Patients with advanced chronic illness receive increasingly fragmented care as they near the end of life. Multiple hospital readmissions are the rule, followed by intermittent episodes of home health care. Pain management, advance care planning, and preparation for dying may be lacking. Because prognosis is uncertain, particularly in noncancer cases, access to hospice and palliative care services is often denied to these patients until they are very near death. Home-based transition management can provide high-risk chronically ill patients better continuity of care until they are eligible and emotionally ready for hospice, and can manage their dying if referral to hospice is refused. Home care is positioned to provide innovative services that would increase access to end of life care. This paper outlines limitations of current approaches to end of life care, proposes potential components of transition management services, and discusses operational, regulatory, and reimbursement challenges to implementation.
Get full access to this article
View all access options for this article.
References
1.
Berk, M. C., & Monheit, A. C. (2001). The concentration of health care expenditures, revisited. Health Affairs, 20(2), 9-18.
2.
Brumley, R. D. (2002). Future of end of life care: The managed care organization perspective. Journal of Palliative Medicine, 5, 263-270.
3.
Desbiens, N. A., Wu, A. W., Broste, S. K., Wenger, N. S., Connors, A. F., Lunn, J., et al. (1996). Pain and satisfaction with pain control in seriously ill hospitalized patients. Critical Care Medicine, 24, 1953-1961.
4.
Emanual, E. J., & Emanuel, L. L. (1994). The economics of dying: The illusion of cost savings at the end of life. New England Journal of Medicine, 330, 540-544.
5.
Fried, T. R., van Doorn, C., O’Leary, J. R., Tinetti, M. E., & Drickamer, M. A. (1999). Older persons’ preference for site of terminal care. Annals of Internal Medicine, 131, 109-112.
6.
Haidet, P., Hamel, M. B., Davis, R. B., Wenger, N., Reding, D., Kussin, P. S., et al. (1998). Outcomes, preferences for resuscitation and physician-patient communication among patients with metastatic colorectal cancer. American Journal of Medicine, 105, 222-229.
7.
Hayley, D. C., Muir, J. C., Stocking, C., Hougham, G., & Sachs, G. A. (2001). Not ready for hospice: Characteristics of patients in a pre-hospice program. American Journal of Hospice and Palliative Care, 18, 377-382.
8.
Hofmnan, J. C., Wenger, N. S., Davis, R. B., Teno, J., Connors, A. F., Desbiens, N., et al. (1997). Patient preferences for communication with physicians about end-of-life decisions. Annals of Internal Medicine, 127, 1-12.
9.
Hogan, C., Lunney, J., Gabel, J., & Lynn, J. (2000). Medicare beneficiaries’ costs of care in the last year of life. Health Affairs, 20(4), 188-195.
10.
HOPE: Home Care Outreach for Palliative Care Education. (2001). Funded by trhe National Cancer Institute. National Conference, March 2-3, 2001, City of Hope Medical Center, Duarte, CA.
11.
Krumholz, H. M., Phillips, R. S., Hamel, M. B., Teno, J. M., Bellamy, P., Broste, S. K., et al. (1998). Resuscitation preferences among patients with severe congestive heart failure. Circulation, 98, 648-655.
12.
Leff, B., Kaffenbarger, K. P., & Remsberg, R. (2000). Prevalence, effectiveness and predictors of planning the place of death among older persons followed in community-based long-term care. Journal of the American Geriatric Society, 48, 943-948.
13.
Levinsky, N. G., Yu, W., Ash, A., Moskowitz, M., Gazelle, G., Saynina, O., et al. (2001). Influence of age on Medicare expenditures and medical care in the last year of life. Journal of the American Medical Association, 286, 1349-1355.
14.
Lynn, J., Harrell, F., Jr., Cohn, F., Wagner, D., & Connors, A. F. Prognoses of seriously ill hospitalized patients on the days before death: Implications for patient care and public policy. New Horizons, 5, 56-61.
15.
National Hospice and Palliative Care Organization. (2001). Hospice fact sheet 2001. Retrieved from http://www.nhpco.org/public/articles/F&F1201.pdf.
16.
National Program Office of Community-State Partnerships to Improve End of Life Care. (2001). How hospice saves Medicare money. State Initiatives in End of Life Care, 11(4).
17.
Pritchard, R. S., Fisher, E. S., Teno, J. M., Sharp, S. M., Reding, D. J., Knaus, W. A, et al. (1998). Influence of patient preferences and local health system characteristics on the place of death. JAGS, 46, 1242-1250.
18.
Robinson, J. C., & Casalino, L. P. (1995). The growth of medical groups paid through capitation in California. NEJM, 333, 1684-1687.
19.
SUPPORT Principal Investigators. (1995). A controlled trial to improve care for seriously ill hospitalized patients. Journal of the American Medical Association, 274, 1591-1598.
20.
Teno, J. (1998). Looking beyond the “form” to complex interventions needed to improve end of life care. JAGS, 46, 1170-1171.
21.
Tolle, S. W., Tilden, V. P., Nelson, C. A., & Dunn P. M. (1998). A prospective study of the efficacy of the physician order for m for life-sustaining treatment. JAGS, 46, 1097-1102.
22.
Von Gunten, C. F., Ferris, F. D., Kirschner, C., & Emanuel, L. (2000). Coding and reimbursement mechanisms for physician services in hospice and palliative care. Journal of Palliative Medicine, 3, 157-164.
23.
Walsh, T. D. (1990). Continuing care in a medical center: The Cleveland Clinic Foundation Palliative Care Service. Journal of Pain Symptom Management, 5, 273-278.
24.
Weissman, D. F., & Griffie, J. (1998). Integration of palliative medicine at the Medical College of Wisconsin 1990-1996. Journal of Pain Symptom Management, 15, 195-201.
