Hospice Through a

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Hospice Through a insert community
LensBrief Basics, Gaps, and OpportunitiesBarr
y K. Baines, MD
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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

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

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Presentation Title

• Presenter
• Event
• Date

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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 dont know what they dont 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

• Dont 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 patients
  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 its 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 cant 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

• Create the right setting
• Determine what the patient and family know
• 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 dont 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_at_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