provider Number 10517, expiring 01/31/2025. Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois. 3
- 4. Maite Hernandez, RN NationalDirector of Sales Training VITAS® Healthcare
- 5. Goal Panel experts willexamine various facets of healthcare access, equity, and inclusion as it relates to individuals in underserved communities who are coping with advanced illness. Based on their decades of experience in end-of-life care, as well as evidence-based data, panel members will also share strategies on how to mitigate current barriers to quality care, including ensuring patients are granted timely access to hospice and palliative services and that appropriate levels of care are provided. 5
- 6. • Identify underservedpopulations and discuss contributors that impact timely access to quality care at the end of life • Describe how care intensity can be tailored to the patient’s current level of medical and psychosocial needs • Explore opportunities to expand care access and promote care equity into daily practice through the case of a veteran Objectives 6
- 7.
- 8. Increased: • Emergency roomvisits • Hospitalizations • Skilled care and procedures • Other diagnostic tests • Cost to healthcare infrastructure Overmedicalized Care Near the End of Life 8
- 9. History of MedicareHospice Benefit 9 President Ronald Reagan signed into law the Medicare Hospice Benefit, which was capitated at the conservative rates, making hospice one of the original risk-assuming health entities. 1982
- 10. These services aremandated by the Medicare hospice benefit. Interdisciplinary Team of Hospice Professionals Home Medical Equipment Medication Bereavement Support Continuous Care Respite Care Routine Home Care Inpatient Care Medicare Hospice Benefit 10
- 11. Diagnoses Eligibility GuidelinesMedicare Hospice Benefit Other: • Sepsis and Post-Sepsis Syndrome • Renal Disease • Liver Disease (End-stage cirrhosis) • ALS (Lou Gehrig’s Disease) • AIDS Alzheimer’s/dementia and other neurological disease (chronic and acute stroke) Advanced Lung Disease (COPD and other forms of lung disease) Advanced Cardiac Disease (heart failure or other heart disease) Cancer 11
- 12. Courageous Conversations Are wewaiting too long to initiate goals of care conversations? At what point are we asking about the type of care they wish to receive or don’t wish to receive? Where do they wish to spend the last year or 6 months of life?
- 13. Recent Studies “There isgrowing evidence of disparities in access to hospice and palliative care services to varying degrees by socioeconomic groups.” Nelson KE, et al. Sociodemographic Disparities in Access to Hospice and Palliative Care: An Integrative Review. American Journal of Hospice and Palliative Medicine®. 2021;38(11):1378-1390. doi:10.1177/1049909120985419
- 14. Underserved Communities • Race •Ethnicity • Gender • Socioeconomic status • Religion • Level of education • Geographic location • Veteran status
- 15. Today’s Panelists 15 Joseph Shega,MD Chief Medical Officer B. David Blake, MD, DABFM Associate Medical Director Martin Escueta Regional Director of Admissions Ileana Leyva, MD Regional Medical Director Larry Hetu-Robert M.Div. Bereavement Services Manager/ Veteran Liaison
- 16. Joseph Shega, MD ChiefMedical Officer VITAS® Healthcare
- 17. Ongoing Demonstration ofHospice Quality Advantage to Patient, Families, and Caregivers Aldridge M., et al. (2022). Association between hospice enrollment and total health care costs for insurers and families, 2002-2018. JAMA Health Forum. 3(2), e215104-e215104). Harrison, et al. (2022). Hospice Improves Care Quality For Older Adults With Dementia In Their Last Month Of Life: Study examines hospice care quality for older adults with dementia in their last month of life. Health Affairs, 41(6), 821-830. Kleinpell, et al. (2019). Exploring the association of hospice care on patient experience and outcomes of care. BMJ Supportive & Palliative Care, 9(1), e13-e13. Kumar, et al. (2017). Family perspectives on hospice care experiences of patients with cancer. Journal of Clinical Oncology, 35(4), 432. Wright, et al. (2010). Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers' mental health. Journal of Clinical Oncology, 28(29), 4457. *Cancer patients, when comparing death in hospital to death in hospice **Compared to death in ICU ***Compared to hospital deaths Families remarked patients received just the right amount of pain medicine and help with dyspnea Families of patients receiving >30 days of hospice reported the most positive EOL outcomes Families more often reported patients’ EOL wishes were followed and rated quality of EOL care as excellent Family Less risk for PTSD with home hospice deaths** Home hospice reduced risk for prolonged grief disorder*** Hospice admission in last 6 months of life correlated with increases in patient satisfaction and better pain control, reductions in hospital days Less physical and emotional distress and better quality of life at EOL* Caregivers Patients 60% reduction in end-of-life transitions, allowing patients to die in location of choice Hospice beneficiaries saw a cost savings of $670 in out-of-pocket expenses during the last month of life compared to non-hospice users 17
