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HOSPICE NEWS NETWORK

Recent News On End-of-Life Care

Volume 17, Number 25 June 25, 2013

A Service of State Hospice Organizations

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MEDPAC SENDS JUNE REPORT TO CONGRESS

The Medicare Payment Advisory Commission (MedPAC) has released its June Medicare Payment Policy report to Congress. The report features updated analyses to support reform of hospice payments and the improvement of accountability measures. The summary of the chapter on hospice identifies the key issues that the report addresses. These include the following.

1)  The “Commission recommended that Medicare move away from the flat per diem payment to one that is higher at the episode’s beginning and end and lower in the intervening period.”

2)  The summary also says that, due to high number of long-term stay patients, “It is important that an initial step toward payment reform be taken as soon as possible.” Medical review of hospice patients who are cared for more than 180 days should be implemented, says the report.

3)  The rate of live discharges is too high for many hospices, with 18% of 2010 hospice benefit patients being discharged alive. This underscores the need to be sure that appropriate patients are admitted.

4)  Due to what the report labels as an “overlap in responsibilities between the hospice and the nursing facility,” the Commission explores “the potential for a reduction to the hospice payment rate for patients residing in nursing facilities.

The report offers details on the four issues above and focuses “on improving the hospice payment system and enhancing the accountability of the benefit.” The report provides details on the methods and outcomes of their study. The document provides data, offers conclusions or ideas about the meaning of some of the findings in this and earlier studies, and relays information on the four issues above. Random examples of some of the findings include that:

* Labor costs for hospice care exceeds $86 on the first day of service, falls to $21 for days 5-7, continues to decline to roughly $15 per day over 30 days and, increases significantly on the last seven days of life.

* “Unusually high rates of patients discharged alive among some providers raise concerns about questionable business practices and potential quality-of-care issues.”

* Of the 1.2 million hospice patients in 2010, 18% received live discharge—with a range by provider of 11% to 38%. Debility patients’ live discharge rates were “three times higher than that of patients with lung and other chest cavity cancers.” And, for non-cancer patients, live discharges were 1.7 times more than for cancer patients. Seventy-three percent of these live discharges were still alive six months after discharge and 56% were still alive a year after discharge.

* Research confirms that hospices often have multiple patients in individual nursing facilities.

The report concludes by identifying areas for future research. Moving forward, says MedPAC, “the Commission may explore ways to improve the end-of-life care options available to beneficiaries. For example, we may explore options for providing more flexibility for concurrent hospice and conventional care.” Consideration will also be given to shared decision making, to insure that patients receive the kind of care they want. “In our continued work on shared decision making, we may explore efforts by the medical community and commercial insurers to develop and implement shared-decision-making tools for patients with advanced illnesses.” The complete MedPAC report is available online at the link below. (MedPAC Report to Congress, 6/2013, http://www.medpac.gov/document_search.cfm)

STUDY EXAMINES HOW TO REDUCE STRESS FOR CAREGIVERS OF NEWLY ADMITTED HOSPICE PATIENTS

A study published in the Journal of Palliative Medicine examines the anxiety experienced by many family caregivers when their loved ones are admitted into a hospice program. In 2011, family caregivers served around 400,000 in-home hospice patients. Despite the fact that these home caregivers generally report satisfaction with the care received from hospice, “they continue to report anxiety, feeling unprepared, and lacking confidence for their often new caregiver role.” Researchers found that caregivers could be aided through the development of “cognitive schema” and the basic skills required for caring for family members at the end of life.

The research team devised a conceptual framework that guides the development of schema and skill building intervention, providing caregivers with information and caregiving skills for their new, and often unfamiliar, role. Caregivers were given a range of helpful information, including: “(1) The range of possible physical sensations and symptoms pertaining to the dying patient and the caregiver, (2) the range of possible causes of the sensations and symptoms experienced by both the patient and the caregiver, (3) possible temporal characteristics for both the patient and caregiver, and (4) possible environmental features.” Informational sessions were delivered through professionally recorded CDs.

