The goal of this webinar is to help healthcare professionals improve care coordination for patients with advanced illness and to reduce hospital readmissions and length of stay (LOS).

1. Reducing Readmissions
and Length of Stay

2. CE Provider
Information
VITAS Healthcare programs are provided CE credits for their Nurses/Social
Workers and Nursing Home Administrators through: VITAS Healthcare
Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved
By: Florida Board of Nursing/Florida Board of Nursing Home
Administrators/Florida Board of Clinical Social Workers, Marriage and
Family Therapy & Mental Health Counseling.
VITAS Healthcare programs in Illinois are provided CE credit for their
Nursing Home Administrators and Respiratory Therapists through: VITAS
Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL
60487/NHA CE Provider Number: 139000207/RT CE Provider Number:
195000028/Approved By the Illinois Division of Profession Regulation for:
Licensed Nursing Home Administrators and Illinois Respiratory Care Practitioner.
VITAS Healthcare, #1222, is approved to offer social work continuing education
by the Association of Social Work Boards (ASWB) Approved Continuing
Education (ACE) program. Organizations, not individual courses, are approved
as ACE providers. State and provincial regulatory boards have the final authority
to determine whether an individual course may be accepted for continuing
education credit. VITAS Healthcare maintains responsibility for this course.
ACE provider approval period: 06/06/2018 – 06/06/2021. Social workers
completing this course receive 1.0 ethics continuing education credits.
VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine,
CA 92602. Provider approved by the California Board of Registered Nursing,
Provider Number 10517, expiring 01/31/2023.
Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC:
No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA:
No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not
required – RT only receive CE Credit in Illinois.

3. Goals
• Discuss hospital readmissions in today’s
ever-changing healthcare environment
• Understand hospice care’s positive
impact on hospital readmissions,
length-of-stay, and CMS quality metrics

4. Objectives
• Describe HRRP (Hospital Readmission
Reduction Program) within the context
of healthcare reform and an
aging population
• Appreciate the readmission-related
conditions that risk penalties
• Identify the various factors that define
a hospital readmission
• Explore the patient profile
for readmissions
• Recognize the role of hospice and
advance care planning to support
patients with advanced illness,
help prevent hospital readmissions, and
reduce length-of-stay metrics

5. 20.46%
42.57%
26.65%
9.15%
Unintentional
Injuries
0.57%
Intentional Injuries
0.53%
Birth Defects
0.08%
COVID-19
Heart Disease
Malignant Neoplasms
Chronic Lower Respiratory Disease
Unintentional Injuries
Intentional Injuries
Birth Defects
Top Causes
of Death
for Those
Age 65+
Woolf, S. (2021). COVID-19 as the Leading Cause of Death in the United States. JAMA, 325(2), 1-2.
Retrieved from https://jamanetwork.com/journals/jama/fullarticle/2774465
Ages 65 and over

6. Place of Death in US
Teno, J., et al. (2018). Site of death, place of care, and health care transitions among US Medicare beneficiaries, 2000-2015. JAMA, 320(3), 264-271.

7. Healthcare
Spending in
the US: 2019
• Continued to far exceed other
industrialized countries
• Accounted for $3.8 trillion
($11,582 per person per year)
– 17.7% of the nation’s GDP
• Hospital care accounted for 31%
of total healthcare spend, a 6.2%
increase from 2018
– Equates to $1.2 trillion
Centers for Medicare and Medicaid Services. National Health Expenditures 2019 Highlights.
Retrieved from https://www.cms.gov/files/document/highlights.pdf

8. Healthcare
Spending
as Percent
of Gross
Domestic
Product (GDP)
Kamal, R., et al. (2021). How does health spending in the U.S. compare to other countries? Retrieved from
https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-start
Health Consumption Expenditures as Percent of GDP, 1970-2019

9. Future US
Healthcare
Spending
Projections
Health Care Spending and the Medicare Program. (2020). MedPAC. Retrieved from
http://www.medpac.gov/docs/default-source/data-book/july2020_databook_entirereport_sec.pdf
Healthcare spending growth rates have begun
to gradually increase following recent slowdown