- 18. Total Cost ofCare Comparison by Disease State and Hospice Use in Last Year of Life* *To be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill. An individual is considered to be terminally ill if the medical prognosis is that the individual’s life expectancy is 6 months or less if the illness runs its normal course. Only care provided by (or under arrangements made by) a Medicare certified hospice is covered under the Medicare hospice benefit. The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient's attending physician (if any). NORC at the University of Chicago (2023). Value of Hospice in Medicare. Available at: https://www.nhpco.org/wp-content/uploads/Value_Hospice_in_Medicare.pdf Disease Group No Hospice Hospice < 15 Days 15 – 30 31 – 60 61 – 90 91 – 180 181 – 266 > 266 ALL $67,192 4% -5% -9% -12% -14% -10% -12% Circulatory $66,041 7% -4% -8% -10% -11% -8% -10% Cancer $76,625 10% -1% -6% -9% -13% -14% -20% Neuro- degenerative $61,004 12% -6% -9% -11% -11% -5% -4% Respiratory $77,892 -2% -11% -14% -17% -19% -18% -22% CKD/ESRD $82,781 1% -14% -21% -24% -24% -23% -27% • Hospice care saved Medicare approximately $3.5 billion for patients in their last year of life • Those patients with hospice stays of ≥ 6 months* yielded the highest percentage of savings – For patients whose hospice stays were between 181-266 days, total cost of care was almost $7K less than non-hospice users – Hospice patients with stays of > 266 days spent approximately $8K less than non-hospice users Spending is greater than Spending is less than non-hospice users non-hospice users No difference / not statistically significant 18
- 19. The Medicare HospiceBenefit Is a 6-Month Benefit: Quality and Cost Evidence Corroborate the Need for Timely Access* *To be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill. An individual is considered to be terminally ill if the medical prognosis is that the individual’s life expectancy is 6 months or less if the illness runs its normal course. Only care provided by (or under arrangements made by) a Medicare certified hospice is covered under the Medicare hospice benefit. The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient's attending physician (if any). under the Medicare hospice benefit. The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient's attending physician (if any). NORC at the University of Chicago (2023). Value of Hospice in Medicare. Available at: https://www.nhpco.org/wp-content/uploads/Value_Hospice_in_Medicare.pdf Over the last 12 months of life, as hospice use increases, total spending decreases relative to non-hospice users. The reduction in costs when patients across all disease classes, including neurodegenerative diseases, use hospice can be significant. 19
- 20. Larry Hetu-Robert M.Div. BereavementServices Manager/Veteran Liaison VITAS® Healthcare
- 21. The Case ofMr. Jesus Cepeda • 97-year-old Filipino male, US Navy veteran, Steward Branch • Lived with a daughter in Florida before moving in with son and daughter-in-law • Family faced with increased care needs • Home care support and medical equipment necessary for symptom management 21
- 22. B. David Blake,MD, DABFM Associate Medical Director VITAS® Healthcare
- 23. • Healthy People2030 • Environments where people: Social Determinants of Health Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved October 26, 2023 from https://health.gov/healthypeople/objectives-and-data/social-determinants-health 23 Are born Live Learn Work Play Worship Age
- 24. • Five Domains –Economic stability – Education access and quality – Healthcare access and quality – Neighborhood and built environment – Social and community context Social Determinants of Health (cont.) 24 Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved October 26, 2023 from https://health.gov/healthypeople/objectives-and-data/social-determinants-health
- 25. • Affordable healthinsurance or being underinsured • Geographic location • Proximity to healthcare facilities • Reliable transportation • Take time off work for healthcare visits • Ability to attend follow-up appointments Access to Healthcare 25
- 26. • No matteryour community, people generally want the same at the end of life • Everyone deserves equal access to healthcare • Everyone wants to feel their best, live without pain, and be treated well at end of life • Hospice is the beginning of a new healthcare journey—the opportunity to spend your last year or months of life in your location of choice Importance of Goals of Care Meier, et al. “Defining a good death (successful dying): literature review and a call for research and public dialogue.” The American Journal of Geriatric Psychiatry 24.4 (2016): 261-271. 26
- 27. Advance Care Planning Baile,W.F. Buckman, et al. (2000). SPIKES- a six-step protocol for delivering bad news: application to the patient with cancer. The oncologist, 5(4), 302-311. 27
