Richard Brumley

Increased Satisfaction with Care and Lower Costs: Results of a Randomized Trial of In-Home Palliative Care

OBJECTIVES: To determine whether an in‐home palliative care intervention for terminally ill patients can improve patient satisfaction, reduce medical care costs, and increase the proportion of patients dying at home.

Effectiveness of a home-based palliative care program for end-of-life.

CONTEXT Despite the widespread recognition of the need for new models of care to better serve patients at the end-of-life, little evidence exists documenting the effectiveness of these models. OBJECTIVE To evaluate the effectiveness of a palliative program for end-of-life care. DESIGN A comparison group study was conducted between March 1999 and August 2000 comparing subjects enrolled in a palliative care intervention to those receiving usual care. SETTING Home Health Department at Kaiser Permanente, TriCentral Service Area. SUBJECTS During the course of the 2-year study, 558 subjects were enrolled. A subgroup of 300 patients who had died during the course of the study was selected for analysis; 161 were enrolled in the Palliative Care Program and 139 in the comparison group. INTERVENTION The Kaiser Permanente Palliative Care Project is a multidisciplinary care management approach for home-based end of life care and treatment. The program is designed to facilitate the transition from acute to palliative care during the last 12 months of life with the goal of improving quality of life through the provision of symptom control and pain relief, emotional and spiritual support, and patient education. MAIN OUTCOME MEASURES Medical service use and satisfaction with services. RESULTS Palliative care patients had increased satisfaction with services at 60 days after enrollment and significantly fewer emergency department visits, hospital days, skilled nursing facility days, and physician visits than those in the comparison group. Those enrolled in palliative care averaged a 45% decrease in costs as compared to usual care patients. CONCLUSION Through integrating palliative care into curative care practices earlier in the disease trajectory, chronically ill patients nearing the end of life report improved satisfaction with care and demonstrate less acute care use resulting in lower costs of care. In addition, patients enrolled in the palliative care program were more likely to die at home than comparison group patients.

Home-based palliative care study: site of death, and costs of medical care for patients with congestive heart failure, chronic obstructive pulmonary disease, and cancer.

Abstract Purpose: To examine differences in site of death and costs of services by primary diagnosis for patients receiving home-based palliative care as compared to usual care at the end of life verity of illness, service use, and site of death. Design and Methods: A nonequivalent group design was employed with 298 terminally ill patients diagnosed with cancer, CHF, or COPD enrolled. The treatment group received an interdisciplinary home-based palliative care program and the comparison group received usual Kaiser Permanente services. Data collected included patient demographics, se- Results: Among all diseases, patients enrolled in palliative care were more likely to die at home. Enrollment in palliative care was significant associated with cost reductions for patients with cancer, COPD, and CHF. No significant difference was found between diagnostic groups in terms of magnitude of cost savings. Implications: Provision of interdisciplinary home-based palliative care at end of life can effectively increase the likelihood of dying at home for patients with CHF, COPD, and cancer while realizing significant COSt savings.

Risk of Medication Errors at Hospital Discharge and Barriers to Problem Resolution

SUMMARY Medication errors are common among older adults, particularly among those who are at heightened risk due to transfer between care settings. Determining accurate medications for hospitalized patients is a complicated process. This paper presents findings from a small pilot study conducted to identify medication documentation problems at the point of hospital discharge among older adults and the problems encountered in developing new technological systems to address these problems. A prospective study was conducted within a managed care medical center that included patient and physician surveys and chart reviews. A review of 104 medical records revealed several problems in the documentation of patient medication including legibility, use of medical abbreviations and incomplete and missing entries. While patients overall were satisfied with medications communication efforts at discharge, physicians surveyed reported that these methods were inadequate in transmitting medication lists to primary care physicians, patients and other care providers. Patients reported taking more drugs than what were listed in the medical record. These findings led to the development, testing, and implementation of an electronic medication sheet. Despite the success in developing this new system, few physicians engaged in its use, with most preferring to continue with their standard discharge practices of written communication.

