Orlando—Characteristics of hospice care places it in the best position to prevent hospital readmission, according to Joseph W. Shega, MD, regional medical director, VITAS Healthcare, who presented at the NAMCP forum. These characteristics include “the structure and availability of clinical staff after hours, the frequency of clinical visits by staff, and the availability of continuous care, which provides hospital-like care at home,” he said.
In his presentation, Dr. Shega spoke on the main reasons for hospital readmission and how hospice care can prevent hospital readmissions in people with advanced illness.
“Three common themes leading to hospital readmissions among older persons include failures in discharge planning, insufficient outpatient care and community resources, and patients experiencing severe progressive illness,” he said. He highlighted that 90% of people will die of a life-limiting condition that they typically live with for 5 to 15 years. Of these people, some will experience a predictable, steady decline with a relatively short terminal phase such as with cancer, while others will experience a slow decline punctuated by periodic crises such as patients with congestive heart failure.
For patients in the advanced stages of disease at the end of life, those enrolled in hospice are 85% to 90% less likely to be re-hospitalized 30 days after discharge compared with similar patients who are not enrolled in hospice, he said. Patients enrolled in hospice care also express overall greater satisfaction in their end-of-life care. “Patients supported by hospice reported greater satisfaction with care, better pain and symptom man- agement, and an increased likelihood of dying in their location of choice—at home and out of the hospital—compared to similar patients who die without hospice,” said Dr. Shega.
Dr. Shega reviewed 2 case studies—(1) a patient with congestive heart failure and (2) a patient with rectal cancer—to illustrate situations in which hospice care can prevent hospital readmissions in patients with advanced illness.
For example, in the case of a patient with congestive heart failure, frequent readmission to the hospital is 1 factor for considering hospice care. Data show that for Medicare patients with congestive heart failure, 30-day readmissions were frequent throughout the month following hospitalization.
Other factors for considering hospice include ongo- ing symptoms despite optimal treatment, declining functional status, use of inotropes, goal of the patient focuses on quality of life, and life expectancy of 6 to 12 months.
For patients who choose hospice care, several levels of care are available including routine home care, continuous care at home, inpatient care, and respite care.
In reference to the case study of a patient with rectal cancer, Dr. Shega said that performance status is a key determinant in deciding hospice care for a patient with cancer is appropriate. Indications of a life expectancy of <3 months is a loss of activity and energy (loss of about 70% in the last 3 months of life), and spending more than 50% of time sitting in a chair or lying down. In addition, the prognosis in patients with a solid tumor and not receiving chemotherapy is <6 months.
For both case studies, Dr. Shega emphasized the importance of shared decision-making between the patient/family and the physician that is fundamentally based on the outcomes that are relevant to an individual patient such as interlocking issues of survival, costs/ burden, and quality of life.
“Patients with advanced illness are generally better served with the support of hospice services compared to traditional medical care,” Dr. Shega said.—Mary Beth Nierengarten