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The Role of Hospice in Reducing Hospital Readmissions

Joseph W. Shega, MDRegional Medical Director

Objectives

• Discuss the role of hospice in preventing hospital readmissions and ensuring value‐based care

• Appreciate differences in services provided by palliative care, home health, and hospice

• Identify characteristics of hospice providers best positioned to prevent hospital readmissions

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Death in America

US Overall

• 2.6 million deaths in 2013

• ~1.6 million deaths in hospice in 2013

• Causes of death– Heart disease

– Cancer

– Chronic lower respiratory diseases

– Accidents

– Stroke

– Alzheimer's disease

Hospice—2014

• Median LOS 17.4 days – 35.5% LOS < 1 week

– 10.3% LOS >6 months 

• Causes of death– Cancer 

– Debility unspecified

– Dementia

– Heart disease

– Lung disease

– Other

– Stroke or coma

CDC 2013, NHPCO 20142

Hospice Care• Part A Medicare Benefit

• Interdisciplinary team‐oriented approach to end‐of‐life (EOL) care

• Patient, family center of care

• Goals of care/shared decision‐making

• Aggressive care at the EOL: medical care, pain and symptom management, and emotional and spiritual support

• Provided in any setting

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Medicare Hospice BenefitBasic Hospice Benefit• Prognosis of 6 months or less if the terminal illness runs its 

normal course 

• Patients elect hospice via informed consent

• Hospice reimbursed at flat per‐diem based on one of 4 levels of care:

1. Routine home care• Includes patients living in LTC or ALF

2. Continuous home care

3. General inpatient care

4. Respite inpatient care

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Hospice and Palliative Care

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• Improved satisfaction with care

• Improved pain and symptom management

• More likely to die in location of choice

• Decreased hospital readmissions

• Decreased condition-specific 30-day hospital-specific mortality

• Decreased healthcare cost

• Live longer

• Family support

• Bereavement services

Conner et al JPSM 2007

Kelly, A et al. Health Affairs  2013

Benefits of Palliative and Hospice Care

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Outcome Hospice Nursing Home

Home Health

Hospital

Not enough help with pain, %

18.3 31.8 42.6 19.3

Not enough emotional support, %

34.6 56.2 70 51.7

Not always treated with respect, %

3.8 31.8 15.5 20.4

Not enough information about dying, %

29.2 44.3 31.5 50

Quality care excellent, % 70.7 41.6 46.5 46.8

Teno et al. Family Perspectives on End of Life Care. JAMA 2004

Patient Experience

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Hospital Readmissions and Hospice

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Hospice Use Decreases Hospital Utilization

Kelly, A. Hospice enrollment saves money and improves quality. Health Affairs  2013

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2015 Condition‐Specific Hospital 30‐day Mortality

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Hospice and Medicare Cost Savings

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Hospice and Life Expectancy

• Hospice patients live on average ~29 days longer

• Prolonged survival

– Lung cancer

– Pancreatic cancer

– Colon cancer

– CHF

• No survival difference

– Prostate cancer

– Breast cancer

Connor S., Comparing Hospice and Nonhospice Patient Survival Among Patients Who Die Within a Three‐Year Window. JPSM 2007 12

Cancer: A Case‐Based Example

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Case of RC

RC is a 59 y/o male with rectal cancer admitted to hospital with shortness of breath, nausea, vomiting, pain and increased ostomy output five days after receiving third line of chemotherapy. He spends about 50% of his time in a chair or bed.

• Antibiotics for pneumonia• IVF for dehydration• Anti-emetics for nausea and vomiting• Analgesics for pain management

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Allen L A et al. Circulation 2012;125:1928-1952

• Treat pneumonia

• More chemotherapy

• Full code

• Symptom control

• PT to improve strength

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Elements Important to Goals‐of‐Care Conversations, Shared Decision‐Making

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Communicating News about Serious Illness Is Difficult Because . . .

