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News Roundup: March 25, 2013

Patient-centered palliative care leads to lower costs, happier patients

Published by Fierce Healthcare
Ashley Gold
March 21, 2013

The medical community can do a better job with expensive end-of-life care, which often is poorly coordinated and fails to acknowledge patient preferences, according to a new perspective piece published in JAMA Surgery.

Patient-centered end-of-life care that avoids aggressive treatments patients might not want also helps reduce costs, researchers from the University of California, Los Angeles Department of Urology noted in their article. They looked at studies analyzing end-of-life preferences, delivering value-congruent care and coordinating the care recommended by healthcare providers.

"When an individual patient's preference is addressed by any clinician, then care delivered at the end of life adheres better to values expressed by that individual," the authors state. "Cost of care in the last week of life can be reduced by 36 percent; death is less likely to occur in an intensive care unit, physical stress is reduced, and all of this can be achieved without shortening survival."

The article points out that neither end-of-life care nor end-of-life counseling is routinely taught in medical school or residency, despite the central role it holds in healthcare delivery. "Our curricula reflect our priorities as a medical community, and we should show that we value end-of-life care by teaching it to each trainee," study authors urge.

The researchers say many physicians are driving costs up by making end-of-life care decisions that don't improve outcomes, like aggressive treatments, with their intentions to prolong life. They also found patient-centered end-of-life care--defined as ensuring that a dying person's wishes are known and followed, without taking aggressive measures a patient doesn't want--resulted in happier patients who survive longer with less pain, according to an announcement from UCLA.

"Patients come in with incurable diseases and there's no discussion of prognosis and goals of care," author Jonathan Bergman, M.D., said in a statement. "Then a lot of very aggressive treatments can occur, due to inertia--patients are placed in an intensive care unit with oxygen and feeding tubes, and that's not always in line with their goals."

Bergman said costs are often lower when treatment plans are tailored to patient goals.

Shortages of palliative-care doctors may be part of the problem. The American Academy of Hospice and Palliative Medicine Workforce Task Force recently reported there is only one palliative care doctor for every 1,300 patients with a serious illness. The healthcare industry needs another 18,000 palliative-care doctors to meet demand, the group said.

PBS News: Costs Putting Long-Term Care Services Out of Reach

Published by Home Health Care News
Jason Olivia
March 21, 2013

High costs of long-term care threaten to put community-based services out of reach for a majority of seniors nationwide, according to PBS interview with Dr. Bruce Chernof.

Having recently been appointed to the Congress-created Long-Term Care Commission, Chernof suggests that many people associate the word “long-term care” with nursing homes.

While long-term services and supports can be found in a nursing home, they are more than likely to occur in a community setting, as well as the home, he says.

The issue with the nation’s current healthcare system, he suggests, is that most American seniors—especially those living on fixed incomes—will only be able to afford these services once Medicaid “picks up the tab” after their savings have been depleted.

PBS reports:

Most people don’t understand that 70 percent of us — when we’re over the age of 65 — will need some form of long-term services and support. That could be a nursing home, but more than likely it will be in the community. And on average, we’ll need that for three years. So all of us should be planning for this.

The average nursing home today costs about $81,000 a year. And part-time help at home and in the community is in the range of $21-$22,000 a year. So it’s not insignificant.

And so for most individuals, what it means is they end up having to spend those resources or savings to pay for various needs — it could be in the community, it could be in a nursing home.

Medicare generally pays for the acute care components that you have. But when it comes to those long-term care needs, extended time in a nursing home, or extended community needs, those are often paid for by Medicaid.

Unfortunately, the Medicaid program was built in a different time and place. And while many states are working to re-balance their services and make more services available in the home and the community, for many folks, the only option may be in a nursing home.

Seniors, their families, and even Americans who are years from retiring will have to plan both financially and mentally to ensure that their savings last throughout their retirement, Chernof says.

Walking: The Key to Reducing Senior Hospital Readmissions?

Published by Home Health Care News
Jason Olivia
March 19, 2013

Among recent studies conducted in a quest to reduce hospital readmissions among senior patients, a new study shows part of the answer may be as simple as putting one foot in front of the other.

While not found to have a direct cause-and-effect relationship, the study indicates that simply walking around could help older adults lessen their chances of a return visit after being admitted to a hospital for the first time.

Outfitting 111 adults aged 65 and older with ankle-bound “step activity monitors,” researchers of Mobility After Hospital Discharge as a Marker for 30-Day Readmission were able to track seniors’ mobility during their hospital stays.

The pager-sized device was able to count every step an individual took during hospitalization and for a week after discharge.

“We’re using activity here as a biomarker, similar to the way you might use blood pressure,” said the study’s lead author Steve R. Fisher, an assistant professor at the University of Texas Medical Branch at Galveston.

Of the 111 adults surveyed, the study found 13 were readmitted within 30 days of discharge, or 11.7% of total participants.

There was also a significant association between the average amount of daily steps taken after discharge and 30-day readmission.

Average daily steps were the strongest predictor among known readmission risk factors, the study notes, as the least active participants post-discharge were more likely to be readmitted and have longer hospital stays.

“While we can’t say whether activity is a cause or effect in these cases, we can use it as a marker to tell us whether a person is at high risk and we need to intervene,” Fisher said.

Geriatricians want to reduce readmissions among the elderly because hospitalizations can sometimes endanger their health by reducing activity levels, researchers note.

