Hospice and EMS: Transformative Approach to End-of-Life Care€¦ · CONFIDENTIAL- NOT FOR DISTRIBUTION Hospice and EMS: Transformative Approach to End-of-Life Care April 2019

CONFIDENTIAL- NOT FOR DISTRIBUTION

Hospice and EMS: Transformative Approach to End-of-Life Care

April 2019

2© Copyright 2018 Visiting Nurse Service of New York. All rights reserved.


Today’s Presenters

Lorna Canlas, RN

Director,Strategy, Performance & Innovation

Visiting Nurse Service of New York

Ritchell Dignam, MD

Hospice Medical Director, VNSNY Hospice Program

Chief Medical Officer, VNSNY, Provider Services

Visiting Nurse Service of New York

Kevin Munjal, MD

Medical Director, Community Paramedicine

Assistant Professor, Emergency Medicine

Icahn School of Medicine at Mount Sinai



Agenda

• EMS – Hospice Partnership

• Community Paramedicine Overview

• VNSNY Hospice Community Paramedicine Model & Outcomes

• Future of Hospice – EMS Partnerships



Case Presentation

• 86 year old male, on home hospice

• Primary diagnosis: COPD, history of Lung Cancer

• HHA in the home found patient “not as responsive as he was when he was put on the toilet”

• What are possible outcomes of this situation?

-Will the HHA or family call 911?

-Will the non-hospice PCP recommend to call 911?

-Will the HHA call the hospice team?

-What are the goals of care of the family?



Hospice Hospitalizations Lead to Significant Costs

6.7%of all hospice

admissions result in ED visit,

observational stay or in-patient

admission

45%of inpatient

hospital stays were admitted

through ED

>$10,000Average charge to hospice provider

for an ED visit and hospitalization

Impact of Hospice Patient Hospitalization on Health Care System

Source:Phontankuel, Veerawat, et al,“Why do Hospice Patients Return to Hospital? A Study of Hospice Providers Perspective.” Journal of Palliative Medicine, 2016, 19(1): 51-56; Olsen, Mary L.et al., “Characterizing Care of Hospice Patients in the Hospital Setting,” Journal of Palliative Medicine, 2011, 14(2); 185:189; Population Health Advisor Research and Analysis.

Burton, S. ‘Innovative Partnership Breaks Cycle of Rehospitalization in Hospice,’ accessed 2 April 2019, https://www.emsworld.com/article/11290277/innovative-partnership-breaks-cycle-rehospitalization-hospice.

https://www.emsworld.com/article/11290277/innovative-partnership-breaks-cycle-rehospitalization-hospice



Why do Hospice Patients Return to the Hospital?

• Not fully understanding hospice

• Lack of clarity about disease prognosis

• Desire to continue receiving care from non-hospice physicians and hospitals

• Caregiver burden

• Distressing/difficult to manage signs and symptoms

• Caregivers’ reluctance to administer morphine

• 911’s faster response time compared to hospice

• Families’ difficulty accepting patient’s mortality

Source: Phontankuel, Veerawat, et al.,“Why do Hospice Patients Return to Hospital? A Study of Hospice Providers Perspective.” Journal of Palliative Medicine, 2016, 19(1): 51-56; Olsen, Mary L.et al., “Characterizing Care of Hospice Patients in the Hospital Setting,” Journal of Palliative Medicine, 2011, 14(2); 185:189; Population Health Advisor Research and Analysis.

Areas of partnership opportunity

with EMS



Coordination or (Lack Of) With EMS: Benefits & Risks

Patient receives care in line with hospice principles

Avoid ED transport and hospitalization costs

Avoid revocation of hospice benefits

Improved EMS-Hospice Provider relationship

Unwanted treatment inconsistent with hospice principles

Incurred costs for hospice providers and health system

Revocation of hospice benefits

Goals of care not met and confusion of patient wishes by EMS and ED providers

Benefits Risks



Hospice – EMS Partnership

• Provide timely symptom management

• Provide more effective and efficient healthcare

• Prevent unnecessary emergency room visits

• Reduce hospital readmissions

• Prevent revocation of hospice benefits and unnecessary medical costs

VNSNY Hospice - Community Paramedicine Program Goals



VNSNY Hospice

• Founded in 1983

• Largest hospice provider in NYC

• Served 6,101 hospice patients in 2018

• ADC in 2018 was 1,090

• ALOS 71.7 days in 2018



VNSNY Hospice – Community Paramedicine Model Key Components

Hospice Team Managers & After-Hours Managers

• Notified of patients’ symptom crisis

• Triages based on VNSNY Hospice standard practices, CP Procedure and Clinical Scenarios

• Activates CP by calling Mount Sinai Transfer Center

• Participates in CP encounter

Community Paramedic

• Arrives in patient’s home within 30 to 60 minutes

• Initiates conference with Hospice Clinical Manager, Hospice Medical Director and OLMC physician

• Performs enhanced assessments including diagnostic tests

• Provides treatment and follows through with physician orders

Post CP Encounter

• Mount Sinai sends Post-Encounter Clinical Documentation and Patient Follow-Up Action Plan to VNSNY Hospice

• Hospice Team Manager communicates with patient’s physician, updates plan of care and schedules patient visits as needed



VNSNY Hospice – CP Model Clinical Scenarios

Clinical ScenarioWhat Community Paramedicine Can Do

for This Patient

Uncontrolled severe Shortness of

Breath (Dyspnea)

