![HRRP
Penalties and
Conditions
Catalyst, N. E. J. M. (2018). Hospital Readmissions Reduction Program (HRRP). NEJM Catalyst.
Program Year 1 2 3 4 5 6
Fiscal Year 2013 2014 2015 2016 2017 2018
Dates of
Performance
Measurement
8-Jun to
11-Jul
9-Jun to
12-Jul
10-Jun to
13-Jul
11-Jun to
14-Jul
12-Jun to
15-Jiul
13-Jun to
16-Jul
Conditions for
Original
Hospitalization
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
Chronic
Obstructive
Pulmonary
Disease (COPD)
Hip/Knee
Arthroplasty
(THA/TKA)
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
Chronic
Obstructive
Pulmonary
Disease (COPD)
Hip/Knee
Arthroplasty
(THA/TKA)
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
[Expanded]
Chronic
Obstructive
Pulmonary
Disease (COPD)
Hip/Knee
Arthroplasty
(THA/TKA)
Coronary Artery
Bypass Grafting
(CABG)
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
[Expanded]
Chronic
Obstructive
Pulmonary
Disease (COPD)
Hip/Knee
Arthroplasty
(THA/TKA)
Coronary Artery
Bypass Grafting
(CABG)
Maximum
Penalty
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Reducing Readmissions and Length of Stay
The document discusses strategies to reduce hospital readmissions and length of stay for patients with advanced illnesses, emphasizing the role of hospice care in healthcare reform and cost management. It highlights the impact of the Hospital Readmission Reduction Program (HRRP) and provides statistics on healthcare spending, patient demographics, and the causes of readmissions. The document underscores the importance of advance care planning and timely hospice access to improve patient outcomes and reduce unnecessary hospitalizations.
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- 1. Reducing Hospital Readmissions andLength of Stay in Advanced Illness Patients Reducing Hospital Readmissions and Length of Stay in Advanced Illness Patients
- 2. CE Provider Information VITAS Healthcareprograms 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 & 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 Practitioner. 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: 06/06/2018 – 06/06/2021. Social workers completing this course receive 1.0 ethics 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 01/31/2021. 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 2
- 3. Goal Discuss hospital readmissionsin today’s ever-changing healthcare environment and how hospice can have an impact.
- 4. • Describe HRRP(Hospital Readmission Reduction Program) within the context of healthcare reform • Identify what constitutes a hospital readmission • Appreciate the definition of a hospital readmission and the conditions that risk penalties • Recognize the role of hospice in helping prevent hospital readmissions Objectives
- 5. Top Causes of Death forThose Age 65+ National Vital Statistics Reports Volume 66, Number 5 November 27, 2017 Deaths: Leading Causes for 2015 by Melonie Heron, Ph.D., Division of Vital Statistics Heart disease 25.5 Cancer 21.1 CLRD 6.6 Stroke 6 Alzheimer's disease, 5.5 Diabetes, 2.8 Unintentional injuries, 2.6 Influenza and pneumonia, 2.4 Kidney disease, 2.1 Septicemia, 1.5 Other 23.9 Ages 65 and over
- 6. Teno J. M.,Gozalo P., Trivedi A. N., Bunker J., Lima J., Ogarek J., & Mor V. (2018). Site of death, place of care, and health care transitions among US Medicare beneficiaries, 2000-2015. JAMA, 320(3), 264-271. Place of Death US
- 7. • Continued tofar exceed other industrialized countries • Accounted for $3.6 trillion ($11,172 per person per year) – That’s 17.7% of the nation’s GDP • Hospital care accounted for 33% of total healthcare spend, a 4.5% increase from 2017 – Equates to $1.2 trillion Centers for Medicare and Medicaid Services. National Health Expenditures 2018 Highlights. Retrieved from https://www.cms.gov/files/document/highlights.pdf Healthcare Spending in the US 2018
- 8. Healthcare Spending as Percent of Gross Domestic Product(GDP) Schneider E. C., Sarnak D. O., Squires D., Shah A., & Doty M. M. (2017). Mirror, mirror: how the US health care system compares internationally at a time of radical change. The Commonwealth Fund. 0 2 4 6 8 10 12 14 16 18 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 UnitedStates (16.6%) Switzerland (11.4%) Sweden(11.2%) France (11.1%) Germany (11.0%) Netherlands (10.9%) Canada (10.0%) UnitedKingdom (9.9%) New Zealand (9.4%) Norway (9.3%) Australia (9.0%) 1980 - 2014 GDP data (2014).