10. Baby
Boomer
Impact
• 10,000 Baby Boomers reach the age of 65
daily; that’s 7 new Boomers each minute1
• By 2035, there will be 78 million people
65 years and older, compared to 76.4
million children under the age of 182
– Patient access will become an issue
– Hospitals will need to address chronic
care needs, because aging Baby
Boomers are living longer but have
higher rates of chronic disease and
more disability
1
Gibson, W., (2018). Age 65+ Adults Are Projected to Outnumber Children by 2030. Retrieved from
https://www.aarp.org/home-family/friends-family/info-2018/census-baby-boomers-fd.html
2
King, D., et al. (2013). The status of baby boomers' health in the United States:
the healthiest generation?. JAMA Internal Medicine, 173(5), 385-386.

11. Population
65 and Older,
and Hospital
Beds in US
Song, Z., et al. (2018). Baby Boomers and beds: a demographic challenge
for the ages. Journal of General Internal Medicine, 33(3), 367-369.

12. Factors
Contributing
to Healthcare
Waste
• Waste accounts for about 25%
of US healthcare spending
• Estimates range from $760 billion
to $935 billion
– The annual cost of waste from
failed care coordination is
estimated at $27.2–$78.2 billion
– The annual cost of waste from
overtreatment or low-value
care is estimated at
$75.7 billion–$101.2 billion
Shrank, W., et al. (2019). Waste in the US health care system: estimated
costs and potential for savings. JAMA, 322(15), 1501-1509.

13. Costs at
End of Life
• More than 90 million Americans live
with at least one chronic illness
• 7 out of 10 Americans die from
chronic disease
– Patients with multiple chronic
diseases can spend upwards
of $57K per year on their healthcare
• One quarter of Medicare spending
goes toward care for people during
their last year of life
Jha, A. (2018). End-of-life care, not end-of-life spending. JAMA, 320(7), 631-632.

14. Changing
Healthcare
Environment

15. CMS
Value-Based
Programs
Timeline
Centers for Medicare & Medicaid Services. Value-Based Programs. Retrieved from
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs
Value-Based Programs
Legislation
ACA: Affordable Care Act
MACRA: Medicare Access and CHIP
Reauthorization Act of 2015
PAMA: Protecting Access to Medicare Act
Program
APMs: Alternative Payment Models
ESRD-QIP: End-Stage Renal Disease Quality Incentive Program
HACRP: Hospital-Acquired Condition Reduction Program
HRRP: Hospital Readmissions Reduction Program
HVBP: Hospital Value-Based Purchasing Program
MIPS: Merit-Based Incentive Payment System
VM: Value Modifier or Physician Value-Based Modifier (PVBM)
SVFVBP: Skilled Nursing Facility Value-Based Purchasing Program
2008 2010 2012 2014 2015 2018 2019
Legislation
Passed
MIPPA ACA PAMA MACRA
Program
Implemented
ESRD-QIP
HVBP
HRRP
HAC VM SNF-VBP
APMs
MIPS

16. CMS, FAQ for the Risk-Standardized Outcomes & Payment Measures Public Reporting Year 2019 (July 1, 2019 - June 30, 2020). VITAS Proprietary Case Study.
Hospice Care’s Impact on CMS Hospital
Quality Measures
Hospice
Enrollment
Mortality
Hospital
Readmission
ICU and
Hospital Bed
Availability
Medicare Per
Beneficiary
Spend
12 months
before
First day of
index
admission
After the first
day of index
admission
No hospice
Risk-adjustment
look- back period
Outcome timeframe
Index Admission
(day 0) Day 30
12 Months Before the
Index Admission
Patient
dies
Patient
dies
Patient
dies
Patient
dies
Medicare Hospice
Medicare Hospice
Medicare Hospice
No Hospice

17. The Value
Equation
Value of Healthcare = Quality
Cost
Numerator problems
• 100,000 deaths/year from
medical errors1
• Millions more harmed by
overuse, underuse, and misuse
• Fragmentation
• Medical practice based on evidence
< 50% of the time2
• Healthcare spending as % of GDP
1Kohn, L., et al. (2000). To Err is Human: Building a Safer Health System (Vol. 6). Washington, DC: The National Academies Press.
2Medicine, I. (2011). Learning What Works Best: The Nation's Need for Evidence on Comparative Effectiveness in Health Care: AN ISSUE OVERVIEW.
In Learning What Works: Infrastructure Required for Comparative Effectiveness Research: Workshop Summary. The National Academies Press.