Registered nurses worked with home caregivers to deliver the skill-building materials and assist in education. A total of 18 caregivers enrolled in the program; 12 completed the study. The caregivers who were involved rated the program very highly, and there was a statistically significant positive change in caregivers’ beliefs and confidence. The program also seemed to have some impact on post-intervention anxiety. Caregivers said that they would recommend the materials and program to a friend, citing their “increased... understanding [of] what to expect in their loved one’s disease trajectory and care needs.” Caregivers reported wishing that “they had had this information years prior to the initiation of hospice to more optimally care for their loved one.”

While researchers acknowledge that the “findings from this study should be cautiously interpreted due to a small sample and one-group design,” they are hopeful that such interventions can reduce anxiety and develop capacity for volunteer caregivers in a home setting. The authors suggest further research with multiple groups to continue to develop and evaluate the efficacy of this equipping program. (Journal of Palliative Medicine, 6/2013, http://online.liebertpub.com/doi/abs/10.1089/jpm.2012.0198http://www.online.liebertpub.com/doi/full/10.1089/jpm.2012.0198)

HOSPICE NOTES

* The New York State Assembly has passed a bill that “will permanently add bed capacity to hospice facilities across New York State.” Up to 16 beds per facility will be allowed. The bill, sponsored by Assemblywoman Barbara Lifton (D-Ithaca), is now headed for Governor Cuomo’s signature. (Ithaca Journal, 6/19, www.ithacajournal.com/article/20130618/NEWS01/306180077/Lifton-hospice-bed-bill-passes-State-Legislature)

* The federal government announced on June 17 that CMS seeks $112 million for ‘“false claims for payment’” made to the former San Diego Hospice. (U-T San Diego, 6/18, utsandiego.com/news/2013/jun/18/hospice-bankruptcy-san-diego-millions/; Mercury News, 6/18, www.mercurynews.com/news/ci_23489130/feds-say-calif-hospice-owes-112m-fake-claims; Connecticut Post, 6/18, www.ctpost.com/news/article/Feds-say-Calif-hospice-owes-112M-for-fake-claims-4608711.php)

* Maggie Callanan, a long-time hospice nurse and author, observes something about almost all of the 2000 deaths of patients she has attended. No matter what the patient’s background, patients speak in “nearly identical terms” as they near death. “They said they could see family members who had died. They said their loved ones were waiting for them, or telling them it wasn't time yet. They had to get their bags together for a trip. They had someplace important to go. They had to go home,” said Callanan in a recent speech in Chicago. Other hospice nurses who were present agreed. Callanan does not attribute this to patients’ confusion. Instead, she says, the remarks are common and offer “important insights into patients’ spiritual and emotion needs and their experience of death.” This state is called, says Callanan,‘“nearing death awareness.’” (Chicago Tribune, 6/19)

* Hospice Savannah Inc. has broken ground on the new “Center for Living” facility, which will be home to the Edel Caregiver Institute. The Edel Caregiver Institute “trains and assists caregivers. It will include full-circle bereavement programs that will have three master’s degree-level social workers who will offer training. Education will be available for medical professionals and community volunteers.” The facility plans to open in mid-2014. (Savannah Morning News, 6/16, http://savannahnow.com/opinion/2013-06-16/hospice-upgrade-quality-life#.Uce9kz6AYw-)

* Hospice of Santa Barbara has an official school outreach program. “The mission of the program is to provide no-cost grief counseling to students in local middle and high schools related to any issues they are experiencing related to the death of a friend or family member.” Over 100 students in seven schools were served in the 2012-13 school year. (NOOZHAWK, 6/18, www.noozhawk.com/article/061813_hospice_of_santa_barbara_school_outreach_program/)

* Slate published “Approaching Death,” an article by Kimberly Condon. An ER nurse for any years, Condon shares her transition to hospice nursing. (Slate, 6/19, http://www.slate.com/articles/life/family/2013/06/nurses_and_hospice_care_personal_essay_from_a_nurse_working_in_end_of_life.single.html)