• Unable to deal with intensity of response

• Fearful of reaction 

• Don’t want to take hope away from patient

• Illness as an indication of failure

• The task is unpleasant

• Lack of training

• Stress

• Feelings of inadequacy 

• Requests by family to withhold information

• Takes time

• Personal fear

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Chemotherapy Bias

Weeks JC NEJM 201217

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Physician Prognosis Estimates

Communication of Prognosis

Lamont et al. Ann Intern Med 2001;134:1096-110519

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Concurrent Appropriateness of Hospice and Anti‐Tumor Therapy

• Competing priorities of anti‐tumor therapy  versus hospice

– Chemotherapy requires a good performance status

– Phase‐1 chemotherapy typically needs an estimated survival of 3 months

– Hospice enrollment possible at 6 months or less

• Must agree to forgo “curative” treatment and focus on quality of life

• Accurate prediction of prognosis important for good clinical decision‐making

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Case of RC (Cont.)• Pneumonia and shortness of breath slowly improve with 

antibiotics

• Nausea and vomiting resolve with IVF

• IV hydromorphone for pain control

• Ostomy output decreases

• Physical therapy consult

– Participation but unclear prospects for improvement

– Appointment in oncology 4 weeks

• Transferred to skilled rehabilitation 

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Case of RC (cont.)• Week 1

– Completes antibiotics for pneumonia

– Participation in physical therapy

• Improvement in strength but not endurance

– Pain in rectal area develops and worsens—po hydromorphone

• Week 2

– Fever developed

– Increased fatigue

– Purulent drainage from rectum

• Transfer to acute-care hospital, admitted to the ICU

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Hospital Readmissions

30‐DayReadmission

Skilled Care 22.6%

Home Health 21.4%

Home 18.0%

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Krueger K et al. Nursing Research and Proactive 2011

Reason for Hospital Admission from Nursing Home

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Case of RC (Cont.)

• CT scan demonstrated progression of lung and liver metastasis plus rectal abscess

– Rectal drain and antibiotics initiated

– IVF for sepsis

• Patient has 10/10 rectal pain with hyperalgesia

– Parenteral hydromorphone

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Allen L A et al. Circulation 2012;125:1928-1952

• Treat rectal abscess

• More chemotherapy

• Full code

• Pain control

• PT to improve strength

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Elements Important to Goals‐of‐Care Conversations, Shared Decision‐Making

Case of RC (Cont.)

• Oncologist and patient talk with hospitalist about additional chemotherapy 

– Needs to be stronger

– Resolution of rectal abscess

• Agrees to return to skilled facility 

– IV antibiotics for four weeks

– Physical therapy

– Outpatient oncology appointment 4 weeks

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Case of RC (Cont.)

• Week 1

– Participates in PT and gains some strength but not endurance

– Continues IV antibiotics with some improvement in abscess and pain

• Week 2

– PT recommends discharge with home health, as not making any more progress

– Also needs 2 more weeks of IV antibiotics

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Only 1.5% enrolled in hospice at discharge

SNF Use by Older Adults in Last 6 Months of Life

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Service Hospice Home Health

Nurse 24 hours/day Yes Variable

Nurse frequency of visits Unlimited Diagnosis Driven

Palliative care physician support Yes No

Medications included Yes No

Equipment included Yes No

Levels of care HomeInpatientRespiteContinuous Home

Home

Bereavement support Yes No

Primary care/specialty Visits Yes Yes

Advanced therapies Yes Yes

Care Plan review Weekly Variable

Service Differentiators

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Case of RC (Cont.)

• Family elects home health

– Rectal abscess antibiotics 2 weeks IV

– Physical therapy deconditioning

– Continue pain management

• One week later, patient becomes short of breath and experiences some chest pain

• Called home health, which requested patient return to hospital

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Cumulative Incidence of ED Use—Last 6 Months of Life

• 41% > 1 ED visit in last 6 months of life• 12% > 1 ED visit in last month of life• Almost 10% in ED last day of life 32

Case of RC (Cont.)

• In ED, patient hypotensive and tachycardia

• Severe respiratory acidosis

– PE and pneumonia diagnosed

– Anticoagulation and antibiotics initiated

• Less responsive over next hour and intubated

• Transferred from ED to ICU

• One week later, family stops life‐sustaining therapy; patient dies in hospital

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Healthcare Utilization Cancer and the Last Year of Life

Utilization Non‐Hospice

Hospital Admission 65.1%

ICU Admission 35.8%

Invasive Procedure 51%

Died Hospital/SNFHospitalSNF

74.1%50.2%23.9%

Cost $71,517

Obermeyer, Z et. al. Association Between the Medicare Hospice Benefit and Health Care Utilization and Costs for Patients With Poor Prognosis Cancer. JAMA 2014