- 9. Future US Healthcare Spending Projections Medicare PaymentAdvisory Commission. Report to the Congress: Medicare and the Health Care Delivery System. June 2019. Available at: http://medpac.gov/docs/default-source/reports/jun19_medpac_reporttocongress_sec.pdf?sfvrsn=0
- 10. Baby Boomer Impact • 10,000 BabyBoomers reach the age of 65 daily, that’s 7 new Boomers each minute1 • By 2035, there will be 78 million people 65 years and older, compared to 76.4 million children under the age of 182 – Patient access will become an issue – Hospitals will need to address chronic care needs, because aging Baby Boomers are living longer but have higher rates of chronic disease and more disability 1Gibson W.E. (2018). Age 65+ Adults Are Projected to Outnumber Children by 2030. Retrieved from https://www.aarp.org/home-family/friends-family/info-2018/census-baby-boomers-fd.html 2King D. E., Matheson E., Chirina S., Shankar A., & Broman-Fulks J. (2013). The status of baby boomers' health in the United States: the healthiest generation?. JAMA Internal Medicine, 173(5), 385-386.
- 11. Population 65 Years and Older andHospital Beds in US Song Z., & Ferris T. G. (2018). Baby Boomers and beds: a demographic challenge for the ages. Journal of General Internal Medicine, 33(3), 367-369.
- 12. Factors Contributing to Healthcare Waste • Wasteaccounts for about 25% of US healthcare spending • Estimates range from $760 billion to $935 billion – The annual cost of waste from failure of care coordination is estimated at $27.2 billion–$78.2 billion – The annual cost of waste from overtreatment or low-value care is estimated at $75.7 billion–$101.2 billion Shrank W. H., Rogstad T. L., & Parekh N. (2019). Waste in the US health care system: estimated costs and potential for savings. JAMA, 322(15), 1501-1509.
- 13. • More than90 million Americans live with at least one chronic illness • 7 out of 10 Americans die from chronic disease – Patients with multiple chronic diseases can spend upwards of $57K per year on their healthcare • One quarter of Medicare spending goes toward care for people during their last year of life Jha, A. K. (2018). End-of-life care, not end-of-life spending. JAMA, 320(7), 631-632. Costs at End of Life
- 14.
- 15. CMS Value-Based Program Timeline Centers for Medicare& Medicaid Services. Value-Based Programs. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs
- 16. CMS, FAQ forthe Risk-Standardized Outcomes & Payment Measures Public Reporting Year 2019 (July 1, 2019 - June 30, 2020). VITAS Proprietary Case Study Hospice Enrollment Mortality Hospital Readmission ICU and Hospital Bed Availability Medicare per- Beneficiary Spend 12 months before First day of index admission After the first day of index admission No hospice Risk-adjustment look back period Outcome timeframe Index Admission (day 0) Day 30 12 months before the index admission Patient dies Patient dies Patient dies Patient dies Medicare Hospice Medicare Hospice Medicare Hospice No Hospice Hospice Impact on CMS Quality for a Hospital
- 17. Value of Healthcare= Quality Cost Numerator problems • 100,000 deaths/year from medical errors1 • Millions more harmed by overuse, underuse and misuse • Fragmentation • Medical practice based on evidence <50% of the time2 • Healthcare spending as % of GDP 1Kohn L. T., Corrigan J., & Donaldson M. S. (2000). To Err is Human: Building a Safer Health System (Vol. 6). Washington, DC: The National Academies Press. 2 MEDICINE, I. R. O. E. B. (2011). Learning What Works Best: The Nation's Need for Evidence on Comparative Effectiveness in Health Care: AN ISSUE OVERVIEW. In Learning What Works: Infrastructure Required for Comparative Effectiveness Research: Workshop Summary. The National Academies Press. The Value Equation
- 18. The Value Equation Value ofHealthcare = Quality Cost Denominator problems • Insurance premiums increased by >200% in the last 10 years1 • US spending 17% GDP2 • Healthcare spending is the #1 threat to the American economy and way of life 1Kaiser Family Foundation. Employer Health Benefits 2019 Annual Survey. Retrieved from http://files.kff.org/attachment/Report-Employer-Health-Benefits-Annual-Survey-2019 2Centers for Medicare and Medicaid Services. National Health Expenditures 2018 Highlights. Retrieved from https://www.cms.gov/files/document/highlights.pdf
