Hospice Through a ‘[insert community]’ Lens:Brief Basics, Gaps, and Opportunities

Barry K. Baines, MD

Objectives

• Develop measurable objectives that explain what the learner will be able to do as a results of your presentation

• Tie the presentation evaluation to the objectives you plan to meet

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(Source: http://www.mountcarmelhealth.com/medical-education/physician-planning-faculty-resources/how-to-write-cme-objec-2.html, 10/5/10)

Presentation Title

Presenter

EventDate

Objectives:

• Present an overview of the TRUE Project• Summarize the ‘Voices’ of the [insert

community] community related to serious illness and hospice

• Name two gaps and two areas of opportunity to optimize hospice utilization in the [insert community] community

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Targeting Resource Use Effectively (TRUE)

Goal: Optimize hospice use– Increase appropriate referrals to hospice– Increase the length of stay of hospice patients

(days of care)

How: By forming multidisciplinary community based teams to implement strategies to address barriers to optimal hospice use in the Waconia area community

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The Medicare Hospice Benefit• Provides coverage for services related to a terminal illness

• Does not require patients to have a "do not resuscitate" (DNR) order or advance directive to be admitted to a hospice program

• Allows patients to keep their regular physician (or nurse practitioner)

• Hospice programs can provide consultation with a terminally ill patient who is not yet in a hospice

• Consult can focus on care options, goals, and advance care planning in addition to symptom issues

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The Medicare Hospice Benefit is Still Grossly Underutilized

• The median (50th percentile) length of stay in hospice was 18.7 days in 2012

• 30% of all Medicare Beneficiaries who died were in hospice for three days or less

• 35-40% of patients enrolled in hospice died in seven days or less

• 43% of cancer patients and 36% of advanced dementia patients were in hospice for at least three days

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Community Voices

• [Insert community name] area TRUE team members conducted a number of brief, structured conversations.

• Information was gathered from:

– Community residents

– Healthcare Professionals

– Patients and/or families of hospice patients.

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Community Voices

• Nearly all community residents indicated that they would want to talk with their doctor about the hospice care option if they knew or understood that their illness was serious or life-limiting

• Healthcare professionals believed that the most significant barriers to the use of hospice by their patients are patient/family denial or lack of acceptance of the serious nature of their illness

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Community Voices

• What if:– patient denial or lack of acceptance was

actually a lack of knowledge? – our patients don’t know what they don’t

know?

• How would our patients even know what questions to ask us?

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The Gap: Prognostication

• Many physicians believe 3-6 months of hospice care is appropriate

• Physicians overestimate prognosis by 500%• The Gap:

– Median length of stay in hospice is 18.7 days (2012 data)

– 35-40% of patients enrolled in hospice die in seven days or less

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The Opportunity: Prognostication• Don’t ask yourself if your patient has a prognosis

of 6 months or less; consider asking yourself the “surprise” question:

“Would I be surprised if I saw my patient’s name in the obituary column of the local newspaper in the next year?”

• These are the patients where having ‘The Talk’ is most important

• Your community hospice programs are an excellent referral resource for helping in this effort

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The Gap: Having The Talk

• Patients and their families think that if they have a serious illness, their doctor will start the talk about hopes and goals for care

• Doctors say that they will have these talks if their patients bring up the topic first

• Doctors and their patients both think that having these talks are important

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The Gap: Having The Talk

• The Problem:– Doctors and patients are each waiting for

the other to start the conversation

– As a result, these talks may not take place at all

– Or, they may take place during a health crisis when it’s very stressful for everybody

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The Gap: Having The Talk

• The Curse of Knowledge– Once we know something, it is very difficult or

impossible to put ourselves in the situation of not knowing

– We (as providers) know the different focus of curative, remissive, and palliative treatments

– Our patients generally do not understand these differences

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The Gap: Having The Talk

• The Curse of Knowledge Examples:– We know that advanced cancer can’t be cured

– 70% of advanced lung cancer patients and 81% of advanced colon cancer patients believe their chemotherapy will cure them

– We know that the six year survival rate for Congestive Heart Failure is 20-25%

– 60% of patients with heart failure did not understand that their illness was life-limiting

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Opportunities: Having “The Talk” Sooner

• For Patients:– Encouraging patients to ‘ask their doctor’ if they

have a serious illness

– Providing a list of specific questions to initiate “the talk” (see patient brochure)

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Opportunities: Having “The Talk” Sooner

• For Providers:– Review and use an established protocol for

conducting goals of care discussion

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Goals of Care: A Seven Step Protocol to Negotiate Goals of Care With Your Patient:1. Create the right setting

2. Determine what the patient and family know

3. Explore what they are expecting or hoping for

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Goals of Care: A Seven Step Protocol to Negotiate Goals of Care With Your Patient:4. Suggest realistic goals

5. Respond empathically

6. Make a plan and follow through with it

7. Review and revise periodically, as appropriate

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Opportunities: Having “The Talk” Sooner

• For Providers:– Check patient/family understanding of the

goals/expected outcomes of treatments– Know what resources are available to you so that

‘The Talk’ can take place earlier in the course of a life-limiting illness

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Having the “The Talk”

• Distinguish curative, remissive and comfort focused treatments early on in the course of a serious illness

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Having the “The Talk”“In our practice, we believe that patient comfort and quality of life are as important as curing a disease or prolonging life. When curative treatments no longer have the desired effect, and when a disease continues to worsen in spite of treatments to slow it down, we have found that hospice care is a good option because it offers patients the opportunity to stay at home and to make personal decisions about how to spend the time that remains. We work with local hospices that offer these services.”

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Having the “The Talk

“We have a number of options to choose from. Chemotherapy may eradicate the cancer, so you might want to start there. Next we could try…. You should also know about hospice, which cares for people at home if treatments don’t help.”

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Opportunities: Having “The Talk”:• Remember:

– Early palliative interventions are shown to improve both quantity and quality of life

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Thank You!

Questions?Contact Information for Barry K. Baines, MD

Cell: 651-600-6413

E-Mail: barry@celebrationsoflife.net

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Stratis Health is a nonprofit organization based in Minnesota that leads collaboration and innovation in health care quality and safety, and serves as a

trusted expert in facilitating improvement for people and communities. 

This template was prepared by Stratis Health, the Quality Improvement Organization for Minnesota, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the US Department of Health and Human Services.

The contents presented do not necessarily reflect CMS policy. 10SOW-MN-SIP TRUE HOSPICE-14-66 042814