Today’s Message… We must provide end-of-life care - We must provide end-of-life care - notnot doing so is doing so is
not not an optionan option Options are..Options are..
Where Where its provided, its its provided, its qualityquality and associated and associated costs costs
Significant disparities exist among VISNs and Significant disparities exist among VISNs and facilities in their provision of this carefacilities in their provision of this care
Evidence suggests that the provision of palliative Evidence suggests that the provision of palliative care results in cost savings relative to acute care care results in cost savings relative to acute care alternatives alternatives
What is Palliative Care in VA?
Care focused on enhancing quality of life Care focused on enhancing quality of life for patients with life-limiting and terminal for patients with life-limiting and terminal illnessesillnesses
UtilizingUtilizing Dedicated nursing home bedsDedicated nursing home beds Consult teamsConsult teams Coordination of home hospices and Coordination of home hospices and
management in HBPCsmanagement in HBPCs
Assumptions and Possibilities…
AssumptionAssumption: Instituting or expanding a : Instituting or expanding a palliative care program would just be an palliative care program would just be an additional expense we cannot afford…additional expense we cannot afford…
PossibilityPossibility: Maybe a palliative care : Maybe a palliative care program would more than pay for itself program would more than pay for itself through shifting workload, resulting in net through shifting workload, resulting in net cost savingscost savings
Assumptions and a Certainty…
Assumption:Assumption: We have no choice where people die We have no choice where people die (or how much it costs) because…(or how much it costs) because… Deaths are unpredictableDeaths are unpredictable Patients want aggressive carePatients want aggressive care Deaths in acute care are fundamentally different Deaths in acute care are fundamentally different
from those on a hospice wardfrom those on a hospice ward Certainty: Certainty: If veterans who cannot die at home If veterans who cannot die at home
have no alternative to acute care, that is where they have no alternative to acute care, that is where they will diewill die And its going to be And its going to be Expensive…Expensive…
Where to die?Veteran choice or the default mode – ICU and Acute Care? Very few people Very few people wantwant to die in acute care or to die in acute care or
the ICUthe ICU Veteran Veteran choicechoice is most affected by having is most affected by having
no choice no choice If veterans cannot die at home and only If veterans cannot die at home and only
acute care is available, they will die in acute care is available, they will die in acute care acute care by defaultby default
Where would YOU want to die, if unable to die at home?
Demographics of Dying in VA –the Need…
Serving an older, sicker population because Serving an older, sicker population because of WWII generationof WWII generation
674,461 estimated veteran deaths in 2001 674,461 estimated veteran deaths in 2001 (28% total national deaths) – 1,800 per (28% total national deaths) – 1,800 per day*day* Veteran deaths peak in 2005 at 687,273Veteran deaths peak in 2005 at 687,273
*Office of the Actuary , Vet Pop2000
TAPC Survey Highlights
80/107 facilities had some palliative care in 80/107 facilities had some palliative care in nursing homesnursing homes 41 dedicated bed programs for 403 beds 41 dedicated bed programs for 403 beds
totaltotal 45//109 facilities had palliative care/hospice 45//109 facilities had palliative care/hospice
consult teamsconsult teams 30 HBPC programs included some 30 HBPC programs included some
palliative carepalliative care
TAPC Worrisome Findings
29 respondents reported 29 respondents reported nevernever using using community hospice resourcescommunity hospice resources
63 facilities reported never using fee basis 63 facilities reported never using fee basis for home hospice carefor home hospice care
64% of facilities reported serving <100 patients per year…
Palliative Care - ? A Good Investment? Zero-Sum Game financing: Zero-Sum Game financing:
To spend more on palliative care in the To spend more on palliative care in the short run means to spend less on short run means to spend less on something else something else
However, However, if if workload shifts and workload shifts and if if net cost-net cost-savings are realized , in the long run you savings are realized , in the long run you will save moneywill save money
Management Argument: “We cannot afford palliative care” Assumptions-Assumptions-
We have a We have a choice choice as to whether or not to as to whether or not to care for very ill and dying patientscare for very ill and dying patients
Palliative care service would just be an Palliative care service would just be an additional expense without true cost additional expense without true cost savingssavings
Management Arguments for Why Palliative Care Cannot be Expanded
We cannot afford itWe cannot afford it Just an additional cost – no cost savingsJust an additional cost – no cost savings
We have no choice as to where patients die We have no choice as to where patients die or how much this costsor how much this costs
Implied Message…
Management: “Deaths in acute care are unavoidable because…”
Patients have different illnessesPatients have different illnesses We do not know these patients are going to We do not know these patients are going to
diedie Selection bias – some patients choose more Selection bias – some patients choose more
aggressive care and others less aggressive aggressive care and others less aggressive (cheaper) care(cheaper) care
What does this suggest?
Good evidence that the provision of palliative care Good evidence that the provision of palliative care is less expensive than acute/ICU care for dying is less expensive than acute/ICU care for dying patientspatients
Most veterans dying in acute care have serious, Most veterans dying in acute care have serious, life-limiting illnesseslife-limiting illnesses
Program development may affect where people Program development may affect where people die in your facilitydie in your facility
The provision of palliative care services may save The provision of palliative care services may save you money (and it’s a nice thing to do)you money (and it’s a nice thing to do)