- 19. Hospital Readmission Reduction Program (HRRP) • Part ofthe Affordable Care Act (ACA) • Intended to drive meaningful reductions in all-cause readmissions by aligning payment with outcome • Ultimate objectives: – Improve care transitions – Relieve Medicare beneficiaries of the burden of returning to the hospital – Relieve taxpayers of the cost of readmissions The MedPAC Blog. (2018). The Hospital Readmissions Reduction Program has succeeded for beneficiaries and the Medicare program. Retrieved from: http://www.medpac.gov/-blog-/the-hospital-readmissions-reduction-program-(hrrp)-has-succeeded-for-beneficiaries-and-the- medicare-program/2018/06/15/the-hospital-readmissions-reduction-program-has-succeeded-for-beneficiaries-and-the-medicare-program
- 20. Components of Readmission Measure Component Description TargetPopulation Medicare fee for service age 65 and older discharged from acute care or VA hospital with an index condition. Beginning in FY 2019, the 21st-Century Cures Act requires CMS to assess a hospital’s performance relative to other hospitals with a similar proportion of patients who are dually eligible for Medicare and full-benefit Medicaid Definition Patient is discharged from the applicable hospital to a non- acute care setting and is admitted to the same or another acute-care hospital for any reason Exclusions Planned readmission within 30 days Applicable Data Three years of discharge data calculates excess readmissions Risk Adjustment Patient-related factors that may impact readmissions including age, gender, comorbidity and disease severity. Patient data for risk is obtained from claims for 12 months prior to and including index admission
- 21. HRRP Penalties and Conditions Catalyst, N.E. J. M. (2018). Hospital Readmissions Reduction Program (HRRP). NEJM Catalyst. Program Year 1 2 3 4 5 6 Fiscal Year 2013 2014 2015 2016 2017 2018 Dates of Performance Measurement 8-Jun to 11-Jul 9-Jun to 12-Jul 10-Jun to 13-Jul 11-Jun to 14-Jul 12-Jun to 15-Jiul 13-Jun to 16-Jul Conditions for Original Hospitalization Heart Attack (AMI) Heart Failure (HF) Pneumonia Heart Attack (AMI) Heart Failure (HF) Pneumonia Heart Attack (AMI) Heart Failure (HF) Pneumonia Chronic Obstructive Pulmonary Disease (COPD) Hip/Knee Arthroplasty (THA/TKA) Heart Attack (AMI) Heart Failure (HF) Pneumonia Chronic Obstructive Pulmonary Disease (COPD) Hip/Knee Arthroplasty (THA/TKA) Heart Attack (AMI) Heart Failure (HF) Pneumonia [Expanded] Chronic Obstructive Pulmonary Disease (COPD) Hip/Knee Arthroplasty (THA/TKA) Coronary Artery Bypass Grafting (CABG) Heart Attack (AMI) Heart Failure (HF) Pneumonia [Expanded] Chronic Obstructive Pulmonary Disease (COPD) Hip/Knee Arthroplasty (THA/TKA) Coronary Artery Bypass Grafting (CABG) Maximum Penalty 1% 2% 3% 3% 3% 3%
- 22. What Counts asa Readmission? Any time an AMI, COPD, pneumonia, or heart failure patient is readmitted to a hospital within 30 days of the initial hospitalization, it is considered a readmission. Counts as a readmission for Hospital A – patient discharged with HF and readmitted within 30 days Counts as a readmission for Hospital A even if patient readmitted to a different hospital Counts as a readmission for Hospital A when patient is readmitted from a PAC provider Counts as only one readmission for Hospital A, even if patient readmitted more than once during the 30-day period Scenario 1 Scenario 2 Scenario 3 Scenario 4 Each of these scenarios would count as ONE readmission for Hospital A Hospital A Heart Failure Home Hospital A UTI Home Hospital A Heart Failure Home Hospital B UTI Home Hospital A Heart Failure SNF Hospital A UTI SNF Hospital A Heart Failure SNF Hospital A UTI SNF Hospital B Pneumonia 0 days 30 days
- 23. Readmission Rates for Targeted and Nontargeted Conditionswithin 30 Days after Discharge Zuckerman R. B., Sheingold S. H., Orav E. J., Ruhter J., & Epstein A. M. (2016). Readmissions, observation, and the hospital readmissions reduction program. New England Journal of Medicine, 374(16), 1543-1551.
