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Emphasize Quality of Care in Hospice and Palliative Care

Posted 1/10/2013 Categories: palliative care, patient goals of care, hospice

In his New York Times opinion piece about end-of-life care, Better, if Not Cheaper, Care, Ezekiel Emanuel makes some perfectly valid points. Yes, hospice care is usually better able to meet the needs of patients in the last months of life than hospitals. Yes, patients deserve hospice care at home even if the health care system is unable to save money doing so. Yes, reliable evidence that hospice care costs less than traditional care remains hard to come by and, where it exists, is inconsistent and thus inconclusive. And yes, among the overriding reasons the cost of end-of-life care may be so high is, as he suspects, that patients are often transferred to hospice at home too late.

But in addition to addressing the costs of end-of-life care, we’d like to put the emphasis on the right care at the end-of-life for our nation’s citizens. The quality of the care given during a patient's final weeks and months should be respectful, palliative and holistic. In our view, those care qualities are at the heart of hospice.

The premise that hospice care saves no money for the health care system in the long run strikes us as debatable. In the best of scenarios, it does. On this much we can certainly agree: let's all take a harder, peer-reviewed look at the dollar figures involved in end-of-life care than we have to date. But let's make sure quality is always part of the equation.

If our experience at Amedisys in providing hospice and palliative care to more than 25,000 patients across the United States has taught us anything, it's that patients expect and deserve an end-of-life experience based not on economics but, rather – and above all – on clinical skill in meeting the patient’s goals of care and the deepest possible compassion.

About the Authors

Michael Fleming, MD, FAAFP is the chief medical officer for Amedisys, and Past President of the American Academy of Family Physicians and the Louisiana Academy of Family Physicians.

Kevin Henning, MD, FAAFP, FAAHPM, is chief medical director of Amedisys Home Care and Hospice. He is a nationally recognized leader in hospice and palliative medicine.

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Longitudinal Chronic Care Needed to Reduce Burden of Disease

Posted 12/20/2012 Categories: heart health, home health, diabetes, chronic care

Last week an important new study drove home a point that deserves wider attention. It is this: managing chronic disease requires an effort that is sustained 24 hours a day, seven days a week, 365 days a year. And no approach is better equipped to achieve that objective than the new, ever-evolving discipline of healthcare at home.

The study, published in the British journal, The Lancet, took a look at the global burden of disease over the last 10 years. It came as no surprise to me that the single biggest contributor to this burden is chronic disease. As life expectancy climbs in the U.S., so, too, does the number of years people will live with chronic diseases ranging from diabetes and high blood pressure to heart disease and mental health disorders. This shift in longevity calls for the U.S. healthcare delivery system to change its paradigm, and dramatically so.

That overarching shift in strategy can only be accomplished through a model that truly integrates and coordinates care – and that, more specifically, partners primary care physicians, nurse practitioners, therapists and other healthcare professionals with providers of high-quality healthcare at home. Healthcare delivery should no longer consist, for example, of a twice-a-year check for a blood pressure or a four-day hospital visit for pneumonia. That kind of episodic engagement, though highly valuable, ultimately represents short-term thinking.

Rather, healthcare has to be practiced year-round, and even minute-by-minute. Managing patients with chronic disease should involve daily monitoring of the most vital criteria, including blood pressure, diet and physical activity. Only then can our patients meet the daily functional goals of day-to-day living.

Others have made this argument before. Dr. Ed Wagner and colleagues at the MacColl Center pioneered a model of chronic care management that incorporates these principles. Susan Dentzer, editor-in-chief of the policy journal Health Affairs, said this model “delivers superior patient care and health outcomes.” In short, primary care teams everywhere must reorient themselves. They must team up ever-more with the highly skilled clinicians who are increasingly deployed to care for patients at home.

You can read the entire Global Burden of Disease study at The Lancet.

About the Author

Michael Fleming, MD, FAAFP is the Chief Medical Officer for Amedisys, and Past President of the American Academy of Family Physicians and the Louisiana Academy of Family Physicians. Dr. Fleming has served as Speaker of the Congress of Delegates of the AAFP and as Board Chair of the AAFP Board of Directors. He serves as an assistant clinical professor in the Department of Family Medicine at the LSU Health Science Center and in the Department of Family and Community Medicine at Tulane University Medical School.
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Discuss Patient Goals of Care for Home Health and Hospice Month

Posted 11/19/2012 Categories: chronic care, home health, patient goals of care, hospice, caregiving

As patients age and develop chronic medical conditions, they usually begin to modify their medical care goals. The burden of chronic illness and its associated debility causes many people to want to alter their medical treatment to meet their goals.

