Sourcebook : Improving Care for the End of Life : 12.7 Initiatives That Would Support Suggestions for Improvement

Reform the structure of current reimbursement rates, thus appropriating funds to improve health care for those who need multiple services in their final weeks.
It is not uncommon for people to die with multiple diseases and costly health care needs. Reimbursement mechanisms need to be altered to allow for this scope of services at the end of life and allow providers to tailor care to the needs of each patient.
Promote structures that value continuity and reduce incentives to treat episodically.
This change needs to come not only from individual providers but from the entire health care system. Our focus needs to change quite dramatically. Physicians who treat a patient from the onset of chronic illness should follow up and continue to be involved even after the patient has been referred to hospice, for example. Instead of bouncing patients from hospital to nursing home to home care - with a different health care provider in each setting - patients should be attended by a team that understands the patient's overall needs. Such continuous care requires a different approach and changes in medical education, physician practice, and consumer demand and expectation.
Pay for continuity.
To accomplish continuity of care, the health care financing system must also change direction. Insurers need to create incentives to promote continuous, flexible end-of-life care. For instance, Medicaid could give providers incentives based on avoiding disruptive transfers to and from nursing homes.
Revise the hospice benefit.
The way the Medicare hospice benefit is written and interpreted allows for too much variation based on facility and geographic region. The various fiscal intermediaries that enact eligibility guidelines vary in their flexibility and allowance for provider subjectivity. No matter how rates are set, it is advantageous for the hospice to choose the lower-cost patients. The narrowly interpreted language of the Medicare hospice benefit, "six months or fewer to live," has resulted in median lengths of stay of less than 30 days in many programs. Various strategies could expand and regularize eligibility and service mix.
Provide palliative care services in many settings.
End-of-life care is most prominently available through and funded for in hospice programs. Hospice includes a range of medical and social services with some emphasis on palliative care. Hospice programs may operate or contract for inpatient services and may even run their own freestanding inpatient facilities.

However, most hospice care is provided in the patient's home. Indeed, most hospices require that patients have a home and a caregiver available to provide assistance. These restrictions limit hospice availability for many people, including those who have no family and those who do not have a home in which hospice services can be provided.

Many hospitals now offer palliative care services, aimed at treating symptoms and reducing suffering. These programs do not have the kinds of restrictions posed by hospice services and are able to meet the needs of more diverse populations, including those whose diseases are not swift killers, those who do not have caregivers, and those whose prognosis goes beyond the six-month hospice rule.
Establish standards for end-of-life care in nursing homes.
Nursing homes and other long-term care facilities need to assure that plans are in place for most expectable emergencies. Further, nursing homes should have in place both transfer practices and review processes to determine whether such moves cause patients and/or families unnecessary distress. All staff should be trained to communicate with patients and families about change in status or preferences for "do not resuscitate" orders. Patient dignity should be emphasized as well.
Promote grassroots and community-based programs.
Many organizations become involved in state- and community-wide programs to increase awareness of end-of-life issues, encourage communication among various health care organizations, and achieve some economies of scale.
- Albemarle Home Health and Hospice, which spans 12 counties in rural North Carolina, is establishing a statewide demonstration through the state's office of rural health. The program would create a single point of entry for patients with life-limiting diseases. Albemarle presented information about end-of-life issues to the annual meeting of North Carolina's public health association, trying to expand the base of organizations that see a role for themselves in this field. Albemarle Home Care is also working to develop a North Carolina Collaborative to Improve End-of-Life Care, in conjunction with medical schools, health care organizations, and others throughout the state. According to Director Kay Cherry, the keys to success in such endeavors are "persistence, passion, and patience."
- The Minnesota Partnership to Improve End-of-Life Care is being developed by three large health care systems: Allina Health Systems, Health Partners, and Fairview Systems. Together, the three systems cover 85 percent of Minnesotans. According to participants, Minnesota has a history of organizations collaborating to improve public health. The partnership is strengthened by the involvement of physicians and executives who champion end-of-life care.
  
  The three have managed to overcome some potential barriers to collaboration, including concerns about recognition, payment and cost issues, oversight and audit, governance of the collaborative, and the need to have a common focus for effort. The group resolved finance and oversight issues by enlisting the Area Agency on Aging to be its fiscal agent. The coalition's board of directors will include two representatives from each partner and the fiscal agent.
  
  Each partner is finding that it learns from others involved in the process. Ultimately, the group plans to bring end-of-life policy issues to public attention and to develop public education campaigns around improving end-of-life care.
- The New Hampshire Collaborative on End-of-Life Care is an organization of almost 70 individuals seeking to bridge the gaps between organizations involved in end-of-life care. It was created as the result of a 1997 survey that asked 2,500 health care professionals and other community members what they would do to improve end-of-life care. Over a six-month period, the group has undertaken 16 different improvement projects, focusing on issues such as improved advance care planning; increased awareness of cultural issues; improved communication among health care providers, patients, and families; improved service delivery to rural patients; and increased use of existing hospice and palliative care programs.

Summary of Recommendations from The National Task Force on End-of-Life in Managed Care
Improve Access: Provide managed care insurance products that cover humane and effective end-of-life care for patients and families. Create specific programs for patients dying of chronic, degenerative conditions and their family caregivers. Base access to hospice care on severity of need, not estimated life expectancy. Ensure continuity of care for patients and families across different providers and care settings. Strengthen Accountability Focus continuous quality improvement efforts on end-of-life care Develop valid, standardized measures to assess the quality of end-of-life care. Report on quality of care to Medicare, Medicaid, commercial purchasers, and consumers. Improve the clinical competence of physicians, nurses, and other health care professionals providing care to patients near the end of life. Reach out to patients and families as partners in end-of-life care. Develop and Evaluate Payment Methods Test new methods for aligning financial incentives with the provision of humane and effective care. Ensure access by developing risk-adjustment strategies or other payment methods that properly compensate managed care providers and plans for the costs of caring for patients near the end of life. Develop and study the effects of alternative reimbursement methods capable of enhancing coordination between managed care organizations and hospice programs.

Summary of Recommendations from The National Task Force on End-of-Life in Managed Care

Improve Access:

Provide managed care insurance products that cover humane and effective end-of-life care for patients and families.
Create specific programs for patients dying of chronic, degenerative conditions and their family caregivers.
Base access to hospice care on severity of need, not estimated life expectancy.
Ensure continuity of care for patients and families across different providers and care settings.

Strengthen Accountability

Focus continuous quality improvement efforts on end-of-life care
Develop valid, standardized measures to assess the quality of end-of-life care.
Report on quality of care to Medicare, Medicaid, commercial purchasers, and consumers.
Improve the clinical competence of physicians, nurses, and other health care professionals providing care to patients near the end of life.
Reach out to patients and families as partners in end-of-life care.

Develop and Evaluate Payment Methods

Test new methods for aligning financial incentives with the provision of humane and effective care.
Ensure access by developing risk-adjustment strategies or other payment methods that properly compensate managed care providers and plans for the costs of caring for patients near the end of life.
Develop and study the effects of alternative reimbursement methods capable of enhancing coordination between managed care organizations and hospice programs.

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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.

For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].