Hospital Readmission: A case-based analysis

Transcription

1 Hospital Readmission: A case-based analysis Joseph W. Shega, MD Regional Medical Director I have no financial relationships to disclose. 1

2 Objectives Appreciate differentiators in services provided by palliative care, home health and hospice Recognize hospice s role in preventing hospital readmissions Identify characteristics of hospice providers best positioned to prevent hospital readmissions Recognize hospice-appropriate patients for common disease states How People Die <10% die suddenly of an unexpected event: MI, accident, etc. >90% die of a life-limiting condition, typically over a 5 15-year period. Predictable, steady decline with a relatively short terminal phase (cancer) Slow decline punctuated by periodic crises (CHF, COPD, dementia) 2

3 What Do Patients With Serious Illnesses Want? Control pain and symptoms Avoid inappropriate prolongation of the dying process Achieve a sense of control Relieve burdens on family Strengthen relationships with loved ones Singer et al, JAMA Benefits of Hospice Care Improved satisfaction Improved pain management More likely to die in location of choice Decreased costs Family support Bereavement services Live longer? Conner et al JPSM

4 Last-Place-of-Care Experience Outcome Hospice Nursing Home Home Health Hospital Not Enough Help with Pain, % Not Enough Help with Emotional Support, % Not Always Treated with Respect, % Not Enough Information about Dying, % Excellent Quality Care, % Teno et al. Family Perspectives on End of Life Care. JAMA 2004 Where do patients spend their last days? With Hospice Hospital Home Nursing Facility 8 4

5 Hospice Use Decreases Hospital Utilization Kelly, A. Hospice enrollment saves money and improves quality. Health Affairs 2013 Hospice and Medicare Cost Savings 5

6 Medicare Hospice Utilization NHPCO Facts and Figures: Hospice Care in America. Alexandria, VA: National Hospice and Palliative Care Organization, October, Case 1: Congestive Heart Failure 6

7 Case of AF 84 y/o female w/ 6-year history of CHF, relatively stable until past 6 months Presents to ED with third exacerbation in 4 months Recent EF 55% with diastolic dysfunction Long-standing ACE inhibitor, b-blocker and diuretic Doppler negative DVT, CXR CHF PMH- s/p CVA, HTN, DJD, hard of hearing Admitted to hospital with CHF exacerbation Case of AF (Cont.) Admitted to hospitalist service IV diuresis Optimization of BP medications Education about CHF Patient had cut back on diuretics due to functional urinary incontinence 7

8 AF s Health Status Clinical Impression: Likely to die within 6 to 12 months? Nutrition: Lost approximately 7.5% of weight in last 5 months, fair appetite Function: No falls; ADLs new dependent bathing, new assistance with transfers; independent ambulation, dressing, feeding Cognition: Stable Disease Specific: NYHA class III/IV, recurrent hospitalizations, ongoing symptoms Healthcare utilization: 3 hospitalizations over 4 months Symptoms: Shortness of breath/fatigue, no delirium Elements Important to Goals-of-Care Conversations Shared Decision-Making No more hospitals Minimal tests Improve shortness of breath Continue to live in house Keep alive as long as possible Allen L A et al. Circulation 2012;125:

9 Hospice Decreases Days in Hospital Hospice Guidelines NYHA Class IV : Symptomatic at rest despite maximal therapies and/or therapies are not tolerated or are refused NYHA Class III : Symptoms with minimal exertion multiple co-morbidities, renal disease, pulmonary disease, syncope, arrhythmia 9

