1. MATCHING TREATMENTS TO PATIENTS GOALSAn Update on Palliative Care in Delaware Sheila Grant, BSN, RN, CHPNCommunity LiaisonHeartland Hospice

2. DISCLOSURESI work as a Community Liaison for HeartlandHospice, Homecare & I.V. 3. OBJECTIVES1. Participants will understand the difference between palliative care and hospice and the current efforts to re-design hospice to break down barriers to care.2. Participants will be able to list the palliative care programs available to Delaware patients in hospital, home care, and long-term-care settings.3. Participants will be able to explain the successes and the needs for expansion and improvement in palliative care in Delaware.4. Participants will know the benefits of the Delaware Medical Orders for Life-Sustaining Treatment, where to download copies of the form, and know how to use it in practice. 4. WHEN THE TIME COMES . . .Most people say they want But 75% die in a hospital or nursing hometo die at homeIf you want to stay home, you need a plan. Palliative care helps match treatments to preferences. Source: Means to a Better End, Robert Wood Johnson Foundation, 2002. 5. TRAJECTORY OF ADVANCED ILLNESSWHAT DO COMMONWAYS OF DYINGLOOK LIKE? 6. EMPOWERING PATIENTS TREATMENT CHOICESINFORMED CONSENT = ACCURATE INFORMATION ABOUTPROGNOSIS AND OPTIONS, INCLUDING PALLIATIVE CARE AND HOSPICE.Health System Efforts Legislative Efforts CA, PA, WV Launched initiatives to improve communication about prognosis and treatments options between doctors and patients. NY Passed legislation requiring physicians to discuss palliative options with terminally ill patients 7. Joint CommissionNew Speak UP Initiative features Palliative Carejointcommission.org/speakup.aspx 8. JOINT COMMISSION HAS A NEWCERTIFICATION PROGRAM 9. THE CONVERSATIONPROJECT.ORG 10. WHATS THE DIFFERENCE?Palliative CareProvided by an interdisciplinary team of specialistsFocused on quality of life by relieving:Hospice Palliative care in the pain last 6 months of life, symptoms after curative stress of serious illnesstreatments stopProvided at any stage of an illness, along withcurative treatment Palliative Care is provided further upstream from hospice. 11. HOSPICE & PALLIATIVE CARESameDifferent Patients Timeframe Goals Reimbursement method Knowledge base Setting (maybe) Interdisciplinaryteam 12. HOW DO HOSPICE & PALLIATIVE CARE FIT TOGETHER IN THE CONTINUUM OF CARE? Hospice Care About 6 About 13 mos. Period of living with illnessmos.DiagnosiDeaths 13. WHEN THE MEDICARE HOSPICEBENEFIT WAS CREATED, BACK IN 1982, Eligibility requirements were put in place to limitcosts, not because they made sense, clinically. 1. 6 mo. Prognosis 2. No Curative Treatments allowed Didnt foresee the explosion of eol care costs Small studies have found that hospice care doesnot increase costs at end of life. (Aetna) ACA authorized demo projects for concurrentcare (no funding, yet). 14. 6-month prognosis requirement is clinically arbitrary and practically difficult. Limiting hospice to patients who forego curative treatments creates an artificial distinction and impedes enrollment and quality of care. Medicares unique Hospice eligibility criteria conflicts with efforts to integrate care and align incentives across providers and settings. Suggestions:--Change the hospice eligibility criteria: Concurrent Care (Demonstration project passed, not funded) Eligibility based on need, not prognosis 15. RETHINKING HOSPICEELIGIBILITY CRITERIADAVID J. CASARETT, MD, MAJAMA. 2011;305(10):1031-1032. 3 problems with Medicare Eligibility Criteria for Hospice:1.They encourage late referrals + shortLOS2.They are based on prognosis(uncertain). Should be based onNEEDS, like every other benefit.3.They reduce access for some groups(e.g. African Americans less likely to usehospice.) 16. The H-WordHOSPICE Be afraid. Be very afraid. 17. 