Susan Enguidanos

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.

30-Day Readmissions among Seriously Ill Older Adults

BACKGROUND Inpatient palliative consultation are generally provided to seriously ill hospitalized patients with the intent to alleviate pain and suffering and develop a plan of care for the patient. Although numerous benefits of this service have been documented, little is known about hospital readmission rates and factors associated with these readmissions. OBJECTIVE Our aim was to investigate factors associated with 30-day hospital readmission among patients receiving a consultation from an inpatient palliative care (ICP) team. DESIGN We conducted a retrospective cohort study. SETTING/SUBJECTS Data from 408 managed care patients 65 years old and older were collected in 2007-2009 following an IPC consultation and subsequent hospital discharge. MEASUREMENTS IPC and medical service use records were utilized. RESULTS Among IPC patients, 10% of those discharged from the hospital were readmitted within 30 days. Factors associated with hospital readmission included being discharged from the hospital with no care in the home or to a nursing facility. Receipt of hospice or home-based palliative care post-discharge was associated with significantly lower odds of hospital readmission. CONCLUSIONS This study found that receipt of palliative care following hospital discharge was an important factor in reducing 30-day hospital readmissions. Further study is needed to evaluate the effectiveness of longitudinal palliative care models in reducing 30-day hospital readmissions among seriously ill patients.

Ethnic variation in site of death of older adults dually eligible for Medicaid and Medicare.

This is a retrospective study using secondary data to investigate variation in site of death by ethnicity and to determine how hospice enrollment affects site of death. Data for this study were obtained between 1996 and 2000 from linked Medi‐Cal and Medicare claims from 18 California counties participating in a state legislated effort to improve chronic care services in California. Subjects examined in this study included 38,519 decedents aged 65 and older who died between 1997 and 2000 and were dually eligible the entire year immediately before death. Demographic variables were site of death, cause of death, hospice use, and care setting in the year before death. Results revealed that blacks and Latinos were significantly more likely than whites to die at home, although being black or Asian was negatively associated with hospice use. This variation did not change when hospice use was controlled. Thus, although minorities were more likely to die at home, they were less likely to receive hospice care. Because patients dying at home without hospice care report higher rates of pain than those who have hospice care, physicians must work to ensure that minority patients understand all end‐of‐life care options, including hospice, and how these care options can be delivered in a culturally competent manner.

Palliative Care and Cardiovascular Disease and Stroke: A Policy Statement From the American Heart Association/American Stroke Association

The mission of the American Heart Association/American Stroke Association includes increasing access to high-quality, evidence-based care that improves patient outcomes such as health-related quality of life and is consistent with the patients’ values, preferences, and goals. Awareness of and access to palliative care interventions align with the American Heart Association/American Stroke Association mission. The purposes of this policy statement are to provide background on the importance of palliative care as it pertains to patients with advanced cardiovascular disease and stroke and their families and to make recommendations for policy decisions. Palliative care, defined as patient- and family-centered care that optimizes health-related quality of life by anticipating, preventing, and treating suffering, should be integrated into the care of all patients with advanced cardiovascular disease and stroke early in the disease trajectory. Palliative care focuses on communication, shared decision making about treatment options, advance care planning, and attention to physical, emotional, spiritual, and psychological distress with inclusion of the patient’s family and care system. Our policy recommendations address the following: reimbursement for comprehensive delivery of palliative care services for patients with advanced cardiovascular disease and stroke; strong payer-provider relationships that involve data sharing to identify patients in need of palliative care, identification of better care and payment models, and establishment of quality standards and outcome measurements; healthcare system policies for the provision of comprehensive palliative care services during hospitalization, including goals of care, treatment decisions, needs of family caregivers, and transition to other care settings; and health professional education in palliative care as part of licensure requirements.

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.

Integrating Social Workers into Primary Care: Physician and Nurse Perceptions of Roles, Benefits, and Challenges

The primary aim of this article is to identify, from the perspective of primary care physicians and nurses, the challenges encountered in provision of health care to older adults and to identify potential roles, challenges, and benefits of integrating social workers into primary care teams. As more older adults live longer with multiple chronic conditions, primary care has been confronted with complex psychosocial problems that interact with medical problems pointing to a potential role for a social worker. From a policy perspective, the lack of strong evidence documenting the benefits that will accrue to patients and providers is a key barrier preventing the wider use of social workers in primary care. This article presents findings from three focus groups with primary care physicians and nurses to examine the perspectives of these key providers about the benefits and challenges of integrating social workers into the primary care team.