- 24. • 2019 penaltiesbased on discharges July 2015–June 2018 • 2,583 hospitals were penalized in 2019. Of these: – 1,177 hospitals’ 2019 penalty > 2018 penalty – 1,148 hospitals’ 2019 penalty < 2018 penalty – 64 hospitals received the same penalty in both years • 194 hospitals that were not penalized in 2018 were penalized in 2019 • The 3% maximum penalty was assessed against 56 hospitals • 372 hospitals avoided penalties in both 2018 and 2019 Rau, Jordan. (2019). New Round of Medicare Readmission Penalties Hits 2,583 Hospitals. Kaiser Health News. Retrieved from https://khn.org/news/hospital-readmission-penalties-medicare-2583-hospitals/ HRRP: 2019 Penalties
- 25. Readmission Patient Profile • 15% ofMedicare enrollees age 65+ were readmitted within 30 days of hospital discharge in 2019 • Readmitted patients have 2–3 times longer length of stay in the ICU than non- readmitted patients • Readmitted patients have 2–10 times higher risk of death than patients who are not readmitted • ICU re-admissions are associated with dramatically higher hospital mortality America's Health Rankings analysis of The Dartmouth Atlas of Health Care, United Health Foundation, AmericasHealthRankings.org, Accessed 2020.
- 26. Reasons for Readmission • Failurein discharge planning • Insufficient outpatient and community care • Severe progressive illness Jencks S. F., Williams M. V., & Coleman E. A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360(14), 1418-1428.
- 27. • University ofIowa Retrospective Chart Review • Penultimate admission within 12 months of death – 84% (175/209) of patients were within 6 months of their actual deaths • Documentation of hospice discussion – Terminal admission: 23% – Penultimate admission: 14% Freund K., Weckmann M. T., Casarett D. J., Swanson K., Brooks M. K., & Broderick A. (2012). Hospice Eligibility in Patients Who Died in a Tertiary Care Center. Journal of Hospital Medicine, 7(3), 218-223. Readmission: Severe Progressive Illness
- 28.