Monitoring seniors’ mobility during and post-hospitalization can be a similar precaution as patients who suffer congestive heart failure, suggests Fisher, as these patients receive a follow-up call from a nurse during their first week home.

“This is the same kind of principle,” he writes. “We want to know how much people are moving around, because we want to know whether they’re going downhill.”

Making Seniors’ Homes Safe for Aging in Place

Published by Senior Care Corner
March 18, 2013

Aging in place is a goal for seniors across the country. Many of us want to live out our lives in the home of our choice, whether our lifelong home, the home where we raised our children or a more accessible, easier to maintain home near loved ones or a favorite locale.

There are many modifications that we can make to whichever home we choose to age in place. Caregivers can help make these modifications for their senior loved ones to be sure that they are safe and able to maintain independent function.

Home Modifications for Aging in Place Seniors

Lighting – be sure there is adequate lighting in the stairways, landings and hallways to prevent trip and falls. Also check adequacy of outside lighting including possibly making existing lighting motion sensitive for after dark needs without a switch.

Handrails – maintain handrails so that they are firmly in place, install additional rails if they are not in place on both sides or at the correct location including on outside porches and entryways.

Floor surface – update the flooring to be sure all surfaces are non-skid, reduce contrasting colors if dementia is present, remove throw rugs, repair any loose or missing boards or tiles, tack down carpeting, and remove clutter to prevent falls.

Stair lift – consider installing a stair lift. This is a chair that allows the seniors or any one with decreased mobility to sit in a chair usually with a seat belt to ascend/descend the stairs in comfort and safety. This device is not generally covered by Medicare but may be worth the purchase price to allow senior loved ones to remain independent and safe at home.

Entryway – modify the front entry door to remove stairs and widen doors to make it accessible for the future.
Home monitoring technology – install home monitoring devices that can alert family members and first responders if a problem occurs. There are devices that track usual patterns of daily activity and can let a caregiver know if your senior’s activity changes which may signal a problem.

Some of these tips require more than do-it-yourself skills and may require the use of a handyman or construction pro. There are numerous quick fixes that you and other family members can accomplish to make living at home safer and easier for your senior loved ones including level style faucets and door handles, motion controlled lights in the home, programmable thermostats, grab bars, hand rails, and home seniorization changes.

You may want to consult with a Certified Aging in Place Specialist (CAPS) to plan larger modifications to be sure you are making all the most effective alterations that are needed to keep your senior safe.

There may be some costs associated with home modifications for aging in place, but the improved safety and prevention of falls which could lead to loss of functional ability will far outweigh the costs.

Reducing readmissions with a scheduled presence in the post-acute care setting

Published by McKnight's Long-Term Care News
Jerome Wilborn
March 13, 2013

Post-acute care facilities are a leading source of hospital readmissions. Approximately one-quarter of all patients who are sent to a skilled nursing facility setting (all cause DRGs) are readmitted to the hospital within 30 days. There has certainly been a great deal of emphasis on three particular DRGs (pneumonia, acute MI, and CHF), but the reality is that these patients have multiple comorbidities. The index diagnoses only contribute to their illness and frailty, and aren't necessarily the driver for the readmission itself. Clinicians who spend any modicum of time in the post-acute setting understand that these patients are very sick. Throughout the skilled nursing community, there's often a paucity of clinical presence which directly affects rates of re-hospitalizations.

This is one of the reasons, as a pulmonary critical care physician and acute care hospitalist, I decided to bring the principles of acute care hospital medicine to the post-acute facilities. Our group sees these patients with the same sense of urgency as their clinical conditions dictate. Acute changes in condition are addressed because we have a scheduled presence in these facilities. Moreover, acute changes in condition (once they're addressed) can lead to decreased re-hospitalizations and we've shown this quite convincingly. Scheduled presence improves nursing competency as oftentimes impromptu in-services contribute to the nursing staff's understanding of physician expectations.

Scheduled presence allows us to detect clinical problems earlier such that they can be addressed, again lowering the readmit rate. For instance: being in a facility at least 3-5 days a week within a defined well-publicized 2-3 hour time frame allows the nursing staff to save non-urgent clinical concerns about our patients for our discussion. We can discuss the issues and, if needed, evaluate the patients. This affords opportunity to teach the nurses and improve their evaluation and communication skills. Furthermore, being on-site creates a lower threshold to conduct face-to-face patient visits to ensure that a new sign or symptom does not represent a serious change in medical condition that could result in a readmission if not addressed quickly.

A good example would be a patient that has a fall with a subsequent minor skin tear. These patients commonly are handled on the phone and may not be seen by providers for weeks afterwards because it is communicated as an insignificant minor fall without injury (save a skin tear). But the reality is these patients may have fallen because of UTI with subsequent confusion/toxic metabolic encephalopathy. The skin tear was an epiphenomenon of something much more serious, such as azotemia that may have precipitated a UTI and the patient is now becoming septic. The only way to find that out, given that the nurses may not appreciate the other early signs or symptoms, is to see the patient.

Families also appreciate publicized scheduled site visits so they can plan conferences about their loved ones. Their understanding of a realistic care plan is an essential ingredient to lowering unnecessary discharges to the hospital.

In summary, patients in nursing facilities are frail, sick, elderly, have multiple comorbidities, and are oftentimes on many more medications than they need. It is only through frequent, publicized scheduled presence in the facility that these issues can be addressed and readmissions can be prevented.

Jerome Wilborn, M.D., F.C.C.P, is the national medical director for Post-Acute Care IPC: The Hospitalist Company.