ADVANCE CARE PLANNING NOTES

* Families of patients in ICU care often would like to be more engaged and informed in the care of loved ones. A recent article in the Journal of Gerontological Nursing identifies “strategies nurses can use to help guide the family through the end-of-life decision-making process, support families as difficult and complex decisions are made in collaboration with the health care team, and prepare families for the dying process.” (Journal of Gerontological Nursing, June 2013, http://www.ncbi.nlm.nih.gov/pubmed/23758114)

* An article at heart2soul.com addresses the special issues that must be addressed by LGBT persons whose spouses or partners die. The article, which stresses the importance of advance care planning, is posted online. (heart2soul, www.heart2soul.com/lgbt-issues-spouse-dies-partner-death)

* California’s North Bay Business Journal published an article on Five Wishes, POLST, and other aspects of advance care planning. (North Bay Business Journal, 6/17, http://www.northbaybusinessjournal.com/74500/in-dealing-with-end-of-life-five-wishes-can-help/)

* Margie Jenkins, a Houston psychotherapist, speaks, writes and councils persons to plan for dying. Jenkins, who is 90, travels and offers presentations, has written a book on end-of-life planning, and is currently creating a series of six videos on the materials in her work. (US News and World Report, 6/17, http://money.usnews.com/money/blogs/the-best-life/2013/06/17/living-a-good-life-includes-preparing-for-death)

END-OF-LIFE NOTES

* Dr. Amy Kelley, Mt. Sinai School of Medicine, offers a brief report on “average Medicare recipient’s medical expenses during the last five years.” The podcast and transcript are available online. (Inside Higher Ed, 6/17, http://www.insidehighered.com/audio/2013/06/17/end-life-health-care-expenses)

* “Philip C. Higgins of the Boston College Graduate School of Social Work in Massachusetts recently developed and tested a new scale called the Caregiver Evaluation of Quality of End-of-Life Care (CEQUEL).” Higgins’ rating scale evaluates multiple dimensions of both caregiving itself and quality of end-of-life care. Four elements, Higgins found, most significantly impact quality of end-of-life care—“caregiver’s perception of patient suffering, death preparation, the prolonging of death, and sharing in the decision-making process.” If the tool is ‘“validated in future work, it may prove a useful quality indicator for the delivery of EOL care and a risk indicator for poorbereavementadjustment.’” (GoodTherapy.org, 6/17, http://www.goodtherapy.org/blog/new-tool-measures-caregivers-perception-of-care-0617131)

* For many physicians, talking to dying patients is difficult. Dr. Atul Gawande is working with others on a “study of an end-of-life conversation guide.” Physicians receive little training on how to talk with patients’ about their “desires and priorities before death,” says Dr. Rachelle Bernacki, the study’s lead author. Dr. Susan Block, a senior author of the study, says physicians are reluctant to have these conversations out of fear of “extreme emotional responses.” Studies, on the other hand, show the value of having these conversations. The three physicians are working on a checklist for physicians to use, using a seven-question guide. Physician and patient experiences will be studied, as will the experiences of those not using the guide. Boston’s NPR station, wbur, also covered this story and it is online for listening. (The Boston Globe, 6/19, http://www.bostonglobe.com/metro/2013/06/18/atul-gawande-new-project-applying-checklists-end-life-care/hQSYq2IqJNDQvKA57b4O5J/story.html; wbur, 6/19, http://www.wbur.org/2013/06/19/ariadne-labs)

Thanks to Don Pendley and Kathy McMahon for contributions.

Glatfelter Insurance Group is the national sponsor of Hospice News Network for 2013. Glatfelter Insurance Group provides property and liability insurance for hospices and home healthcare agencies through their Hospice and Community Care Insurance Services division. Ask your insurance agent to visit their website at www.hccis.com.

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