10 Hospice Triggers Frequent readmissions to the hospital Ongoing symptoms despite optimal treatment Declining functional status Use of inotropes ICD fires despite medical therapies Patient goals focus on quality of life Would we be surprised if this patient died in the next 6 12 months? HFSA 2010 Guideline Executive Summary. Journal of Cardiac Failure 2010; 16 (6) NYHA Class and One-Year Mortality NYHA class I Description (fatigue, palpitations or dyspnea) Symptoms only with more than ordinary activity Mortality one year II Symptoms with ordinary activity 7% III Symptoms with minimal activity 13% IV Symptoms at rest 20 52% Compared NYHA 1, NYHA 4 5Xs increased risk hospital and 20Xs death Eichorn, EJ. Prognosis determination in heart failure. Am J Med

11 CHF Outcomes by Type Gotsman I et al. Plos One 2012 Cachexia and Mortality Cachexia = 7.5% weight loss over 6-month period Mortality rates independent of other factors 18% at 3 months 29% at 6 months 39% at 12 months 50% at 18 months Anker SD. Wasting as an independent risk factor for mortality in chronic heart failure. Lancet

12 Hospitalization, ADL Change & Death (Boyd, et al, 2008) Burden Heart Failure Symptoms Outcome Heart Failure EF< 30% Heart Failure >30% Advanced Cancer Number of physical 9.4 (1.1) 8.7 (1.2) 8.7 (1.5) symptoms Depression score 3.6 (0.6) 4.3 (0.6) 3.2 (0.8) Spiritual well being 35.2 (1.8) 36.3 (1.9) 39.1 (2.3) No significant difference between any of the groups Heart Failure Most common symptoms (>50%) Lack of energy Pain Feeling drowsy Dry mouth Shortness of breath Depression Bekelman DB et al Journal of General Internal Medicine

13 Pharmacologic Treatment Heart Failure Class Examples Indication Adverse Effect Other Comment ACE Inhibitor ARBs Beta blockers Aldosterone Blocker Loop diuretics Cardiac glycosides Enalapril Lisinopril ramipril candesartan losartan valsartan carvedilol metoprolol spironolactone furosemide torsemide bumetanide digoxin HF stage B D HF stage B D HF stage B D NYHA III or IV Volume overload Symptomatic HF after 1 st line Hyperkalemia, renal dysfunction, low BP, cough, angioedema Hyperkalemia, renal dysfunction, hypotension Fatigue, hypotension, depressed mood Hyperkalemia, renal dysfunction Renal dysfunction, frequent urination, increased thirst Cardiac arrhythmias, nausea, VH, delirium First line for systolic HF Add onto ACE inhibitors is not indicated First line for systolic HF monitor hyperkalemia IV or SubQ admin Monitor toxicity closely Service Differentiators Service Hospice Palliative Care Home Health Nurse 24 hours day Yes No Variable Nurse frequency of visits Unlimited Depends on Diagnosis driven program Physician support Yes Maybe No Medications included Yes No No Equipment included Yes No No Levels of care Home Inpatient Respite Continuous Depends on program Home Bereavement support Yes No No Funding Medicare A Variable Medicare B Location of service Anywhere Depends on Home program Care plan review Weekly Variable Variable 13

14 Prolonged Survival Connor SR et al, JPSM 2007; 33: Case of AF (Cont.) Family meeting with patient and daughter; discussed the following: Review of disease trajectory Overall prognosis is poor, but much we can do Hospice services best option to meet patient goals Continue to provide state-of-art CHF care Open to informational visit prior to transfer Elect skilled rehabilitation to improve function with goal of patient being able to live alone again 14

15 Case of AF (Cont.) At NH, patient participates in PT/OT and builds up some strength and endurance Able to get out of seated position and ambulate with quad cane Still short of breath with minimal exertion or at rest End of week 1, appears a little confused, blood work and urine sent for analysis At night, develops confusion and agitation Sent back to hospital Admitted with UTI and delirium Rehospitalization Rates from SNF Mohr 2010 Health Affairs 15

16 Reason for Hospital Admission from Nursing Home Krueger K et al. Nursing Research and Proactive 2011 Congestive Heart Failure: Days to Readmission JAMA 2013 Median Days to Rehospitalization CHF 12 days MI 10 days Pneumonia 12 days 16