- 29. Advanced Illness Continuum Timelier Hospice Access Increased Value •Wishes and values • Advance directive • MOLST/POLST • Goals of care 1. Advance Care Planning • Extra layer of support • Symptom management • Goal-concordant care • Care transitions 2. Palliative Care Medicare Care Choices Open Access Three Pathways to Hospice Hospice Death • Care not consistent with wishes and values • Greater healthcare utilization • Less hospice use and shorter length of stay • Higher healthcare cost 3. Traditional Care Hospice Death Decreased Value
- 30. Index presentation and hospitalizationintroduce natural disease history and concept of advance care planning Acute exacerbations, including ED visits and hospitalizations; ongoing disease education and help to complete an ACP Annual Wellness Visit Assists in timely transition to hospice Advance Care Planning (ACP) Conversations should occur throughout the natural history of serious illness QualityofLife
- 31. Supports the Triple Aim IncreasedSatisfaction with Care on CAHPS Greater Goal-Concordant Care Fewer Hospitalizations Fewer ICU Days Fewer ED Visits Lower Healthcare Cost Greater Hospice Utilization Die in Location of Choice: Home 1Patel M., et al. Effect of a Lay Health Worker Intervention on Goals-of-Care Documentation and on Health Care Use, Costs, and Satisfaction Among Patients With Cancer: A Randomized Clinical Trial. JAMA Oncolology, 4(10):1359-1366. 2El-Jawahri et al. (2016). Randomized, Controlled Trial of an Advance Care Planning Video Decision Support Tool for Patients With Advanced Heart Failure. Circulation, 134(1):52-60. Advance Care Planning Evidence Base
- 32. Hospice Enrollment and Hospital Readmissions Holden T.R., Smith M. A., Bartels C. M., Campbell T. C., Yu M., & Kind A. J. (2015). Hospice Enrollment, Local Hospice Utilization Patterns, and Rehospitalization in Medicare Patients. Journal of Palliative Medicine, 18(7), 601-612. Kaplan-Meier survival curves for hospice enrollees and non- enrollees demonstrating the proportion of patients remaining out of the hospital in the 30-day post-discharge period.
- 33. 0.00 0.10 0.20 0.30 0.40 0.50 In-hospital deaths ICUadmissions 30-day hospital readmissions Incrementalreductionin variousoutcomes (proportion) 53-105 days 15-30 days 8-14 days 1-7 days Hospice enrollment: Hospice Use Decreases Acute-Care Utilization Kelly, A. (2013). Hospice Enrollment Saves Money and Improves Quality. Health Affairs, 32 (3):552–561. 0 2 4 6 8 10 Hospital Days ICU days HospitalandICU daysavoided 53-105 days 15-30 days 8-14 days 1-7 days Hospice enrollment:
- 34. Hospice and Medicare Cost Savings Kelly,A. (2013). Hospice Enrollment Saves Money and Improves Quality. Health Affairs, 32 (3):552–561. 0 2,000 4,000 6,000 8,000 53-105 days 15-30 days 8-14 days 1-7 days TotalMedicaresavings(s) Hospice enrollment range
- 35. • 76 y/o,6-year history of HF, relatively stable until past 6 months secondary to ischemic cardiomyopathy – Presents to ED with third exacerbation in 6 months – Recent EF 23% – Long-standing ACE inhibitor, B-blocker and diuretic – ICD placed several years ago – Dopplers negative DVT, CXR HF – PMH: s/p CVA, HTN, DJD, hard of hearing • Admitted to hospital with HF exacerbation, unclear reason Case of AF
- 36. • Admitted tohospitalist service – IV diuresis – Optimization of BP medications – Education about HF • Patient had cut back on diuretics due to functional urinary incontinence • Start consideration of discharge process • Prior to admission, ambulates with assistance, shortness of breath w/ minimal exertion Case of AF (Cont.)
