Many care providers are testing the waters by developing some special service array which emphasizes symptom management, continuity, and family concerns. The Washington meeting was the first to consider implementing innovations contemporaneously, and with careful measurement of process and outcomes, aiming to develop the information needed to guide changes in Medicare financing and regulation.
MediCaring is the name being given to a strategy of developing, financing, and evaluating tailored services for persons with serious illness which will eventually prove fatal. MediCaring might well encompass cancer patients not yet ready for hospice, people with organ system failures, and people dying slowly of neurologically disabling diseases.
The guiding principle behind MediCaring is that people facing life-limiting illnesses have similar needs and concerns, such as comfort, family relationships, spiritual issues, and advance planning. These priorities are often rather different from those of the usual person with an acute illness, who wants the problem fixed and life prolonged. The care system that accommodates the needs and fears of that usual person with acute illness is sadly mismatched with the needs and fears of a person whose illness will inexorably worsen through to death. MediCaring providers would serve these persons with a tailored mix of supportive, preventive, palliative, and even life-prolonging care.
The MediCaring demonstration project would aim to learn how, for a defined population, financing and regulation might be implemented that would make it possible to develop and sustain good care.
ome of the major issues discussed at the Washington planning meeting were:
After much discussion, meeting participants tended to center upon the appropriateness of working with congestive heart failure and chronic obstructive lung disease patients. Participants agreed that careful measures of resource use in conventional and improved models of care would be essential. After a wide-ranging discussion of the opportunities and problems in proceeding, participants overwhelmingly voiced continued interest in developing MediCaring as a sustainable demonstration.
Only hospice now offers special services for end-of-life care. However, hospice serves a very small portion of the dying population, and only for a short period of time. Hospice has a myriad of limitations in serving all of a MediCaring population, including a Medicare eligibility requirement for a life expectancy of 6 months or less.
Other funding streams regularly thwart efforts to create sustainable and excellent systems of care. Managed care organizations cannot afford to generate a good reputation for such costly patients, since attracting high cost patients is seriously disadvantageous when payment for all patients is the same. Fee-for-service payments discourage continuity, emotional support, advance planning, and team care, all of which seem essential for excellent care for that last phase of life. MediCaring might resolve some of the critical issues in end-of-life care settings.
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