17 Reason for CHF 30-Day Readmission JAMA 2013 Case of AF (Cont.) Hospital plan of care Antibiotics Gentle hydration Safe and supportive environment Cognition improves within 2 days and PT evaluation recommends skilled Family elects to return to skilled facility for PT 17

18 Case of AF (Cont.) Participates in PT/OT and continues to improve endurance and strength Discharge planning initiated with discussions of home health or hospice NYHA Class III or IV Daughter wants PT in home for a couple of sessions when patient transitions Home health aides to help bathe patient SNF Use by Older Adults in Last 6 Months of Life Only 1.5% enrolled in hospice at discharge 18

19 Case of AF (Cont.) Daughter elects home health, as SNF believes hospice would not cover PT Patient makes a smooth transition home Two weeks later, on Sunday, patient develops acute shortness of breath Call home health service Answering service recommends going to ED In ED, daughter asks what can be done to keep mom out of the hospital Care Transitions 19

20 Readmission Rate Levels of Care Routine Home Care Continuous Care at Home Inpatient Care Respite Care 20

21 Case AF (Cont.) Elects hospice benefit Inpatient hospice, contract bed or continuous care at home? Continuous care Diuresis with subcutaneous furosemide CHF exacerbation improved; 4 days later transitions to routine home care Physical therapy assessment initiated Dies 5 months later at home with one additional episode of acute exacerbation CHF on ICC Case 2: Cancer 21

22 Cancer End-of-Life Care Where People Die What patients want Survey of >2,500 Medicare patients 86% want to die at home 9% want to die in hospital What cancer patients get Dartmouth Atlas Project (Medicare) 29% die in the hospital 24% are admitted to the ICU in their last month of life Chemotherapy Administration 62% last 2 months of life 20-50% last month of life 6.2% last week of life Dartmouth Atlas Barnato AD et al, Med Care 2007, 45: Becarro M et al, J Epidemiol Community Health 2006;60: Hospice Enrollment, Last Month of Life 22

23 Hospice Enrollment, Last 3 Days of Life Case RC RC is a 59 y/o male with rectal cancer admitted to hospital with nausea, vomiting and increased ostomy output five days after receiving fourth line of chemotherapy. He spends about 50% of his time in a chair or bed and has significant lower back pain IVF initiated Anti-emetics initiated Pain management 23

24 RC Health Status Nutrition: Lost approximately 5% of weight in last 30 days, fair appetite Function: No falls; now walks with a walker; 50% of time in a bed or chair Cognition: Intact Disease specific: Progression of pulmonary and hepatic metastasis Healthcare utilization: Current hospitalization Symptoms: Fair appetite, worsening pain Elements Important to Goals-of-Care Conversations Shared Decision-Making More chemotherapy Full code Pain and nausea control PT to improve strength Allen L A et al. Circulation 2012;125:

25 Concurrent Appropriateness of Hospice and Anti-Tumor Therapy Competing priorities of anti-tumor therapy versus hospice Chemotherapy requires a good performance status Phase 1 chemotherapy typically needs an estimated survival of 3 months Hospice enrollment possible at 6 months Accurate prediction of prognosis important for good clinical decision-making Communicating News about Serious Illness is Difficult because Unable to deal with intensity of response Fearful of reaction Don t want to take hope away from patient Illness as an indication of failure The task is unpleasant Lack of training Stress Feeling of inadequacy Requests by family to withhold information Takes time Personal fear 25

26 Communication of Prognosis Lamont et al., Ann Intern Med 2001;134: Cancer Hospice Appropriateness Performance status is key determinant Activity and energy Lose about 70% in last 3 months of life How much time do you spend sitting in a chair or lying down? >50%, then prognosis less than 3 months Patients with solid tumor and not receiving chemotherapy, prognosis less than 6 months 26