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Value‐Based Healthcare

Value‐Based Outcome Non‐hospice

30‐Day Re‐Hospitalization 2

30‐Day Condition‐Specific Mortality Yes

Patient ExperienceSatisfactionPain Management

Not ExcellentNot Excellent

Dollar Cost High

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Case of RC

RC is a 59 y/o male with rectal cancer admitted to hospital with shortness of breath, nausea, vomiting, pain and increased ostomy output five days after receiving third line of chemotherapy. He spends about 50% of his time in a chair or bed.• Antibiotics for pneumonia• IVF for dehydration• Anti-emetics for nausea and vomiting• Analgesics for pain management

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RC Health Status• Nutrition: Lost approximately 5% of weight in last 30 days, 

fair appetite

• Function: No falls; now walks with a walker; 50% of time in a bed or chair

• Cognition: Intact

• Disease specific: Progression of pulmonary and hepatic metastasis. New malignant pleural effusions 

• Healthcare utilization: Current hospitalization

• Symptoms: Fair appetite, worsening pain, nausea and vomiting

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Patient-Centered Care•Treat pneumonia•More chemotherapy•Full code•Symptom control•PT to improve strength

Right Care, Right Place, Right Time• Patient experience• Other quality metrics• Hospital readmissions• Mortality• Cost

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Goals of Care

Case of RC (Cont.)

• Pneumonia and shortness of breath slowly improve with antibiotics

• Nausea and vomiting resolve with IVF

• IV hydromorphone for pain control

• Ostomy output decreases

• Physical therapy consult

– Participation but unclear prospects for improvement

– Appointment in oncology 4 weeks

• Palliative care consulted

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Palliative Care Versus HospiceCharacteristic Hospice Palliative Care

Prognosis 6 months or less Advanced illness

Team Members PhysicianNurseSocial workerPastoral servicesNursing assistantVolunteer

Program‐dependent

Other services MedicationsMedical equipmentAfter‐hours careBereavement

None

Funding Medicare Part A Medicare Part BGrants

Location Patient‐dependent Traditionally hospital

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SPIKES Protocol

• Setting up the Interview and listening skills

• Patient perception

• Invitation

• Knowledge

• Explore emotions and empathize

• Strategy and summary

Baile WF et al. Oncologist 2000

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Cancer Prognosis

• Performance status is key determinant

– Activity and energy

– Lose about 70% in last 3 months of life

• How much time do you spend sitting in a chair or lying down?

– >50% then prognosis less than 3 months

• Patients with solid tumor and not receiving chemotherapy prognosis less than 6 months

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Index/symptoms Value Median Survival

>50% of day sleeping

Present ~3mos or less

KPS < 40 ~< 3 months

Anorexia Present <58 days

Confusion Present <38 days

Dysphagia Present <30 days

Dyspnea Present <30 days

Xerostomis Present <50 days

Physician Estimate

3 months 30 days

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Cancer and Prognosis Clinical Indicators

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Cancer Prognosis: Helpful Numbers

Cancer Syndrome Estimated Survival

Malignant Hypercalcemia 8 weeks (except newly diagnosed breastor MM)

Malignant Pericardial Effusion 8 weeks

Carcinomatous Meningitis  8‐12 weeks

Multiple brain mets 1‐2 months no XRT, 3‐6 months with XRT

Malignant Ascites  Less than 6 months

Malignant pleural effusion Less than 6 months

Malignant bowel obstruction Less than 6 months

Fast Fact 13

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In‐Hospital CPR

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EOL Discussions and Psychological Well‐Being

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EOL Discussions and Medical Care in Last Week of Life

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Quality of Life and Aggressive EOL Care

Wright AA. JAMA 2008;30048

AfferentPainFiber

Brainstem

CognitiveBehaviorTherapy

NSAIDs/DEX

LA/Anticonvulsants

Opioids/NMDA/α2-δ Ca Channel

TCA/SNRI’s49

Pain Management

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Wood GJ,  Shega JW, Lynch B, Von Roenn JH. Management of Intractable Nausea and Vomiting in Patients at the End of Life: “I Was Feeling Nauseous All of the Time . . . Nothing Was Working." JAMA. 2007;298(10):1196‐1207 50

Nausea and Vomiting Pathways

Case of RC (cont.)