- 37. Heart Failure Trajectory Function Death Low Multiple hospitalizationsDeath after exacerbation High NYHA Class III/IV Hospice Eligible NYHA Symptoms: Shortness of breath Fatigue Chest pain Palpitations
- 38. Hospitalizations and End ofLife Dunlay S., Redfield M., Jiang R., Weston S., Roger V. (2015). Care in the Last Year of Life for Community Patients with Heart Failure. Circulation: Heart Failure, 8(3):489-96 • 80% HF patients hospitalized last 6 months of life • 28% died in the hospital • Mean number hospitalizations last 6 months 2.5-3.6; LOS 11-13 days 0 50 100 150 200 250 300 350 331-365 301-330 271-300 241-270 211-240 181-210 151-180 121-150 91-120 61-90 31-60 0-30 NumberofHospitalizations Days Prior to Death Hospitalizations Days in Hospital
- 39. • Symptoms w/minimal exertion or rest (NYHA Class III/IV) despite standard of care • Inability to tolerate standard of care medical therapies • Recent history of cardiac arrest or recurrent syncope • Inotropic support required and not LVAD/transplant candidate • Oxygen requirement secondary to poor cardiac function • ED visits and hospitalizations from HF exacerbations HF and Hospice
- 40. HF Functional Status and Survival PPS Level Ambulation Activity &Evidence of Disease Self-Care Intake Conscious Level 100% Full Normal activity and work No evidence of disease Full Normal Full 90% Full Normal activity and work Some evidence of disease Full Normal Full 80% Full Normal activity with effort Some evidence of disease Full Normal or reduced Full 70% Reduced Unable normal job/work Significant disease Full Normal or reduced Full 60% Reduced Unable hobby/house work Significant disease Occasional assistance necessary Normal or reduced Full or Confusion 50% Mainly Sit/Lie Unable to do any work Extensive diseas Considerable assistance required Normal or reduced Full or Confusion 40% Mainly in Bed Unable to do most activity Extensive disease Mainly assistance Normal or reduced Full or Drowsy +/- Confusion 30% Totally Bed Bound Unable to do any activity Extensive disease Total Care Normal or reduced Full or Drowsy 20% Totally Bed Bound Unable to do any activity Extensive disease Total Care Minimal to sips Full or Drowsy +/- Confusion 10% Totally Bed Bound Unable to do any activity Extensive disease Total Care Mouth care only Drowsy or Coma +/- Confusion 0% Death — — — —
- 41. HF Functional Status and Survival (cont.) Creber etal. Use of the Palliative Performance Scale to estimate survival among home hospice patients with heart Failure. ESC: Heart Failure, 2019;6:371-378 Patients with a PPS score of ≤50 or lower are generally hospice- eligible; some patients with a higher PPS may also be eligible
- 42. HF Location of Death 2006–2015 Al-KindiS., Koniaris C., Olivera G., Robinson M. (2017). Where Patients With Heart Failure Die: Trends in Location of Death of Patients With Heart Failure in the United States. Journal of Cardiac Failure, (9):713-714. Year of death PercentageallHFdeaths Hospital 32.3% Home 24.4% Nursing Home/LTAC 28.8% Hospice 5% ED/Outpatient 4.9% Other/Unknown 4.2% 2015 Location of Death
- 43. Heart Failure Symptom Burdens Allen etal. (2012). Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation, 125(15), 1928-1952. Outcome Heart Failure EF < 30% Heart Failure >30% Advanced Cancer Number of Physical Symptoms 9.4 (1.1) 8.7 (1.2) 8.7 (1.5) Depression Score 3.6 (0.6) 4.3 (0.6) 3.2 (0.8) Spiritual Well-Being 35.2 (1.8) 36.3 (1.9) 39.1 (2.3) No significant difference between any of the groups
- 44. Most Common HF Symptoms >50% • Lackof energy • Pain • Feeling drowsy • Dry mouth • Shortness of breath • Depression Blinderman C. D., Homel P., Billings J. A., Portenoy R. K., & Tennstedt S. L. (2008). Symptom distress and quality of life in patients with advanced congestive heart failure. Journal of Pain and Symptom Management, 35(6), 594-603.
- 45. Class Examples IndicationAdverse Effect Other Comment ACE Inhibitor Enalapril Lisinopril HF stage B-D Hyperkalemia, Dec Cr, low BP, cough, angioedema First-line for systolic HF ARBs Candesartan losartan valsartan HF stage B-D Hyperkalemia, renal dysfunction, hypotension No not add to ACE inhibitors Beta-blockers carvedilol metoprolol HF stage B-D Fatigue, hypotension, depressed mood First-line for systolic HF Aldosterone blocker spironolactone NYHA III or IV Hyperkalemia, renal dysfunction Monitor hyperkalemia Loop diuretics furosemide bumetanide Volume overload Renal dysfunction, frequent urination, increased thirst IV or subq admin Cardiac glycosides digoxin Symptomatic HF after 1st line Cardiac arrhythmias, nausea, VH, delirium Monitor toxicity closely Pharmacologic Treatment HF Al-Kindi S., Koniaris C., Olivera G., Robinson M. (2017). Where Patients With Heart Failure Die: Trends in Location of Death of Patients With Heart Failure in the United States. Journal of Cardiac Failure, (9):713-714.
