Transcript
Page 1: Todays Message… We must provide end-of-life care - not doing so is not an option We must provide end-of-life care - not doing so is not an option Options

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

Page 2: Todays Message… We must provide end-of-life care - not doing so is not an option We must provide end-of-life care - not doing so is not an option Options

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

Page 3: Todays Message… We must provide end-of-life care - not doing so is not an option We must provide end-of-life care - not doing so is not an option Options

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

Page 4: Todays Message… We must provide end-of-life care - not doing so is not an option We must provide end-of-life care - not doing so is not an option Options

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…

Page 5: Todays Message… We must provide end-of-life care - not doing so is not an option We must provide end-of-life care - not doing so is not an option Options

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?

Page 6: Todays Message… We must provide end-of-life care - not doing so is not an option We must provide end-of-life care - not doing so is not an option Options

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

Page 7: Todays Message… We must provide end-of-life care - not doing so is not an option We must provide end-of-life care - not doing so is not an option Options

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

Page 8: Todays Message… We must provide end-of-life care - not doing so is not an option We must provide end-of-life care - not doing so is not an option Options

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…

Page 9: Todays Message… We must provide end-of-life care - not doing so is not an option We must provide end-of-life care - not doing so is not an option Options

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

Page 10: Todays Message… We must provide end-of-life care - not doing so is not an option We must provide end-of-life care - not doing so is not an option Options

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

Page 11: Todays Message… We must provide end-of-life care - not doing so is not an option We must provide end-of-life care - not doing so is not an option Options

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…

Page 12: Todays Message… We must provide end-of-life care - not doing so is not an option We must provide end-of-life care - not doing so is not an option Options

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

Page 13: Todays Message… We must provide end-of-life care - not doing so is not an option We must provide end-of-life care - not doing so is not an option Options

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)