A Tunneled Catheter Placement Program for Community Hospices.

CONTEXT: The symptoms associated with the excessive fluid accumulation of ascites or pleural effusions can be intractable to medical management and can have a significant negative impact on quality of life of hospice patients. Hospice of the Valley, a community-based, nonprofit hospice agency has historically referred patients to outpatient providers for paracentesis, thoracentesis, and placement of tunneled drainage catheters. OBJECTIVES: To describe an in-house pilot program of tunneled catheter placement to provide immediate and longer-term symptom relief for selected hospice patients. METHODS: The logistics and cost of the pilot program are described. Key data elements, including select demographics, patient eligibility screening, and incidence of procedure-related or late complications are reported. RESULTS: A total of 135 drainage procedures completed on 127 unique hospice patients over 27 months (2020-2023) were reviewed. The rate of procedure-related complications (<4%) and late complications (<3%) are low. The average cost per procedure ($1030) compares favorably with outpatient providers' fees. The program was well-accepted by the interdisciplinary hospice team, patients, and families. CONCLUSIONS: An in-house program of tunneled catheter placement is a feasible option for hospice providers with low-cost exposure and high potential for improved quality of life and symptom relief for selected patients.

A Model Hospice Inpatient Unit Specializing in Patients Living with Advanced Dementia.

Objective: This report describes a pilot hospice inpatient unit dedicated to individuals experiencing distressing behaviors from dementia. Background: Patients with dementia who experience distressing symptoms cannot be well managed on typical inpatient units. Hospice of the Valley selected one unit to dedicate to dementia care. Methods: Data were analyzed from 237 patients admitted to the unit between May 2019 and April 2020. Behaviors were identified and rated for severity on admission, discharge, and postdischarge. Rates of inpatient death and associated behaviors were calculated. Results: Fifty percent of patients had their behaviors sufficiently managed to allow discharge. The most common behavior exhibited was agitation; the most common symptom leading to death was pain. Discussion: An inpatient hospice unit dedicated to patients with dementia can be successful. The hospice agency gains admissions that would otherwise be diverted to behavioral care settings. This successful pilot may be a model for other hospices.

Impact of a Hospital Community Based Palliative Care Partnership: Continuum from Hospital to Home.

Objectives: To discuss the outcomes of a formalized care transition process for palliative care patients from the hospital to the community. Background: Patients who received inpatient palliative care services from the specialist palliative care team in the hospital or who were identified as needing community palliative care services have inadequate support on discharge. Methods: A retrospective review of the medical records of patients admitted to the community based palliative care (CBPC) program, Arizona Palliative Home Care (AZPHC) over a 12-month period (June 2018 to May 2019) was undertaken with a focus on the frequency and pattern of hospital events pre- and postadmission to the program. Patient/family satisfaction data obtained from telephone surveys were evaluated. The medical records from patients (n = 294) with advanced complex illnesses who were admitted to AZPHC from the five Honor Health Network hospitals were included in this study. Results: Of the 294 patients' records reviewed, 80% were in the 65 and older age group and had a mean length of stay on AZPHC of ∼40 days. Comparing acute care utilization pre and post AZPHC admission, there was a reduction of 68.95% at 60 days and 68.22% at 90 days. In addition, 128 avoided hospital events were recorded, and 86% of patients were very likely to recommend AZPHC to family or friends. Discussion: Collaboration between a hospital palliative care team and a CBPC program resulted in high quality transitions across care settings and reduction in acute care utilization.

Avoided Hospitalization Criteria: Validating the Impact of a Community-Based Palliative Care Program.