Prevalence of Potential Medication Problems among Dually Eligible Older Adults in Medicaid Waiver Services

Background: Methods for identifying potential medication problems among older adults at risk for nursing home placement have generally not included clinical risk factors in addition to medication lists. Objective: To assess the prevalence of potential medication problems for older adults enrolled in a Medicaid waiver service using tested Home Health Criteria that combine medication use and clinical risk factors for screening drug regimens. Methods: A cross-sectional survey screened 615 community-dwelling, dually eligible, functionally impaired adults aged 65 years and older enrolled in a Medi-Cal (Californias Medicaid) waiver care management program, Californias Multipurpose Senior Services Program (MSSP). Measures included prevalence and predictors of having 1 of 4 potential medication problems: unnecessary therapeutic duplication, use of psychotropic drugs with concurrent falls or confusion, cardiovascular medication problems, and use of nonsteroidal antiinflammatory drugs with risk of peptic ulcer complications. Results: Forty-nine percent of the sample had a potential medication problem, with unnecessary therapeutic duplication being most prevalent (24%). Nearly 20% of patients screened had 2 or more potential problems. Independent predictors of any potential medication problem were age (OR 1.029; 95% CI 1.01 to 1.05), new MSSP enrollment (OR 1.634; 95% CI 1.14 to 2.35), and number of medications (OR 1.183; 95% CI 1.13 to 1.24). Conclusions: Prevalence of potential medication problems in MSSP was markedly higher than reported in the original home healthcare sample used to test the Home Health Criteria. The prevalence rate for older adults at risk for nursing home placement necessitates expanded screening and medication therapy management interventions, especially upon initial enrollment and for those taking multiple medications. Interventions are needed to increase medication problem identification and resolution while promoting collaboration among physicians, consultant pharmacists, and waiver service providers.

From Hospital to Home: A Brief Nurse Practitioner Intervention for Vulnerable Older Adults

A randomized controlled trial was conducted to evaluate the impact of a brief nurse practitioner (NP) intervention on care transitions among older hospitalized adults discharged to home (N = 199). Immediately following discharge, participants randomly assigned to the intervention received up to three home visits and two telephone calls from a registered NP that included medication review, care coordination, assessment of medical care needs, and brief coaching in self-management skills. Usual care participants received all standard medical care, including access to case management services. Intervention participants reported improved satisfaction with medical care (p = 0.008) and self-efficacy in managing medical conditions (p = 0.001) and had fewer primary care visits (p = 0.036) but no change in hospital readmissions at 6 months following enrollment. These findings suggest that intervening at the point of transition may extend the reach of the primary care physician by improving patient outcomes through nursing support at a high-risk period of care-the transition from hospital to home.

Physician and Nurse Perceptions of a New Inpatient Palliative Care Consultation Project: Implications for Education and Training

BACKGROUND Few studies have examined ease of integrating palliative care programs into hospital culture. The purpose of this article is to report findings from focus groups conducted among physicians and nurses to elicit their perceptions of an inpatient palliative care team consultation service after 1 year of operation. METHODS The study consisted of four homogeneous focus groups drawn from a purposive sample of physicians (2 groups; total n = 16) and nurses (2 groups; n = 17) at a large urban managed care center. Structured interview protocols were used to elicit participant perceptions regarding the impact of implementation. Focus groups were audiotaped and transcribed verbatim. We analyzed the data using grounded theory techniques to elicit themes and subthemes. RESULTS Five major themes emerged regarding the positive and/or transformational impact of the program on patient/family services, medical staff, the hospital, quality of care, and time. Physician and staff observations regarding perceived barriers to integration included subthemes pertaining to the sharing of information, patient/family resistance and cultural differences, and the need for increased services. CONCLUSIONS The vast majority of comments expressed were related to positive aspects of the program. However, barriers exist that prevent some terminally ill patients from receiving these services. Findings from this study have implications for the need for education and training among providers on palliative and hospice services and, in particular, on the benefits of an inpatient palliative care team for patients, regardless of their attitudes toward end-of-life care programs.