18. The Value
Equation
Value of Healthcare = Quality
Cost
Denominator problems
• Insurance premiums increased
by > 200% in the last 10 years1
• US spending 17% GDP2
• Healthcare spending is the #1
threat to the American economy
1Kaiser Family Foundation. Employer Health Benefits 2019 Annual Survey. Retrieved from http://files.kff.org/attachment/Report-Employer-Health-Benefits-Annual-Survey-2019
2Centers for Medicare and Medicaid Services. National Health Expenditures 2018 Highlights. Retrieved from https://www.cms.gov/files/document/highlights.pdf

19. Hospital
Readmission
Reduction
Program
(HRRP)
• Part of the Affordable Care Act (ACA)
• Intended to drive meaningful reductions
in all-cause readmissions by aligning
payment with outcome
• Ultimate objectives:
– Improve care transitions
– Relieve Medicare beneficiaries of
the burden of returning to the hospital
– Relieve taxpayers of the cost of
readmissions
The MedPAC Blog. (2018). The Hospital Readmissions Reduction Program has succeeded for beneficiaries and the Medicare program.
Retrieved from: http://www.medpac.gov/-blog-/the-hospital-readmissions-reduction-program-(hrrp)-has-succeeded-for-beneficiaries-and-the-
medicare-program/2018/06/15/the-hospital-readmissions-reduction-program-has-succeeded-for-beneficiaries-and-the-medicare-program

20. Components
of Readmission
Measure
Component Description
Target Population Medicare fee for service age 65 and older discharged from
acute care or VA hospital with an index condition. Beginning
in FY 2019, the 21st Century Cures Act requires CMS to
assess a hospital’s performance relative to other hospitals
with a similar proportion of patients who are dually eligible
for Medicare and full-benefit Medicaid
Definition Patient is discharged from the applicable hospital to a
non-acute care setting and is admitted to the same or
another acute-care hospital for any reason
Exclusions Planned readmission within 30 days
Applicable Data Three years of discharge data calculates excess
readmissions
Risk Adjustment Patient-related factors that may impact readmissions
including age, gender, comorbidity, and disease severity.
Patient data for risk is obtained from claims for 12 months
prior to and including index admission

21. Program Year 1 2 3 4 5 6 7 8
Fiscal Year 2013 2014 2015 2016 2017 2018 2019 2020
Dates of
Performance
Measurement
8-Jun to
11-Jul
9-Jun to
12-Jul
10-Jun to
13-Jul
11-Jun to
14-Jul
12-Jun to
15-Jul
13-Jun to
16-Jul
14-Jun to
17-Jul
15-Jun to 18-Jul
Conditions
for Original
Hospitalization
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
Chronic
Obstructive
Pulmonary
Disease (COPD)
Hip/Knee
Arthroplasty
(THA/TKA)
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
Chronic
Obstructive
Pulmonary
Disease (COPD)
Hip/Knee
Arthroplasty
(THA/TKA)
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
[Expanded]
Chronic
Obstructive
Pulmonary
Disease (COPD)
Hip/Knee
Arthroplasty
(THA/TKA)
Coronary Artery
Bypass Grafting
(CABG)
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
[Expanded]
Chronic
Obstructive
Pulmonary
Disease (COPD)
Hip/Knee
Arthroplasty
(THA/TKA)
Coronary Artery
Bypass Grafting
(CABG)
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
[Expanded]
Chronic
Obstructive
Pulmonary
Disease (COPD)
Hip/Knee
Arthroplasty
(THA/TKA)
Coronary Artery
Bypass Grafting
(CABG)
Heart Attack
(AMI)
Heart Failure
(HF)
Pneumonia
[Expanded]
Chronic
Obstructive
Pulmonary
Disease (COPD)
Hip/Knee
Arthroplasty
(THA/TKA)
Coronary Artery
Bypass Grafting
(CABG)
Maximum Penalty 1% 2% 3% 3% 3% 3% 3% 3%
HRRP Penalties and Conditions
Catalyst, N. E. J. M. (2018). Hospital Readmissions Reduction Program (HRRP). NEJM Catalyst.

