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The Big Talk Every Physician Owes Older Patients

Posted 2/17/2014 Categories: hospice, long-term, home health

 
All too often, physicians decide against initiating a conversation with elderly patients about long-term care without an urgent need to do so.
But talking the talk literally comes down to a matter of life and death.
What to do?
For starters, medical education should be improved. Universities should adopt training in long-term care, including how to talk with patients about it. As it happens, Amedisys conducts two Continuing Medical Education programs for physicians about long-term care, one focused on healthcare at home, the other on hospice.
Second, conduct peer-reviewed research into physician and patient attitudes toward long-term care. Explore outcomes, too, to foster a better understanding of the issues at hand and develop potential solutions.

Third, advocate for the creation of guidelines, policies and protocols about physician-patient conversations about long-term care. Right now a recommendation of long-term care is seen as a negative metric. But we’ve got it exactly backwards. It’s actually a step in the right direction.
Fourth, pass the torch. Encourage other medical professionals – nurse practitioners, physicians’ assistants, therapists and social workers – to likewise talk the talk.
So think long-term. Only then will every patient you see get his or her due.
Please see my new commentary piece about this topic – about why this issue exists in the first place and more of my blueprint on how physicians should start this conversation – in the latest issue of Modern Healthcare: http://www.modernhealthcare.com/article/20140201/MAGAZINE/302019979
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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CME Webinar: Goals of Care and Hospice Eligibility

Posted 11/25/2013 Categories: patient goals of care, webinar, hospice

November is National Home Health and Hospice Month, so we teamed up with Antidote CME on a series of webinars to help you ensure your patients have access to the home-based care they need.

Today’s featured webinar is about one of the most challenging situations a physician can face: caring for a patient when the options for curative treatment have been exhausted. This short webinar will give you tips on preparing for and having these conversations, and how to know when a patient is appropriate for hospice.

It's Not Easy, but It's Not That Hard: Discussing Goals of Care and Hospice Eligibility

Length: 29 minutes
Topics: • Discussing patient goals of care up front
• Preparing for an having difficult conversations
• Hospice eligibility requirements
CME: .5 ACCME AMA PRA Category 1 Credit
Launch Webinar ›

Check out the first webinar in this series on home health care, or visit our education and resources page for more about home health and hospice care.

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Updates to CMS Hospice Eligibility Guidelines – What Health Care Providers Need to Know

Posted 8/2/2013 Categories: dementia, hospice, alzheimer's

A pivotal requirement for hospice eligibility is a prognosis of six months or less (following the normal course of a disease). CMS has provided a number of clinical guidelines to help identify when a patient with terminal illness is clinically eligible for hospice. These guidelines are very useful when looking at disease processes that are known and when disease trajectory is more predictable.

However, oftentimes we recognize that elderly patients undergo what is indiscriminately referred to as “the slow dwindles”. In many cases a combination of a number of chronic illnesses is the culprit and the progressive functional and clinical decline associated with these illnesses is indicative of poor prognosis in and of itself. A common practice in these instances has been to consider the use of Debility or Adult Failure to Thrive (FTT) as a primary hospice diagnosis.

Over concerns that Debility and Adult FTT have become “catch all” diagnoses that do not accurately reflect a terminal illness, CMS has recently provided clarification on the use of these two particular diagnoses.

Effective immediately, hospices are no longer allowed to use Debility or Adult FFT as a primary diagnosis.

Instead, hospices are advised to determine the cause of the debility or Adult FFT that they are witnessing. In effect, hospices must now provide a specific diagnosis that has resulted in the debility or FTT, using these two diagnoses in question as a secondary diagnosis further describing the clinical picture that has resulted in the determination of six month prognosis.

For example, consider a patient recently hospitalized for pneumonia who has underlying COPD, Alzheimer’s disease, and renal disease. Clearly all of these diagnoses combined contribute to a poorer prognosis than would one condition by itself. Prior to hospitalization this patient was experiencing symptoms suggestive of adult FTT as evidenced by progressive functional decline, incontinence, weight loss and spending much of the day in bed. The determination must be made which of the underlying diagnoses (e.g., COPD, Alzheimer’s, renal disease) has primarily resulted in the failure to thrive. In this instance, Adult FTT will become a secondary condition.

CMS is also reviewing the use of “dementia” as a primary diagnosis. To be clear, CMS will likely be looking for greater definition related to the specific type of dementia identified as the primary hospice diagnosis. As we all know, there a numerous types of dementia, each with its own disease trajectory and clinical presentation. Although there is no specific requirement issued by CMS at this time, hospices would be well advised to avoid the non-specific diagnoses such as “dementia with behaviors” or “dementia without behaviors” as a primary diagnosis.

Amedisys will be moving forward in a proactive manner, working closely with physicians and medical directors to identify the specific type of dementia that will be listed as the primary diagnosis. The most common forms of dementia seen in hospice today include: Alzheimer’s disease, Vascular dementia, Lewy Body dementia, Parkinson’s Disease dementia, and Frontotemporal dementia.

Hospice Eligibility Kit

Determining prognosis indicative of hospice eligibility is not always easy. If you’d like more details, download our Hospice Eligibility Kit. It includes eligibility criteria for common conditions (like Alzheimer’s, cardiopulmonary disease and liver disease) and guidance on how to have the hospice conversation with a patient, an important part of helping patients receive the right care at the right time.

About the Author

Corrine Connors is a Family Nurse Practitioner and Certified Hospice Administrator with 13 years of experience in hospice and palliative care. Corrine currently works for Amedisys as Chronic Care Program Manager focusing on the development of disease specific programs, trainings and educational materials in support of hospice.
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New Mt. Sinai Research on Hospice Care Benefits

Posted 3/15/2013 Categories: hospice, research, chronic care

The March 2013 issue of Health Affairs features new empirical research on hospice care from Mt. Sinai. The article, "Hospice Enrollment Saves Money For Medicare And Improves Care Quality Across A Number Of Different Lengths-Of-Stay," validates the integration of hospice care for delivering three main benefits:

  • Improved quality of care
  • Medicare cost savings
  • Reduced use of hospital-based services

Click here to read the full article
Amy S. Kelley, Partha Deb, Qingling Du, Melissa D. Aldridge Carlson and R. Sean Morrison. Hospice Enrollment Saves Money For Medicare And Improves Care Quality Across A Number Of Different Lengths-Of-Stay. Health Affairs, 32, no.3 (2013):552-561

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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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