Perform advanced assessment

Determine oxygen saturation (SpO2)

Administer supplemental oxygen

Administer nebulizer treatments (albuterol, ipratropium)

Administer steroids for COPD exacerbation

Administer morphine to reduce “air hunger”

Assist with administration of medications in hospice comfort pack

Fluid Overload

Heart Failure

Non-Heart Failure (End Stage

Liver Disease, Cancer)

Determine oxygen saturation (O2 Sat) IV Lasix can be administered at home

Uncontrolled Anxiety / Agitation Perform advanced assessment

Administer benzodiazepines (diazepam, midazolam)

Assist with administration of medications in hospice care package

Uncontrolled severe pain Perform advanced assessment

Administer morphine for pain management


Chest pain (not GI distress related) Perform advanced assessment, including 12-lead EKG

Administer nitroglycerin, morphine, aspirin




Community Paramedicine - Overview

Community Paramedicine: Rapid evaluation and in-home treatment for patients with acute symptoms



Community Paramedicine - Overview

• Program started in 2017• More than 400 patient

encounters• Servicing 21 physician

partners and groups• VNSNY Hospice is only

hospice provider partnered with program



Community Paramedicine – Better Patient Experience

Upon Arrival • Expanded physical assessment

Advanced Life Support

• Advanced cardiac life support• Advanced airway management• EKG interpretation• IV Access

Medications for Treatment

• Acute congestive heart failure• Asthma and COPD• Allergic reactions• Diabetic emergencies

Patient Comfort• Morphine• Zofran

• Community Paramedics operate with guidance from Online Medical Control (OLMC) Physician

Community Paramedic Skills & Formulary



Community Paramedicine – Encounter Process

1. Call Transfer Center

For authorized providers only

2. Provide Hand-Off

Chief Complaint

Medical History

Allergies DNR StatusLocation Access




3. Paramedic Assessment

Completed in 30-60 minutesDiagnostics (EKG, BGL, etc.) Sent

Electronically or Vsee

4. Video Conference with Medic, OLMC MD, Hospice MD

Immediate Treatments

Additional Diagnostics

Goals of CarePatient’s Own Medications

Comfort Pack




5. Create Action Plan

Self-Care Instructions

Medications Adjustments

Follow-Up Treatments

Transport if need to Hospice contracted

facility

6. Documentation Sent to VNSNY Hospice Post-Encounter

Paramedic Patient Care Report

Action PlanOLMC Physician Note

in EPIC



VNSNY Hospice Model - Encounters by Clinical Reason

0

2

4

6

8

10

12

14

KEY TAKEAWAY: 37.5% of patients were experiencing breathing problems



VNSNY Hospice Model - Patient Disposition Post Community Paramedicine Encounter

4

4

24

Transferred, treat and release Transferred w/Admission GIP Unit No Transfer

75% NOT TransferredNo revocation of Hospice benefits

N=32

Diagnosis:Cancer = 14CHF = 11COPD = 1Pulmonary Fibrosis = 2Dementia =2ESRD =1Cerebral Atherosclerosis = 1



Better Outcomes & Better Value



Success Story Case 1

• 86 year old male

• Primary diagnosis: COPD, History of Lung Cancer

• HHA in the home found patient “not as responsive as he was when he was put on the toilet” and called the Hospice After Hours Supervisor

• Paramedics arrived in 31 minutes and performed assessment and findings conferred with the OLMC MD, ENW Supervisor and Hospice MD on-call. Administered Tylenol suppository for fever of 101.8 and 500 ml NS bolus x 2.

• CP Scene time: 2 hours, 46 minutes

• Patient’s mental status returned to baseline and allowed patient to remain at home honoring family’s wishes

Testimonial: “Wife expressed gratitude for the Community Paramedics and hospice’s assistance in keeping her husband at home”.

• Disposition: Patient remained at home and died peacefully two days later



Case 2

• Female patient, day 2 on home hospice, full code, cardiac comfort pack has not been ordered yet.

• Primary hospice diagnosis: CHF• Patient with SOB and congestion and daughter requesting to take patient to the

hospital to be diuresed• Patient refusing to take morphine according to daughter• Paramedics arrived in 32 minutes and performed assessment and findings

conferred with the OLMC MD and Hospice MD on-call. Administered Lorazepam and oxygen

• CP Scene time: 2 hours• Disposition: Patient remained at home and died on Continuous care 5 1/2 weeks

after CP intervention

Hospice Physician Testimonial:“It was a superb collaboration. Mt. Sinai doctor and their ambulance crewtreated this patient with a very holistic and patient-centered approach….makingsure patient’s DME and functional needs were addressed, we were able to keepthis patient home without much difficulty. I was literally blown away.”



Future of Hospice – EMS Partnerships

• Partnerships are critical for Population Health strategies Drives alignment of financial incentives in value-based environment

Improves overall performance and promotes data sharing

Key to successful clinical and quality outcomes

Reduces costs of end-of-life care

Promotes coalition building

• Challenges Continue Lack of knowledge of Mobile Integrated Health and capabilities

Communication and collaboration with EMS

Lack of awareness and opportunities to innovate



Questions

Documents

Hospice and EMS: Transformative Approach to End-of-Life Care€¦ · CONFIDENTIAL- NOT FOR DISTRIBUTION Hospice and EMS: Transformative Approach to End-of-Life Care April 2019