- 46. HF and Hospice Reduce Hospital Readmissions Kheirbek etal. (2015). Discharge Hospice Referral and Lower 30-Day All-Cause Readmission in Medicare Beneficiaries Hospitalized for Heart Failure. Circulation: Heart Failure, 8(4):733-40. Hospital Readmissions Hospice HF Eligible Patients with and without Enrollment Approximately 10% of HF patients who were admitted to the hospital and died within the next 6 months were referred to hospice. Hospice-eligible HF patients who enroll were 88% less likely to be re-hospitalized compared to non- enrollees
- 47. • Family meetingwith patient and daughter, who want to try skilled rehabilitation to strengthen patient • Open conversation with patient and daughter – Overall poor prognosis – Recommend hospice services to best meet patient goals – Continue to provide state-of-the-art HF care – Open to informational visit prior to transfer Case of AF (cont.)
- 48. – No morehospitals – Minimal tests – Improve shortness of breath – Continue to live in house – Keep alive as long as possible Important Elements of Shared Decision- Making for Goals-of-Care Conversations Allen et al. (2012). Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation, 125(15), 1928-1952. Outcomes Relevant to and individual Patient Survival Costs/Burden Direct Medical Costs Indirect Costs Lost Opportunities Caregiver Burden Quality of Life Symptoms Physical Function Mental Emotional Social
- 49. • At NH,patient participates in PT/OT and builds up some strength and endurance – Able to get out of seated position and ambulate with quad cane – Still short of breath with minimal exertion or at rest • End of week 1, appears a little confused, blood work and urine sent for analysis – At night, develops confusion and agitation – Sent back to hospital – Admitted with UTI and delirium Case of AF (cont.)
- 50. Heart Failure and Hospital Readmission Dharmarajanet al. (2013). Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA, 309(4), 355-363.
- 51. • Hospital planof care: – Antibiotics – Gentle hydration – Safe and supportive environment • Cognition improves within 2 days and PT evaluation recommends skilled • Family elects to return to skilled facility for PT Case of AF (cont.)
- 52. • Participates inPT/OT and continues to improve endurance and strength • Discharge planning initiated with discussions of home health or hospice – NYHA Class III or IV – Daughter wants PT in home for a couple of sessions when patient transitions – Home health aides to help bathe patient Case of AF (cont.)
- 53. Services Overview: Service VITASHome Health Palliative Care Physician Support Yes No Nurse Frequency of Visits Unlimited based on patient need Diagnosis driven RT/PT/OT/Speech Yes Yes Equipment Included Yes No After Hours Staff Availability Yes No Levels of Care 4 Levels Home Care Plan Review Weekly Variable Targeted Disease- Specific Program Yes Variable Bereavement Support Yes No Service VITAS Home Health Eligibility • Physician-certified prognosis <6 months, if disease runs normal course • Hospice prognosis must be re-certified periodically • Patient agrees to palliative, not curative, plan of care • Plan of care determined by initial and ongoing doctor/team assessment, combined with patient/family wishes • Not required to be homebound • Must require skilled level of care and a specific plan of care confirming need, frequency and duration of visits • Skilled nursing care need must be re-certified periodically • As skilled needs change, approved services change • Must be homebound, except for short durations Length of Care Unlimited number of visits based on patient need, if prognosis remains 6 months or less • Limited number of visits • Must document progress within the length of service allowed Medications Included VITAS provides Rx and OTC medications related to hospice diagnosis at no charge to the patient Medications are not covered under the Medicare Home Health Benefit Service Comparison
- 54. Only 1.5% enrolledin hospice at discharge SNF Use by Older Adults in Last 6 Months of Life
- 55. • Daughter electshome health, as SNF believes hospice would not cover PT • Patient makes a smooth transition home • Two weeks later, on Sunday, patient develops acute shortness of breath – Calls home health service – Answering service recommends going to ED – HF exacerbation requires IV diuresis and initiation of inotropes • In ED, daughter asks what can be done to keep mom out of the hospital Case of AF (cont.)