27 Chemotherapy Bias Weeks JC NEJM 2012 In-Hospital CPR 27

28 Cognitive Behavior Therapy NSAIDs/DEX Brainstem Opioids/NMDA/α2-δ Ca Channel TCA/SNRI s LA/Anticonvulsants Afferent Pain Fiber Nausea and Vomiting Pathways Wood GJ, Shega JW, Lynch B, Van Roenn JH. Management of Intractable Nausea and Vomiting in Patients at the End of Life: I Was Feeling Nauseous All of the Time... Nothing Was Working." JAMA. 2007;298(10):

29 Case RC (Cont.) Palliative care consulted Improved pain management Nausea and vomiting resolved Physical therapy consult Participation but unclear prospects for improvement Appointment in oncology 4 weeks Transferred to skilled rehabilitation Case of RC (Cont.) Week 1 Participation in physical therapy Improvement in strength but not endurance Pain in rectal area continued to worsen Week 2 Fever developed Increased fatigue Puss from rectum Transfer to acute care hospital 29

30 Case of RC (Cont.) CT scan demonstrated progression of lung and bone metastasis plus rectal abscess Rectal drain and antibiotics initiated Patient has 10/10 rectal pain with hyperalgesia Parenteral hydromorphone Goals of care conversation with palliative care SPIKES Protocol Setting up the interview and listening skills Patient perception Invitation Knowledge Explore emotions and empathize Strategy and summary Baile WF et al., Oncologist

31 End-of-Life Conversations and Psychological Well-Being End-of-Life Discussions and Medical Care, Last Week of Life 31

32 Elements Important to Goals-of-Care Conversations Shared Decision-Making PT to improve strength More chemotherapy Full code Pain control Allen L A, et al. Circulation 2012;125: Case RC (Cont.) Hospitalist reviews care options Patient ready for hospital discharge Oral antibiotics Hemodynamically stable Not accepted at any skilled facility Wife believes husband too sick to care for at home Only option is hospice to provide support and symptom management 32

33 Case RC (Cont.) Referral made to other hospice for evaluation Prognosis 6 months or less Goals of care not consistent with hospice care Wants more chemotherapy Needs to continue antibiotics Full code Desires physical therapy to build strength and endurance Case RC (Cont.) Decision made to ask VITAS to accept patient, as no other care options exist VITAS does assessment on Friday afternoon Patient elects hospice benefit and transfers to IPU Arrives Friday night 7pm 33

34 Case RC (Cont.) Patient arrives to IPU and discuss goals 10/10 pain with no long-acting pain medication Required 40mg IV dilaudid first 24 hours Psychosocial distress/angry/afraid to die Social worker and chaplain services on weekend Full code Hope for the best, plan for the worst Case RC (Cont.) Continue antibiotics Complete course as directed by ID in hospital Get stronger to get more chemotherapy Physical therapy consult Wound care 34

35 Case of RC (Cont.) Pain control overall improves over next 72 hours Gradual decline over those 72 hours as sleeping more and not eating Ongoing conversations about goals of care DNR Stop physical therapy Finish course of antibiotics No artificial nutrition or hydration Passes away comfortably in IPU after one week Quality of Life and Aggressive End-of-Life Care Wright AA. JAMA 2008;300 35

36 Programs Veterans ED Diversion Cardiac Charity Care Advance Technology Transfusions TPN Palliative XRT Hospice Characteristic Differentiators Team IDG Hospice Aide Respiratory Physical Therapy Speech Pet Visits Massage Therapy Music Therapy Levels of Care Home Continuous Inpatient Respite Service Availability Telecare Visit Frequency Night Visits Quality Readmission Rate Death Attendance Care Satisfaction Symptom Scores Variability Hospice Care Philosophies about advance technology Transfusions, TPN, palliative XRT Oxygen delivery Dialysis Dobutamine/milrinone Antibiotics Home ventilator withdrawal program LVAD 36

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