• Wants to complete treatment for pneumonia

• Not sure about more chemotherapy

• DNR

• Some physical therapy

• Hospice informational visit

– Agreed to hospice

– Oral antibiotics, PT and symptom control

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Case of RC (cont.)• Week 1

– Completes antibiotics for pneumonia

– Participation in physical therapy

• Improvement in strength but not endurance

– Pain in rectal area continued to worsen po hydromorphone

• Week 2

– Fever developed

– Increased fatigue

– Purulent drainage from rectum

• Calls hospice. Nurse instructs patient to take more pohydromorphone and will be there in one hour

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Case of RC (Cont.)

• Patient and family become anxious and goes to ED– CT scan demonstrated progression of lung and liver metastasis plus 

rectal abscess

• Rectal drain and antibiotics initiated

• IVF for sepsis

• Patient has 10/10 rectal pain with hyperalgesia

– Parenteral hydromorphone

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Allen L A et al. Circulation 2012;125:1928-1952

• Be at home

• Treat rectal abscess

• Pain control

• DNR

• PT to improve strength

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Elements Important to Goals‐of‐Care Conversations, Shared Decision‐Making

Hospital(ED/CC/Telemetry/Med-Surg)

IPU GIP or Home

ICC ICC

Home Home

Visit VisitICC ICCTelecare Telecare

VisitFrequency

VirtualED

MobileIntensive Palliative

Care

Visit Frequency

VirtualED

MobileIntensive Palliative

Care

Patient

ED

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Hospital Readmissions

30‐DayReadmission

VITAS Healthcare(Hospice)

3.2%

Skilled Care 22.6%

Home Health 21.4%

Home 18.0%

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Case of RC (Cont.)

• Transfer to home on CC with PICC line

– IV antibiotics for 4 weeks

– Rectal drain

– IVF for sepsis for 2 days

• Patient has 10/10 rectal pain with hyperalgesia

– oral hydromorphone titration at home

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Case of RC (Cont.)

• After 6 days of CC, transitions to routine level of care– Continue IV antibiotics daily for abscess

– Physical therapy for deconditioning

– Pain management

– Ongoing education about disease progression and poor prognosis

– Social worker and patient work on funeral plans and write letters for him to leave for wife and kids

– Massage and music therapy also initiated and helpful

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Case of RC (Cont.)

• One week later, patient become short of breath and experiences some chest pain

• Nurse comes out and places patient on CC

• Goal of care determined to be comfort

• Patient dies peacefully at home several days later, surrounded by family

• Death attendance and bereavement process begin

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Healthcare Utilization Cancer Last Year of Life

Utilization Non‐Hospice Hospice Odds

Hospital Admission 65.1% 42.3% 1.5 (1.5‐1.6)

ICU Admission 35.8% 14.8% 2.4 (2.2‐2.5)

Invasive Procedure 51% 26.7% 1.9 (1.9‐2.0)

Died Hospital/SNFHospitalSNF

74.1%50.2%23.9%

14.0%3.4%10.5%

5.3 (5.1‐5.5)14.6 (13.5‐15.8)2.3 (2.2‐2.4)

Obermeyer, Z et. Al. Association Between the Medicare Hospice Benefit and Health Care Utilization and Costs for Patients With Poor‐Prognosis Cancer. JAMA 2014

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Healthcare Costs Cancer Last Year of Life

Exposure (weeks) Non‐Hospice Hospice Difference

1 $71,582 $66,779 $4,803

2 $70,987 $63,013 $7,848

3‐4 $72,660 $59,595 $13,065

5‐8 $74,890 $56,986 $17,903

9‐26 $72,432 $60,326 $12,106

27‐52 $66,035 $65,300 $735

>52  $48,918 $56,368 ‐$7.387

Total $71,517 $62,819 $8,697

Obermeyer, Z et. Al. Association Between the Medicare Hospice Benefit and Health Care Utilization and Costs for Patients With Poor‐Prognosis Cancer. JAMA 2014

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Value‐Based Healthcare

Value‐Based Outcome Non‐hospice Hospice

30‐Day Re‐Hospitalization 2 0

30‐Day Condition‐Specific Mortality

Yes No

Patient ExperienceSatisfactionPain Management

Not ExcellentNot Excellent

ExcellentExcellent

Dollar Cost Higher Lower

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Summary

• Hospice is value‐based healthcare

– Patient experience

– Hospital re‐admissions

– Condition‐specific 30‐day hospital‐specific mortality

– Healthcare costs

• Hospice—not home health or palliative care— provides comprehensive EOL care

• Differentiators of value: continuous care, visit frequency and after‐hours service 

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