Unfortunately many health care professionals neglect to ask patients about their goals of care. In the haste to provide state-of-the-art complex medical care, whether in the hospital, clinic or home environment, many practitioners simply don’t think about asking patients what is important to them. Sometimes it’s assumed that the patient’s goal of care is obvious or the same as our goal. This assumption can lead to scenarios in which elderly patients receive care that is overly burdensome and undesired.

Most physicians and nurses don’t need to think long to recall patients we know who received medical care they didn’t want. In my primary care and hospice practice I encountered numerous elderly patients who had been treated in the intensive care unit with intravenous infusions, ventilators, dialysis and invasive monitoring devices, and after discussion with the patient and family it became clear that this treatment was never desired by the patient. The problem, of course, was that the physicians and clinicians involved didn’t take the time to ask the patient about his or her wishes.

As we celebrate National Home Health and Hospice Month and Amedisys’ 30th birthday, we urge the health care community to give patients and their families the best gift we can: a discussion with them about their goals of care. Whether you are a physician, nurse, social worker or other caregiver, take the time to sit down with your patients and ask them about what they want in their care plan.

You might ask questions like these:

  • In terms of your medical treatment, what is most important to you at this point? For example, are you interested in getting stronger, reducing the medications you take or strengthening relationships with your family? Is symptom control most important to you or is living as long as possible most important to you?
  • In what setting do you want to be treated? Do you want to go to the hospital or would you rather be treated at home if possible? If needed do you want to go to an assisted living facility or nursing home?
  • What treatment burden are you willing to accept? Would you agree to dialysis if your doctor ordered it? Are you willing to have surgery or be placed on a ventilator?

We must acknowledge several realities when asking patients these questions. First, some patients have goals that are unrealistic. Patients may want to stay at home even when they are unsafe at home or have family members who are unable to care for them. Patients may want their medical problems treated without making necessary lifestyle changes. Second, as patients’ conditions change their goals may change. Finally, patients may not be able to easily answer these questions.

Even though these issues are real, it doesn’t mean we shouldn’t ask the questions. Oftentimes the most difficult discussions are the most important ones to have in health care (learn a helpful technique for difficult medical conversations here). Excellent clinicians will repeatedly discuss these issues with patients so they can continue to clarify and reach realistic goals over time. Only then can patients receive the type of medical care they want in the location of their choice and in a way that will help them reach their goals of care.



Five Wishes Advanced Care PlanningFor detailed advanced planning that patients and their families can work on together, you might suggest Five Wishes. The Five Wishes workbook is a clear, simple way to talk about plans for care at the end of life, and is legally valid in 42 states. Download a copy of Five Wishes »


About the Author

Kevin Henning, MD, FAAFP, FAAHPM, is chief medical director of Amedisys Home Care and Hospice. He is a nationally recognized leader in hospice and palliative medicine.

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Preventing Falls – The #1 Cause of Hospitalization in the Elderly

Posted 9/20/2012 Categories: falls prevention, independence at home, caregiving

For seniors, falls can have serious health and lifestyle consequences. According to the Center for Disease Control (CDC):

  • One in three adults age 65 and older falls each year; this increases to one in two for those 80 and over
  • The cost of fall-related injuries is projected to reach nearly $55 billion by 2020—CDC’s National Center for Injury and Prevention Control
  • The majority of falls take place in the home

“Falls Prevention Week” begins on September 22. To help seniors and their caregivers reduce the risk of falls, we’ve put together these tips on preventing fall injuries. Taking these simple precautions in the home all year round can help you or your loved one live a healthier, more independent life.

(Click Image to Enlarge)

Falls Prevention Infographic
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Shedding Light on the Chronic Care Challenge (Infographic)

Posted 9/12/2012

The sheer size and complexity of the way chronic illness strains the health care system can be hard to grasp. The good news is that this infographic, The Chronic Care Challenge, may shed some light on the problem and an idea that may be a big part of the solution.

(Click image to enlarge)

The Chronic Care Challenge
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