- 28. Call to Action:What Matters Most for Your Patients • Practicing clinicians should advocate for their patients and families through conversations • Feel empowered to initiate these conversations... the earlier, the better – Ask yourself, “Would you be surprised if this patient died within the next 12 months?” • It’s natural to be uncomfortable, but you owe it to your patients and families to understand their wishes and values 28
- 29. Mr. Cepeda’s AdvancedDirectives 29 • Aware of his prognosis • Made the decision to have a DNR • Signed all of his own consents • Family involved with the decision-making process
- 30. Martin Escueta Regional Directorof Admissions VITAS® Healthcare
- 31. Timely Admissions • Timematters for patients and families – Perspective of family vs. clinical need perspective – Earlier access – Response time is critical to gain trust and support • Admission Nurse responsibility to connect with patients and families – Education and advocacy – Understanding the patient/family • Simplifying the transition process – Simplicity of accessing the hospice benefit • Approaching patients who are aware of their prognosis/DNR in place – Education on expectations – DNR/Full Code 31
- 32. • Cognizance thatthe hospice discussion needs to be preempted by an understanding of the patient’s cultural/socioeconomic upbringing • Care teams can approach patients and families who come from underserved communities/cultures by framing the hospice benefit in a way that FITS into their lifestyle • Respect the patient’s background and traditions without letting it be a barrier Call to Action: Hospice Admission Discussions 32
- 33. Time For Action •Referred to hospice by the Atlanta VA with a primary diagnosis of CHF • Required a VA Authorization – timely process at times • Admitted immediately by VITAS with an initial charity payer source • Immediate support and comfort measures provided 33
- 34. Ileana Leyva, MD RegionalMedical Director VITAS® Healthcare
- 35. Hospice Interdisciplinary Team Patientand Family Volunteers Physicians Spiritual Counselors Social Workers Bereavement Counselors Hospice Aides Therapists Nurses 35
- 36. 1. Routine homecare 92.7% • Most common level of hospice care • More robust and comprehensive compared to home health care services • Patient’s preferred setting • Proactive clinical approach helps prevent ED visits/hospital readmissions 2. Intensive Comfort Care® (continuous care) 1.1% • Medical management in the home for up to 24 hours per day for acute symptom management when medically appropriate Four Levels of Hospice Care National Hospice and Palliative Care Organization. (2022). Facts & Figures: Hospice Care in America. Available at: https://www.nhpco.org/hospice-care-overview/hospice-facts-figures/ 3. Inpatient care 5.6% • For symptoms that cannot be managed in the home 4. Respite 0.6% • Provides a temporary break for primary caregiver • Inpatient setting • Up to 5 days of 24-hour patient care management when medically appropriate 36
- 37. Hospice Palliative CareHome Health Eligibility Requirements Prognosis required: ≤ 6 months if the illness runs its usual course Prognosis varies by program, usually life-defining illness Prognosis not required Skilled need not required Skilled need not required Skilled need required Plan of Care Quality of life and defined goals Quality of life and defined goals Restorative care Length of Care Unlimited Variable Limited, with requirements Homebound Not required Not required Required, with exceptions Targeted Disease-Specific Program ✓ Variable Variable Medications Included ✓ X X Equipment Included ✓ X X After-Hours Staff Availability ✓ X X RT/PT/OT/Speech ✓ X ✓ Nurse Visit Frequency Unlimited Variable Limited, based on diagnosis Palliative Care Physician Support ✓ Variable X Levels of Care 44 1 1 Bereavement Support ✓ X X Intensity of Care and Timely Access to Services Hospice is the only post-acute setting that can titrate to the level of care needed without changing care setting. 37
- 38. Benefits to EarlyIdentification of Hospice-Eligible Patients* *Slide demonstrates VITAS® Healthcare care model, not all hospices may provide listed services Levels of Care • Home/Routine • Respite • Continuous • Inpatient High Acuity • Telecare • Intensive Comfort Care® • General inpatient • Visits after hours and on weekends/ holidays • Frequent visits • Physician support Complex Modalities • IV hydration • TPN Lyte • Parenteral opioids • Therapy services: PT, OT, speech • Nutritional counseling • Goals-of-care conversations HME and Supplies • Oxygen • Non-invasive ventilation • Hospital bed • Specialized mattress • ADL assist devices • Incontinence supplies • Wound care supplies Quality Advantage Lower: • Hospital readmissions • Hospital mortality • Medicare spend per-Beneficiary Greater/Improved: • Advance care planning • Symptom management • Patient experience • Bereavement 38