Barriers and Facilitators to Replicating an Evidence-Based Palliative Care Model

SUMMARY Recognition of the difficulties involved in replicating evidence-based interventions is well documented in the literature within the medical field. Promising research findings are often not translated into practice, and if they are, there is a significant time gap between study conclusion and practice adoption. The purpose of this article is to describe the barriers and facilitators encountered by two managed care organizations while replicating an evidence-based end of life in-home palliative care model. Using Diffusion of Innovation Theory as a theoretical framework, results from focus groups and interviews with the projects clinical, administrative and research teams are presented and recommendations made for improving translational efforts. The process of replicating the end of life in-home palliative care model clearly illustrated the key elements required for successfully diffusing innovation. These key elements include marketing and communication, leadership, organizational support and training and mentorship. This qualitative process study provides clear, real world perspectives of the myriad of challenges encountered in replicating an evidence-based project.

Reflection in Action in Caring for the Dying: Applying Organizational Learning Theory to Improve Communications in Terminal Care

ABSTRACT Currently, single loop learning is the predominant method of problem solving orientation engaged in by healthcare institutions. This mode of learning is not conducive to fostering needed communications between health care providers and terminal patients. Reflection in action, second loop learning, focuses on deep listening and dialogue and can be critical in opening communications paths between the dying patient and his or her caregivers. This article discusses organizational learning theory and applies the theories double loop learning technique of reflection in action to end-of-life care. The article further explores an exemplar of reflection in action in a Palliative Care Program, and end-of-life home care program at Kaiser Permanente. In order to more effectively meet the needs of terminally ill patients, greater efforts are needed to incorporate second loop learning into the practice of those caring for these patients.

Models of End-of-Life Care in the Home Environment

People with advanced heart failure spend most of their time living in the community, therefore could benefit by improved access to palliative care in the home. Hospice and home-based palliative care are the primary mechanisms for provision of such care for community-dwelling patients with heart failure. While several barriers to hospice care exist for heart failure patients, significant evidence for improved patient outcomes for home-based palliative care exists. Improved patient satisfaction as well as physical and psychological symptom control has been demonstrated along with considerable reductions in costs of medical care for patients with advance heart disease enrolled in home-based palliative acre programs. Despite this evidence for effectiveness among patients, caregivers of heart failure patients may continue to experience high levels of burden.

RESPONSE LETTER TO DR. BILLINGS: SHORTER SURVIVAL MAY POINT TO BETTER CARE CONSISTENT WITH PATIENT WISHES

To the Editor: Brumley et al. have underemphasized the most significant finding of their randomized, controlled trial comparing standard care at the end of life with a specialized in-home palliative program. As they state: ‘‘There was a strong trend toward shorter survival for those in the palliative care group . . . after study enrollment.’’ The average survival in the palliative care intervention group was 196 days, versus 242 days in the standard care arm (P 5.03). An earlier nonrandomized study by Brumley et al. comparing home-based palliative care with usual care showed a similarly shorter survival time for the intervention group (102 vs 159 days, Po.05). The Journal of the American Geriatrics Society has published the first and only controlled study suggesting that enrollment in a palliative home care program may hasten death. This outcome, consistent with similar recent but smaller and uncontrolled studies and contrary to others, deserves to be highlighted and may have significant bearing on public policy and the decision of patients, families, and clinicians to use similar end-of-life home care programs. More-detailed information on the processes of care involved in the two study arms might help explain this critical finding.

RESPONSE LETTER TO DR. BILLINGS: SHORTER SURVIVAL MAY POINT TO BETTER CARE CONSISTENT WITH PATIENT WISHES: LETTERS TO THE EDITOR

To the Editor: Brumley et al. have underemphasized the most significant finding of their randomized, controlled trial comparing standard care at the end of life with a specialized in-home palliative program. As they state: ‘‘There was a strong trend toward shorter survival for those in the palliative care group . . . after study enrollment.’’ The average survival in the palliative care intervention group was 196 days, versus 242 days in the standard care arm (P 5.03). An earlier nonrandomized study by Brumley et al. comparing home-based palliative care with usual care showed a similarly shorter survival time for the intervention group (102 vs 159 days, Po.05). The Journal of the American Geriatrics Society has published the first and only controlled study suggesting that enrollment in a palliative home care program may hasten death. This outcome, consistent with similar recent but smaller and uncontrolled studies and contrary to others, deserves to be highlighted and may have significant bearing on public policy and the decision of patients, families, and clinicians to use similar end-of-life home care programs. More-detailed information on the processes of care involved in the two study arms might help explain this critical finding.