Demand growing for palliative care

Half of his patients die within two weeks of admission; one-third die within one week of admission. Yet, for Dr. Edward W. Martin, chief medical officer at Home & Hospice Care of Rhode Island, the ability to provide palliative and hospice care to patients with terminal illnesses is “gratifying.”
Growing demand for such care in Rhode Island is at the nexus of attempts to control hospital costs by cutting down on the high rate of hospital readmissions. Home & Hospice currently has a waiting list for its 24-bed facility, which offers a compassionate way for people to die when they are incurably ill. Although Medicare will pay up for up to six months of hospice and palliative care for patients diagnosed as terminally ill, many people only live for a few weeks.
In Rhode Island, with its rapidly accelerating population of aging citizens, there has been what Patricia A. Nolan, executive director of the Rhode Island Public Health Institute, calls “the compression of morbidity” related to the health problems of aging and the accumulation of the burdens of chronic disease. “We age without seeming to get sicker, and then we can crash and burn,” she said.
Deaths from heart disease may occur later in life – in the 70s and 80s instead of the 50s and 60s, Nolan continued. But the burden of an aging population is a demographic reality for Rhode Island, because of the falling birth rate and aging baby boomers, according to Nolan, an adjunct associate professor of community health at Brown University.
The reality of Rhode Island’s aging population is a big concern for hospitals as well. “In Rhode Island, we have a very significant growth in our population over the age of 65. We have one of the highest concentrations of people over the age of 85,” said George A. Vecchione, president and CEO of Lifespan, the state’s largest hospital system. As a result, he continued, there are more complexities, more chronic conditions that need to be maintained.
Home & Hospice of Rhode Island is one of seven hospice facilities in the state, caring for 400 patients on almost any given day, Martin said.
“Our patients might be in their own home, they might be in assisted living, some of them are in a nursing home setting,” Martin said. “The vast majority of our patients are [older than] 65 – 90 percent.” The nonprofit, health-services organization, which in 2009 moved into its newly renovated building at 1085 North Main St. in Providence, has more than 300 employees and almost an equal number of volunteers.
Home & Hospice’s competition in Rhode Island includes two for-profit hospice companies: Beacon Hospice, founded in 1993 to serve the needs of terminally ill patients, with regional locations in Massachusetts, Connecticut, Maine, New Hampshire and Rhode Island; and Odyssey HealthCare Inc. which was acquired in August 2010 by Gentiva Health Services Inc., one of the nation’s largest providers of hospice services.
In recent years, Home & Hospice Care has expanded its efforts to embrace palliative care for its patients.
Palliative care is defined as an approach that “improves the quality of life for patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering,” according to a recent World Health Organization statement.
Palliative care benefits both the patient and the bottom line, according to Martin, who has worked in the field for 24 years. He pointed to the results of two recent studies that said patients receiving palliative care not only live longer, but the treatment can save hospitals money.
In a study of palliative care for patients with metastasizing nonsmall-cell lung cancer published in the New England Journal of Medicine in August 2010, researchers found that “early palliative care led to significant improvements in both quality of life and mood [and] longer survival.”
For the first time, Martin said, talking about the importance of the study, there is strong evidence that palliative care can prolong survival. “They found that patients getting palliative care, in addition to the usual oncology care, had higher quality-of-life scores and less depression,” he said. “I think the surprise was that patients receiving palliative care actually lived longer than patients who didn’t get palliative care.”
A second study, recently published in the March issue of Health Affairs, documented the financial benefits of palliative care. It found that patients enrolled in Medicaid at four New York State hospitals who received palliative care incurred $6,900 less in hospital costs compared with a matched group of patients who received usual care. Further, these palliative-care patients spent less time in intensive care and were less likely to die in intensive care units, consistent with the goals of patients and families, researchers said. In Rhode Island, with increasing growth of its aging population, the greatest challenge Martin said his organization faces is to “allow patients access to hospice in a timely way.”
The waiting list for Home & Hospice’s 24-bed facility is usually five or six people deep, Martin said. “We try to keep our waiting list to a minimum.”
In 2009, 22.5 percent of patients treated at Rhode Island hospitals were readmitted to the same hospital within 30 days of discharge, according to the R.I. Department of Health. About 27 percent of those were over the age of 65. The lack of transition planning for discharged patients was identified as a significant cause of increased costs, according to the R.I. Senate Commission studying hospital costs. Legislation sponsored by Sen. Joshua Miller, D-Cranston, before the General Assembly would require hospitals to participate in “high-quality, comprehensive, patient-discharge planning to decrease readmissions.
Martin called the chronic readmission of patients to hospitals “a failure of our health care system,” moving patients in and out of hospitals several times for the same illness. “Many times, patients were eligible for hospice after the second or third admission, but we don’t get them until after the sixth admission,” Martin said.
To receive palliative care, the patient must receive a physician’s order, explained Martin.
“A physician’s order could be triggered by a nurse practitioner pointing out, ‘Gee, this is the fourth time we’ve had this patient on our unit,’ ” Martin said. “We hope to be able to provide an opportunity for patients to have these discussions, to trigger a palliative-care consultation.”
Martin is hopeful that the view of hospice and palliative care is changing – at least in Rhode Island. “The traditional view is that hospice [and palliative care] is a tradeoff; you’re trading quality of life for quantity of life,” he said. The recent studies, however, point to a different reality, he continued. “Palliative care prolongs survival and saves money,” Martin said. •