Objective: This report describes the experiences of a community-based palliative care (CBPC) program's efforts to understand the patterns of hospital utilization, specifically utilization reduction experienced by admitted patients. Efforts to quantify and describe an avoided hospitalization and opportunities to use these data to strengthen partnerships with local insurance payers to assure sustainability of the CBPC will be discussed. Background: Patients with serious chronic illness experience emergency room care and hospitalizations with increasing frequency as their health deteriorates. CBPC programs are well positioned to decrease hospital utilization by early involvement and improved care management. Methods: Arizona Palliative Home Care (AZPHC) program is a free standing CBPC in Maricopa County, Arizona, serving 3300 patients annually. An interdisciplinary team was formed within the CBPC to facilitate the identification of avoided hospital events and communicate these data to community partners in an effective and consistent manner. The processes developed by this team are described. Results: AZPHC has enhanced its hospitalization avoidance strategies by communicating the rate of hospitalization avoidance events in a consistent and strategic manner. Providing instances of avoided hospitalizations with accompanying patient narratives to payers has enabled AZPHC to demonstrate the impact the CBPC has on improving quality of care and reducing overall costs. Discussion: CBPC programs require payment for sustainability; therefore, partnerships with local insurance payers are essential. Presenting data that validate the impact of a program from a clinical and financial perspective will advance the growth of payer-CBPC provider relationships and secure a future for funded CBPC programs.

Outcome evaluation of a randomized trial of the PhoenixCare intervention: program of case management and coordinated care for the seriously chronically ill.

OBJECTIVE: To document outcomes of a randomized trial of the PhoenixCare demonstration program of palliative care and coordinated care/case management for seriously chronically ill individuals who simultaneously received active treatment from managed care organizations (MCOs). DESIGN: Patients, continuously enrolled between July 1999, and March 2001, were randomly assigned to the PhoenixCare program or a control group receiving usual MCO care. SETTING: Hospice of the Valley, Phoenix, Arizona. PARTICIPANTS: Participants were 192 patients with chronic obstructive pulmonary disease (COPD) or chronic heart failure (CHF), who had an estimated 2-year life expectancy. INTERVENTION: Intensive home-based case management provided by registered nurse casemanagers, in coordination with patients' existing source of medical care, comprised the intervention. Program foci included disease and symptom management, patient self-management of illness and knowledge of illness-related resources, preparation for end-of life, physical and mental functioning, and utilization of medical services. OUTCOME MEASURES: Outcomes, assessed every 3 months by telephone interview, included measures related to all program foci; the SF-36 was used to evaluate physical and mental functioning; emergency department visits exemplified medical service utilization. RESULTS: Compared to controls, PhoenixCare patients exhibited significantly better outcomes on self-management of illness, awareness of illness-related resources, and legal preparation for end of life. They reported lower symptom distress, greater vitality, better physical functioning and higher self-rated health than randomized controls. Emergency department utilization was equivalent across groups. Patients with COPD showed stronger responsiveness to the intervention. CONCLUSION: A novel model of patient care that combined greatly enhanced palliative carefocused case management with ongoing MCO-based treatment was associated with improved functioning of chronically severely ill patients in the last years of life.

Advance directives: overcoming reluctance and getting them done.

Why do less than 10% of healthy adults have them? Why do less than 20% of frail elders have them? If we examine the incentives and the disincentives adults feel to complete advance directives, we can focus our educational efforts for maximal effect and get this important work done.

The PhoenixCare Program.

In response to a perceived need for patient access to palliative care and supportive services prior to hospice eligibility, Phoenix-based Hospice of the Valley (HOV) applied for and received a 3-year demonstration grant (1999-2001) from The Robert Wood Johnson (RWJ) Promoting Excellence in End-Of-Life Care Project. HOV established the PhoenixCare project as a demonstration of palliative and coordinated care (case management) services for seriously chronically ill individuals still undergoing active treatment of their disease within a managed care setting. The model emphasized patient/family self-empowerment and prevention. The goal was to demonstrate that it was possible to expand the scope of care for the seriously chronically ill, add palliative care, and improve patient quality of life at less (or no more) cost than that for a comparable group of managed care patients not receiving PhoenixCare services. The model proved most useful to patients willing and able to assume a degree of control over their own care. Physicians referred fewer than 5% of the patients enrolled while managed care plan case managers and hospital discharge planners referred 83%, suggesting that in organized systems of care physicians are not a primary source for patient referrals. The structure and content of the PhoenixCare model, its general acceptability to patients, physicians and managed care plans, and its applicability to other sites are discussed in this article. Outcomes from the study will be published in a subsequent paper.