- 39. Last Place ofCare Experience Teno, et al. "Family perspectives on end-of-life care at the last place of care." JAMA 291.1 (2004): 88-93. Outcome Hospice Nursing Home Home Health Hospital Not Enough Help With Pain, % 18.3 31.8 42.6 19.3 Not Enough Help Emotional Support, % 34.6 56.2 70 51.7 Not Always Treated With Respect, % 3.8 31.8 15.5 20.4 Enough Information About Dying, % 29.2 44.3 31.5 50 Quality Care Excellent, % 70.7 41.6 46.5 46.8 39
- 40. • When doesa patient potentially meet guidelines for hospice eligibility? • Allow for information session to provide patient and family all options for care in timely basis • Which level of care is best suited for optimal symptom management to improve the QOL of patient and honor their location of choice? • Hospice is an active plan of care to allow patients to live as best, as long as naturally as possible, learn to communicate and advocate appropriately for patients and families. • When in doubt, recommend a hospice information session to empower patients and families with the best information to make the best possible decisions for themselves. Call to Action: Appropriate Levels of Care 40
- 41. • Routine Levelof Care • Community Networking • Catholic Priest • Family Support Home Sweet Home 41
- 42. Every Day isVeterans Day at VITAS Virtual Honor Flight Recognition = Appreciation 42
- 43. Telling My Story •Life Review • Oral History Project • PTSD Support • Appreciation • Education 43
- 44. Higher Levels ofCare • Continuous Care- 12 days • Telecare • Family support • Increased chaplain visits 44
- 45. • Memory Bears •Support Groups • Grief Counseling • Memorial Services • Grief Education and Literature Grief Support 45
- 46. A Profound Impact “Itwas very touching, a very emotional day for the entire family. Mr. Cepeda’s family couldn’t stop telling me how thankful they were to VITAS for doing this for their dad. And Jesus told me, ‘This was the best day of my life. I didn’t realize it would be so emotional.’” 46
- 47. Call to Action:Caring for Those Who Cared for Us 47 • Caring for seriously ill veteran patients requires considering their unique healthcare needs and experiences. • Collaborating with VA healthcare providers and staying up to date on military-related health issues is crucial in providing comprehensive care to veteran patients. • Discuss care goals, end-of-life preferences, care options such as hospice and palliative care, as well as any military-specific benefits and/or support they may be entitled to. • Recognize that the grief experienced by veterans and their families can be different from civilian populations.
- 48.
- 49. What one keytakeaway regarding DEI in healthcare would you like our audience to keep top of mind as they care for underserved patients with advanced illnesses? 49 49 Joseph Shega, MD Chief Medical Officer B. David Blake, MD, DABFM Associate Medical Director Martin Escueta Regional Director of Admissions Ileana Leyva, MD Regional Medical Director Larry Hetu-Robert M.Div. Bereavement Services Manager/ Veteran Liaison
- 50. What is onepractical thing you do every day to ensure DEI is top-of-mind when caring for patients? 50 50 Joseph Shega, MD Chief Medical Officer B. David Blake, MD, DABFM Associate Medical Director Martin Escueta Regional Director of Admissions Ileana Leyva, MD Regional Medical Director Larry Hetu-Robert M.Div. Bereavement Services Manager/ Veteran Liaison
- 51. Q & A ClosingRemarks
- 53. References Aldridge M., etal. (2022). Association between hospice enrollment and total health care costs for insurers and families, 2002-2018. JAMA Health Forum. 3(2), e215104-e215104). Baile, W.F. Buckman, et al. (2000). SPIKES- a six-step protocol for delivering bad news: application to the patient with cancer. The oncologist, 5(4), 302-311. Harrison, et al. (2022). Hospice Improves Care Quality For Older Adults With Dementia In Their Last Month Of Life: Study examines hospice care quality for older adults with dementia in their last month of life. Health Affairs, 41(6), 821-830. Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Available at: https://health.gov/healthypeople/objectives-and-data/social-determinants-health Kleinpell, et al. (2019). Exploring the association of hospice care on patient experience and outcomes of care. BMJ Supportive & Palliative Care, 9(1), e13-e13. Kumar, et al. (2017). Family perspectives on hospice care experiences of patients with cancer. Journal of Clinical Oncology, 35(4), 432.
- 54. References National Hospice andPalliative Care Organization. (2022). Facts & Figures: Hospice Care in America. Available at: https://www.nhpco.org/hospice-care-overview/hospice-facts-figures/ Nelson KE, et al. Sociodemographic Disparities in Access to Hospice and Palliative Care: An Integrative Review. American Journal of Hospice and Palliative Medicine®. 2021;38(11):1378-1390. doi:10.1177/1049909120985419 NORC at the University of Chicago (2023). Value of Hospice in Medicare. Available at: https://www.nhpco.org/wp- content/uploads/Value_Hospice_in_Medicare.pdf Teno, et al. "Family perspectives on end-of-life care at the last place of care." JAMA 291.1 (2004): 88-93. Wright, et al. (2010). Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers' mental health. Journal of Clinical Oncology, 28(29), 4457.