18. ITS NOT AS BAD AS IT LOOKS-- V.A. and Pediatric Hospitalswere not counted (Mcare andIHI data were used.) St. Francis Hospitalspalliative care service misseddeadline for inclusion. Data did not account forhospital size (CCHS countedequal to Beebe) 19. Medicare AAHPM Medicare NBCHPN MedicareNBCHPNMedicareDeaths Certified DeathsCertified DeathsCertified Deaths per Physician per RNsper APRNsCertified s Certified Certified APRN PhysiciaRN nDelaware 106055 (65)96 2 (4)2,6495 (8)Hawaii25 154 37 1041 3848(fewestdeaths/certifiedphys.)Rhode41,26743 1186 845Island(fewestdeaths/certifiedAPRN)Arizona 79 270405 53 92,369(fewestdeaths/ 20. DELAWARE NOW HAS: ABHPMs = 8 ACHPNs = 4 CHPNs = 65 CHPLNs= 10 CHPNAs= 44 CHPCAs= 3 21. HOSPICE & PALLIATIVE CARE BOARD-CERTIFIED PHYSICIANS IN DELAWARE 22. WE ALSO HAVE 2 NEW PALLIATIVECARE FELLOWSHIP-TRAINEDPHYSICIANS IN DE Roshni Guerry, MD at Christiana Care Hospitalist Partners Demetris Platis, MD at St. Francis Hospital, Family MedicineDept. 23. TIM COUSOUNIS, PALLIATIVE CARECONSULTANT Hospitals will likely look to post-acute carenetworks to assist in managing the care ofpatients at-risk for re-hospitalization. Palliative care. . . may be provided undermany health plan benefits, including, ofcourse, The hospice benefit, The home health benefit, and Medicare Part B, for physician outpatient or home-based visit coverage. Tim Cousounis Blog palliativemedicine.blogspot.com 24. PALLIATIVE CARE PROVIDERS INDE Dr. Goodill, Dr. Roshni Guerry, Dr. Linsey ODonnell and NPs Shirley Christiana Care HealthBrogley, MariPat Wellz-Bosna, Jo Melson, Brenda Eastham, Chap. PatSystem Malcolm Dr. Theresa Gillis has an outpt. P.C. practice as part of the Helen GrahamA.I. DuPont Childrens Center. Hospital Wilmington V.A. Med. Full-time medical director, NP, SW, additional full and part-time physicians,Ctr. volunteer chaplain. Inpatient, outpatient and home settings are covered. St. Francis Hospital Dr. Dihenkar, APRNs Maria Ash, and Marie Sedlak-Lupone staff the VA Program. Dr. Dan DePietropaolo and Cindy Jones, APRN provide palliativeDelaware Hospice consults. Dr. Dimitris Patris just finished a P.C. Fellowship Heartland Home Care Home & Community Based Palliative Care Consult Program (ACP & P.C. in NC and Sussex CountiesMedicare B pays) Beebe Hospital Fragile Patient Program thru Home Care Service-pts. need not be eligible for hospice to receive services. Bayhealth (Kent Gen. Dr. Salvatore (pulmonologist) at Beebe has a small, palliative care and Milford Mem.) practice. Plannning stages of forming a Palliative Care Team. They have offered 25. WE ALSO HAVE 26. What are we missing in DE?Access to Palliative CarePalliative Care specialists in ALL hospitalsPalliative Care outside the hospital (though home care or hospice programs)Quality Palliative CareAdequate numbers of board-certified palliative specialistsBetter overall outcomes 27. NOT EVERYONE WITH ADVANCEDILLNESS HAS ACCESS TO NEEDS (ORNEEDS) A PALLIATIVE SPECIALISTPrimary PalliativeSpecialistCare Palliative CareAll health care providers should Certified and fellowship-trainedhave a basic level of expertiseproviders will serve patients with greater needs 28. PALLIATIVE CARE IS NOT NEWSo why are wetalking about itnow?New RESEARCH!New CLINICALGUIDELINES! 29. EARLY PALLIATIVE CARE FOR PATIENTS WITH NON-SMALL CELL METASTATIC LUNG CANCER RCT [standard oncologic care OR standard oncologic care +palliative care] P.C. group showed significant improvements in: quality of life moodAND Less aggressive care at the end of life Longer survival (11.6 mo. vs. 8.9 mo.)n engl j med 363;8 nejm.org august 19, 2010 30. EARLY PALLIATIVE CARE 31. PROVISIONAL CLINICAL OPINION Recent Data: Seven published RCTs form the basis of thisPCO. It is the Panels expert consensus that combined standardoncology care and palliative care should be considered early inthe course of illness for any patient with metastatic cancer and/orhigh symptom burden. 