Commentary: ‘Care’ also includes the end of life

Let’s shift the national healthcare conversation from insurance exchanges to some of the other important components of the Affordable Care Act (ACA): delivering affordable, high-quality care with improved patient satisfaction.

While our first thoughts of “care” might be medical needs or wellness initiatives to prevent chronic diseases, “care” also includes end-of-life care.

Hospice is an inter-disciplinary, collaborative effort addressing complex physical, psychosocial and spiritual end-of-life issues. This is accomplished through a team composed of a physician, registered nurse, licensed vocational nurse, licensed clinical social worker, certified home health aide, chaplain, volunteers and other specialists, such as massage and music therapists. The underlying premise of hospice care dovetails well with what ACA intends to foster. Through hospice, we have the ability to provide the highest quality end-of-life comfort and care at the most affordable cost.

Hospice is paid a flat rate per day and care must be rendered within that amount. This approach to payment is consistent with evolving models of care that seek to put the medical provider at some financial risk versus the traditional fee-for-service model that exists throughout much of the current healthcare profession. This makes hospice a less costly option.

Under ACA, it is anticipated that hospice use will increase due to bundling of payments, where systems are rewarded for coordinated quality care, rather than quantity of care. Health systems and hospitals now have greater incentive to encourage the use of hospice, which saves the healthcare system money. Indeed, a 2013 study conducted by Mt. Sinai School of Medicine confirmed the 2007 Duke University study that estimated $6,400 per beneficiary savings for Medicare for every hospice admission.

These cost savings are primarily attributed to the reduction in emergency room visits and resulting hospitalizations. Families and caregivers working in conjunction with the hospice staff allows for more coordinated delivery of care, which reduces the surprises that many times lead to ER visits.

In the United States, we’ve historically built institutional care — providing care in facilities, which assume total care of the individuals who are admitted. However, delivering end-of-life care in the most comfortable and affordable setting is at home, which includes a patient’s private residence, nursing home or residential facility. Although hospitals offer quality healthcare services, they aren’t designed to provide the comfort and intimacy desired for such private and cherished family time.

While spending one’s final days at home is preferable, there is also a growing need to have places outside of the home for end-of-life care because our population is changing. Today, the adult child is often still actively employed and can’t be a full-time caregiver. And elderly spouses are sometimes as fragile as the patients themselves and unable to provide care at home.

Unfortunately, we also have a dearth of in-patient facilities and homes that are not appropriate for end-of-life, or a patient’s disease state is so advanced they can’t stay at home (5% of patients). There is a need for in-patient facilities in a residential, intimate setting where family members can sleep over and create loving, joyful final days together.

The National Hospice and Palliative Care Organization reported that in 2012, more than 85% of hospice patients died or were discharged within seven to 14 days of admission. Families and physicians often wait until their loved one has reached a painfully advanced state to seek hospice care, which shortchanges the patient on comfort, control, dignity and quality of life.

Chief among the benefits of seeking hospice earlier is that it typically takes seven to 10 days to address all the factors that affect a patient’s care. Pain is addressed and brought under control immediately. However, other issues like mental/emotional health, discussions on modulating the treatment plan, care of skin and medications to make a patient feel better take some time. Once all these things are in place, the amount of comfort medications a patient requires can often be reduced.

We can do more to educate physicians about the benefits of hospice and referring patients earlier. Many physicians are uncomfortable having end-of-life conversations because they are trained to keep patients alive. But physicians must develop the ability to have conversations about hospice and palliative care. The Southern California Hospice Foundation is poised to assist physicians in preparing them to engage in these conversations.

The foundation was established with a grand vision: open a hospice house for terminally ill patients to serve as a residential live-in facility for end-of-life care. We look forward to working with our local stakeholders in order to ensure that all those who may benefit from effective end-of-life care are provided access to safe, high-quality care.

MICHAEL A. URANGA is president of the Costa Mesa-based Southern California Hospice Foundation.