We Honor Veterans:Honoring and Caring for all Veterans

End of Life Care for Veterans

in their Community

How do you change a culture?

Jerry Sternin Story

Coming Home: Era of Service

• World War II: Heroes

* country worked together

• Korea: Ignored

* forgotten war

• Vietnam: Shamed

* country torn apart

Courtesy of Margaret Walkosz, MS, GNP-BC

Video clip

Hospice Foundation of America Living with Grief Series

Improving Care for Veterans Facing Illness and Death

https://youtu.be/77KuIEiL7VA

Demographic Imperative

Only ~3% of Veterans die in VA facilities (~20,000)

~632,931 Veterans died in 2014

PTF file and VetPop for 2012

Many more with advanced serious illness and dementia

(510,314 expected to die in 2025)Source: VetPop 2007

Collaborate (kuh-lab-uh-reyt)

1. To work, one with another; cooperate

2. To cooperate, usually willingly, with an enemy nation

It all begins with…

“Are you a Veteran?”

Can we work together to;

- ensure reliable access,

- to quality hospice and palliative care,

- for all Veterans?

www.WeHonorVeterans.org

• Hospice Veteran Partnerships

• Education• Partner Tools• Best Practices

(e.g., pinning ceremonies)

• Announcements• And more…

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0

500

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Level Three

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Recruit

We Honor Veterans Partners (www.WeHonorVeterans.org)

Veteran-to-Veteran Volunteer Program

• Veterans often have a distinct culture• Common language and experience can

form strong bonds• Camaraderie among Veterans can provide

invaluable support• Identify Veterans in your Volunteer pool,

build on this resource and recruit others

Vision for VA’s Community Engagement

• Empower field leadership to develop and strengthen partnerships

• Communicate VA’s willingness to effectively partner

• Leverage partnerships to expand capacity, resources and access to services

Hospice Veteran Partnerships/ Veteran Community Partnerships

We Honor VeteransTop 10 Reasons to Participate

% of Veterans with CAN > 95 with Pall Care

3.4% got Pall Care

However, avg CAN score for Veterans that got Pall Care Consults is 98

Veterans “at risk” for needing palliative care

CAN- Care Assessment Need score

Goals of Care Conversations

Dr. Atul Gawande

How to have those end of life discussions?

https://www.youtube.com/watch?v=45b2QZxDd_o

A big question…

How would you make culture change happen across VA?

What indicators/measures would convince you VHA is moving towards improved care for Veterans with advanced illness?

% of Inpt Deaths in HospiceMore inpt deaths in hospice than in all of acute

and ICU combined

FY09 FY10 FY11 FY12 FY13 FY140

10

20

30

40

50

60

Funding support

When hospice is available, many will use it(absolute % change in inpatient deaths by venue nationally)

ICU Acute Nursing Home Hospice

Change 8% 17% 14% 39%

FY14 20% 22% 6% 52%

FY04 28% 39% 20% 13%

Note, inpt deaths declined over this period, ~5060 veterans impacted

Inpt Hospice Deaths by VISN(sorted)

20 7 17 19 2 5 9 22 8 3 18 11 1 15 16 12 21 6 4 10 23 Nat'l0%

10%

20%

30%

40%

50%

60%

70%

FY08 FY15 Q1

# of Palliative Care ConsultsLevel 3+ consults considered “comprehensive”

FY 2014

FY 2013

FY 2012

FY 2011

- 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000

31,266

30,511

26,773

19,092

5142

4584

4487

4232

8005

6768

6878

6287

3477

2498

2625

2456

Palliative Care Consult Workload: 2011 - 2014

Inpatient Consults Level 3-5

Inpatient Consults Levels 1-2

Outpatient Consults Level 3-5

Outpatient Consults Levels 1-2

Days between Consult and Inpatient Death Trend

  0-3 days 4-7 days 8-30 days > 30 days

FY 2015 Q1 20% 13% 25% 41%

FY 2014 21% 13% 26% 39%

FY 2013 23% 14% 26% 37%

FY 2012 25% 16% 29% 30%

National Average % of Families Rating Last Month of Care as “Excellent”

FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 goal

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%

52%

56% 57% 58% 59%

63% 62%65%

Families of VA inpatient decedents, response rate ~56%, sample sizes ~11,000/yr

I CARE Initiative

Access Scandal

% of Families Rating End of Life Care as “Excellent” in Acute Units vs. Palliative care vs. Inpatient Hospice Unit Settings

P values< 0.001

N=4,222 N=3,494 N=4,072 FY2011 N=3,178 N=3,836 N=4,005 FY2012 N=2,122 N=3,523 N=3,090 FY20130%

10%

20%

30%

40%

50%

60%

70%

80%

48%50%

52%

61%59%

64%66% 67%

70%

Usual care Palliative Care Inpatient Hospice Unit

p<.001 p<.001

Confronting our “foes”

http://www.nbcnews.com/video/nightly-news/43433937#43433937

Healing can come decades later