32. SPIKESA SIX-STEP PROTOCOL FOR DELIVERING BAD NEWSSettingPrivacy, include sig. others, sit down, manage time,make a connection)PerceptionWhat have you been told about your medicalsituation so far?, ASK-TELL-ASKInvitationAsk the patient if they would like to know moreabout their illness, their prognosis, their treatment options. ASK-TELL-ASK. 33. SPIKES, CONTINUEDKnowledgeShare information. Give a warning shot Im sorry tosay I have some bad news. Unfortunately, the treatment is not working.I wish things were different, but . . . Avoid excessive bluntness. Dontsay Theres nothing more we can do. We can always adjust our plan ofcare to meet new goals when prognosis changes.EmpathyRespond to the patients emotionanger, denial,sadness, relief, etc. (I can see this is upsetting for you. I was alsohoping for better results, I can tell you werent expecting to hear this.)If emotions are not expressed, ask more questions.StrategyPresent treatment options, including palliative care, ifappropriate. 34. DELAWARE NOW HASA NEW EMS REGULATION IN PLACEEMS Providers willhonor a new formcalled MedicalOrders for LifeSustaining Treatment(or MOLST) to takethe place of thePACD 35. OUR DE MOLSTShould beprinted onpurple cardstockand looks likethis: 36. ADVANTAGES OF MOLST: Clear, Standardized Instructions Translates a patients Living Will into an ActionableMedical Order (Ideally patients will have both L.W. and MOLST) PortableFollows pts. thru transitions of care Available On-lineNo cost to the State for printing and distribution 37. ALL ADULTS SHOULD COMPLETE A LIVINGWILL AND HEALTH CARE POA MOLST is recommended only for people with advanced illness or frail elders who want to give instructions for theirMOLST care. 38. 11/11 Study* showed94% overall consistency rate between POLST orders and treatments given.POLST/MOLST Works! *Study included 90 nursing facilities in OR, WI, WV 39. WHY? BECAUSE FAMILIES SUFFER WHEN PATIENTS HAVE A DIFFICULT DEATH Many surrogate decision makers experience symptoms for up to 20 years or more after a death Avoidance Intrusion Hyper-arousal PTSD! 40. PLACE OF DEATH: CORRELATION WITH QUALITY OFLIFE OF PATIENTS WITH CANCER AND PREDICTORSOF BEREAVED CAREGIVERS MENTAL HEALTH Patients with cancer who die in a hospital or ICUhave worse QoL compared with those who dieat home, Their bereaved caregivers are at risk fordeveloping psychiatric illness. Interventions aimed at terminalhospitalizations oro hospiceutilization may enhance patients QoL at theEOL and minimize bereavement-relateddistress. JCO October 10, 2010 vol. 28no. 29 4457-4464 41. ADVANCE CARE PLANNING ANDPOLST/MOLST ARE AN IMPORTANT PARTOF : Coordinated care Look at the examples: delivery Geisinger (PA) Smooth Care Guthrie (PA)Transitions Kaiser Gunderson Accountable Care Cleveland Clinic Organizations Grand Junction, CO 42. WITHOUT WRITTEN INSTRUCTIONS,ITS HARD TO KNOW WHAT A PATIENTWANTS 43. NATIONAL COALITION FORHOSPICE AND PALLIATIVE CARE The NCHPC is designed tofocus on common organizationalgoals. 44. LEGISLATIVE UPDATE: SUPPORTPCHETAProvides funding for : Palliative Care and Hospice EducationCenters Interdisciplinary career incentiveawards (APRNs, SWs, Pharm., Psych.Pursuing advanced degrees in p.c.) Academic Career Awards (for thosewho teach p.c.) 45. LEARN THE LATEST NEWS FROMEXPERTS IN THE FIELDIncreased focus on hospice Is it time for another lawsuit?reform Advocating to change the Medicare Hospice Benefit eligibility requirements 46. WIN PROBAILITY: The expected chance that a team will win a game at a particularmoment in time, given the situation it faces.--from ESPN Magazine viaPallimed.org 47. AS YOU THINK ABOUT RESEARCH, POLICY, REGULATIONS, PAYORS,CERTIFICATIONS, Dontforget:Keep your focus on patientsand families. 48. DO NOT RESUSCITATE BY BRENDA BUTKA, MD VANDERBILT UNIV. SCHOOL OF MEDICINE, PUBLISHED IN JAMA 10/24/12I can say your father is dying . . . I can say do not confuseI can say love does not conquer all . .resuscitation.blind hope is not a recipe for with resurrection, althoughsuccess. . . neither works particularly wellunderdogs usually lose . . .death is not the worst thing, it is just You look like you are drowningthe last thing Pallid and slow inBut for you that is not true. . . . The waiting rooms underwaterI can say we should not do thislightHe will never be the same.I can saySo, Tell meIf it were my father.Tell me again. Tell me about your father. 49. WE NEED TO PROVIDE BETTER CAREFOR PEOPLE WITH ADVANCEDILLNESS Palliative Care is making it happen