- 56. Therapy Indication BenefitsBurdens Other ICD Detects fatal arrhythmia and restores sinus EF<35% Over 1 year survival Survival No QOL/function improvements Pain, trauma, PTSD, anxiety, device issues Life expectancy over 1 year and good function CRT Pacemaker RV plus lateral LV so beat synchrony NYHA III/IV Ambulatory EF<35% and QRS>120 Improved survival with ICD, symptoms, exercise, and QOL. Fewer hospitalizations Surgery- and device-related complications 20–30% no benefit, mortality benefit by 3 months LVAD Channel ejects blood LV to circulation Bridge or Destination therapy systolic dysfunction Improved survival, exercise, QOL Bleeding, infection, and thromboembolic events 2-year survival 58% Cardiac Inotropes Decompensated HF without adequate response diuresis Increased QOL and ability to transition home Continuous infusion, defibrillator shocks Hospice-eligible Advanced Therapies in HF
- 57. • Inotrope providessome symptomatic relief – Less shortness of breath, more awake, more able to concentrate • Maintenance phase and dose, no active titration – No previous hypersensitivity to the agent • More permanent central venous access • Agreeable to hospice plan of care – No monitors, not a bridge to transplant or LVAD – Typically discharged on continuous care for transition – Do not have to deactivate ICD Candidate’s Home Inotropic Therapy
- 58. Inotropes Outcomes • Inotropes canbe used for symptom control in patients with advanced HF who are not candidates for MCS or transplant – Improved NYHA class (mean difference 0.6 95% CI 0.2–1.0) – No association with mortality (0.68 95% CI 0.40–1.17) – No association with hospital readmission p>0.10 – ICD shock 2.4 95% CI (2.1–2.8) • Hospice will cover, since its goal is improved symptom management • Overall improvements in survival over time likely secondary to the incorporation of improved medical management and ICD Nizamic T., Murad M., Allen L., McIlvennan C., Wordingham S., Matlock D., Dunlay S. (2018). Ambulatory Inotrope Infusions in Advanced Heart Failure: A Systematic Review and Meta-Analysis. JACC: Heart Failure, 6(9):757-767.
- 59. Acute Decompensated HF and SQ Furosemide •Subcutaneous Lasix may eliminate the need for an IV for patients at home • Similar outcomes between subq and IV – Similar diuresis – No difference in re-hospitalizations • Dosing has been done in hospice as a continuous infusion as well as intermittent • Limited data in severely obese and end- stage kidney disease patients • Local side effects can occur: stinging, burning, swelling Afari M., Aoun J., Share S., Tsao L. (2019). Subcutaneous Furosemide for the Treatment of Heart Failure: a State-of-the-Art Review. Heart Failure Reviews, 24(3):309-313.
- 60. • Elects hospicebenefit • Inpatient hospice, contract bed or continuous care at home? – Continuous care • Diuresis with subcutaneous furosemide • Continuation of inotrope • CHF exacerbation improved; 4 days later, transitions to routine home care • Physical therapy assessment initiated • Dies 5 months later at home with one additional episode of acute exacerbation HF on VITAS Intensive Comfort Care® Case of AF (cont.)
- 61. • Advanced illnessis a common contributor to hospital readmission • Hospice helps prevent hospital readmissions • Hospice factors associated with lower hospital readmissions: – After-hours care – Availability of continuous care – Visit frequency – “Open access” Summary
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- 68. This document containsconfidential and proprietary business information and may not be further distributed in any way, including but not limited to email. This presentation is designed for clinicians. While it cannot replace professional clinical judgment, it is to guide clinicians and healthcare professionals in reducing hospital readmissions and length of stay in advanced illness patients. It is provided for general educational and informational purposes only, without a guarantee of the correctness or completeness of the material presented. 68