End-of-Life Care: Institute for Change - Research Center Palliative Care Initiative

First Rigorous Study to Examine Effectiveness of In-Home, Community Based Palliative Care

Costs of medical care at the end of life are extraordinary. In an examination of costs in the last year of life, Lubitz & Riley (1993) found that 10-12% of the total U.S. health care budget and 27% of the annual Medicare budget were spent on care at the end of life. Despite the changing demographics of our nation and increased use of hospice, this figure has remained constant over the past two decades (Hogan, Lunney, Gabel, & Lynn, 2001).

Average per-person medical expenditures in the last year of life are estimated at $28,000, with 50% of the expenditures attributed to hospital services (Emanuel et al., 2002). Examination of annual Medicare expenditures found that decedents spend six times as much as survivors (Hogan et al., 2001). Further, a newly published study (Wennberg, Fisher, Baker, Sharp, & Bronner, 2005) found that Los Angeles leads California in end of life care costs with an average cost of more than $58,000 in the last two years of life. Christakis et al. (1996) found that in the 270 days prior to hospice admission, patients averaged 1.6 (s.d.= 1.7) hospital admissions with a mean number of hospital days of 18.3 (s.d. = 23.3). Hospital days remained high even in the 30 days immediately prior to hospice admission, with patients averaging 11.56 (s.d. = 13.7) hospital days.

The last two decades have brought an increased focus on how Americans die (DuPre Brodie & Powers, 2002). Despite this attention, our nation has made little progress in improving the dying experience for many terminally ill patients as well as reducing costs of care.

Moreover, there has been much debate about the actual ability of hospice to reduce service costs at end of life. In a review of studies examining savings from hospice care, Emanual (1996) found inconsistent results between studies, obscured by methodological flaws. Most noticeable in his review was that in randomized studies cost savings were not found (Emanuel, 1996). All of the studies he examined are now more than a decade old. Many were conducted over 20 years ago and have dubious applicability to our current health care environment. More recent investigations have supported the opinion that hospice may not result in significant savings. Hogan and colleagues (2000) found in their analysis of Medicare claims data from 1993 to 1998 that overall costs for hospice users were not significantly different from those of non-hospice users. However, this may be due in part to the high rate of late enrollment into hospice programs. Currently, the median length of stay on hospice is 22 days and 35% of hospice patients died within 7 days or less of enrollment (NHPCO, 2005).

Through reallocation of existing resources, Kaiser Permanente and Partners in Care Foundation developed the In Home Palliative Care (IHPC) program that provides comprehensive, multidisciplinary in home care to terminally ill patients in their last year of life.

The IHPC is an interdisciplinary home-based care program that provides home visits by physicians, nurses, social workers, and other health care professionals to terminally ill patients with an estimated life expectancy of one year and diagnoses of cancer, congestive heart failure, and/or chronic obstructive pulmonary disease.

Provision of these services does not preclude the use of usual and customary services such as physician office services, specialty care, and the emergency department or inpatient care. Consistent with the Medicare Hospice benefit, the IHPC program provides a myriad of medical and supportive care within the patient’s home.

This care includes extensive patient and family education on the disease or medical condition, training in symptom control, and psychosocial support aimed at assisting the patient and family in making care choices in advanced. The clinical structure of the IHPC parallels the Medicare Hospice benefit with several important modifications.

First, care is not limited to the last six months of life. Terminal patients served by the IHPC program may have a prognosis of 12 months or less to live as opposed to the hospice six-month life expectancy criteria. In addition, enrollment in the IHPC program does not entail forgoing curative care in exchange for palliative care. While a complete array of services are provided to the patient by the palliative care team, IHPC patients may continue to seek services such as visits to their primary care physician, outside of IHPC. This allows IHPC patients access to a blended model of care, gradually decreasing curative practices and increasing palliative measures as their needs and desires shift.

The IHPC core team is responsible for coordinating and managing care across all settings as well as providing assessment, conducting evaluation, planning, care delivery, follow-up, monitoring and continuous reassessment of care.

Services are provided in the home, with physicians providing home visits as needed. This patient centered approach integrates patient spiritual, cultural and care preferences into the care plans which are developed jointly with patients and caregivers with the goals of reducing pain and managing other symptoms, and of providing psychosocial support and spiritual-emotional comfort for patients and their families.

This method encourages patients, family members and professional caregivers to exchange knowledge and facilitates communication on treatment preferences (Cherin et al., 2001). In addition, the biopsychosocial interdisciplinary approach ensures that the psychosocial issues are addressed as well as the medical problems. The social worker plays a pivotal role in addressing issues of depression, stress, and coping (Claiborne & Vandenburgh, 2001), issues that are often present at end of life and are critical in improving self-efficacy for disease and symptom control.

These methods manifest the goal of shifting end-of-life care from an acute care inpatient focus to that of a chronic care home-based model, thus reducing costs of care while aligning with patient care preferences. The IHPC program is described more thoroughly elsewhere (Brumley & Hillary, 2005; Brumley, Enguidanos, & Cherin, 2003; Brumley, Enguidanos, & Hillary, 2003; Cherin, Enguidanos, & Brumley, 2001).

Results of studies conducted within KP found that this model of care is successful in reducing both emergency room visits and hospitalizations, resulting in cost savings that range from 37% to 45% less than terminally ill patients receiving traditional care (Brumley & Hillary, 2005; Brumley, Enguidanos, & Cherin, 2003; Brumley, Enguidanos, & Hillary, 2003). Further, patients enrolled in the palliative care program had improved satisfaction with care at 30 and 60 days following enrollment with no change among those receiving traditional medical services (Brumley, Enguidanos, & Cherin, 2003).

This model holds tremendous opportunities for reforming end of life care delivery resulting in significant cost reductions in health care expenditures throughout California as well as nationally. Through restructuring health care delivery and reimbursement streams paired with realignment of financial incentives to provide comprehensive services in the home, end of life care experiences can be improved while simultaneously resulting in a significant reduction in costs.

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Partners welcomes leaders and innovators to join with us in exploring the possibilities of "changing the shape of healthcare" and social services so they work for all.

To discuss a collaborative project or idea contact:
W. June Simmons, President and CEO, 818.837.3755 ext. 101 or email or
Dr. Susan M. Enguidanos, IFC/Research Center Director 562.622.4099 or email

References:

Brumley, R., & Hillary, K. (2005). Developing an Outpatient Based Palliative Care Program. Paper presented at the National Hospice and Palliative Care Organization, Management and Leadership Conference, Hollywood, FL.

Brumley, R. D., Enguidanos, S., & Cherin, D. (2003). Effectiveness of a Home-Based Palliative Care Program for End-of-Life. Journal of Palliative Medicine, 6(5), 715-724.

Brumley, R. D., Enguidanos, S., & Hillary, K. (2003). The Palliative Care Program. The Permanente Journal, 7(2), 7-12.

Cherin, D., Enguidanos, S., & Brumley, R. (2001). Reflection in action in caring for the dying: applying organizational learning theory to improve communications in terminal care. Home Health Care Serv Q, 19(4), 65-78.

Cherin, D., Huba, G. J., Brief, D. E., & Melchior, L. A. (1998). Evaluation of the Transprofessional Model of home health care for HIV/AIDS. Home Health Care Serv Q, 17(1), 55-72.

Cherin, D. A., Huba, G. J., Steinberg, J., Reis, P., Melchior, L. A., Marconi, K., et al. (2001). Satisfaction with services in innovative managed care programs for groups of traditionally underserved individuals with HIV/AIDS: empirical models. Home Health Care Serv Q, 19(1-2), 103-125.

Christakis, N. A., & Escarce, J. J. (1996). Survival of Medicare patients after enrollment in hospice programs. N Engl J Med, 335(3), 172-178.

DuPre Brodie, R., & Powers, P. E. (2002). Improving the Quality of End-of-Life Care for Californians: California Health Care Foundation.

Emanuel, E. J. (1996). Cost savings at the end of life. What do the data show? JAMA, 275(24), 1907-1914.

Emanuel, E. J., Ash, A., Yu, W., Gazelle, G., Levinsky, N. G., Saynina, O., et al. (2002). Managed care, hospice use, site of death, and medical expenditures in the last year of life. Arch Intern Med, 162(15), 1722-1728.

Hogan, C., Ginsburg, P. B., & Gabel, J. R. (2000). Tracking health care costs: inflation returns. Health Aff (Millwood), 19(6), 217-223.

Hogan, C., Lunney, J., Gabel, J., & Lynn, J. (2001). Medicare beneficiaries' costs of care in the last year of life. Health Aff (Millwood), 20(4), 188-195.

Hogan, C., Lynn, J., Gabel, J., Lunney, J., O'Mara, A., & Wilkinson, A. (2000). Medicare Beneficiaries' Costs and Use of Care in the Last Year of Life. Washington DC: Medicare Payment Advisory Commission.

Lubitz, J. D., & Riley, G. F. (1993). Trends in Medicare payments in the last year of life. N Engl J Med, 328(15), 1092-1096.

NHPCO. (2005). NHPCO Facts and Figures. Alexandria: National Hospice and Palliative Care Organization.

Wennberg, J. E., Fisher, E. S., Baker, L., Sharp, S. M., & Bronner, K. K. (2005). Evaluation the efficiency of California providers in caring for patients with chronic illnesses, from http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.526