22. What Counts as a Readmission?
Any time a patient with AMI, COPD, pneumonia, or heart failure is readmitted to a hospital
within 30 days of the initial hospitalization, it is considered a readmission.
Counts as a readmission for Hospital A when
patient discharged with HF and readmitted
within 30 days
Counts as a readmission for Hospital A even
if patient readmitted to a different hospital
Counts as a readmission for Hospital A when
patient is readmitted from a PAC provider
Counts as only one readmission for Hospital
A, even if patient is readmitted more than
once during the 30-day period
Scenario 1
Scenario 2
Scenario 3
Scenario 4
Each of these scenarios would count as ONE readmission for Hospital A
Hospital A
Heart Failure
Home
Hospital A
UTI
Home
Hospital A
Heart Failure
Home
Hospital B
UTI
Home
Hospital A
Heart Failure
SNF
Hospital A
UTI
SNF
Hospital A
Heart Failure
SNF
Hospital A
UTI
SNF
Hospital B
Pneumonia
0 days 30 days

23. Readmission
Rates for
Targeted and
Nontargeted
Conditions Within
30 Days After
Discharge
Zuckerman, R., et al. (2016). Readmissions, observation, and the hospital readmissions
reduction program. New England Journal of Medicine, 374(16), 1543-1551.

24. HRRP: 2020
Penalties
• Of the 3,080 hospitals CMS evaluated,
83% received a penalty
• For those 2,545 hospitals that
were penalized:
– The average reduction is 0.69%
– 613 hospitals received a penalty
of 1% or more
• 2020 penalties based on discharges
July 2016–June 2019
Kaiser Health News. (2020). Medicare Fines Half of Hospitals for Readmitting Too Many Patients
Retrieved from: https://khn.org/news/medicare-fines-half-of-hospitals-for-readmitting-too-many-patients/

25. Readmission
Patient
Profile
• 15% of Medicare enrollees age 65+
were readmitted within 30 days of
hospital discharge in 2019
• Readmitted patients have 2–3 times
longer length of stay in the ICU than
non-readmitted patients
• Readmitted patients have 2–10 times
higher risk of death than patients who
are not readmitted
• ICU re-admissions are associated with
dramatically higher hospital mortality
America's Health Rankings analysis of The Dartmouth Atlas of Health Care, United Health Foundation,
AmericasHealthRankings.org, Accessed 2020.

26. Reasons for
Readmission
• Failure in discharge planning
• Insufficient outpatient and
community care
• Severe progressive illness
Jencks, S., et al. (2009). Rehospitalizations among patients in the Medicare fee-for-service program.
New England Journal of Medicine, 360(14), 1418-1428.

27. Readmission:
Severe
Progressive
Illness
• University of Iowa Retrospective
Chart Review
• Penultimate admission within
12 months of death
– 84% (175/209) of patients were
within 6 months of their
actual deaths
• Documentation of hospice discussion
– Terminal admission: 23%
– Penultimate admission: 14%
Freund, K., et al. (2012). Hospice Eligibility in Patients Who Died in a Tertiary Care Center. Journal of Hospital Medicine, 7(3), 218-223.

28. Hospice and
Hospital
Readmission
Prevention

29. Advanced Illness Continuum
Timelier
Hospice
Access
Increased
Value
• Wishes and values
• Advance directive
• MOLST/POLST
• Goals of care
1. Advance Care
Planning
• Extra layer of support
• Symptom management
• Goal-concordant care
• Care transitions
2. Palliative
Care
Medicare Care Choices
Open
Access
Three Pathways to Hospice
Hospice
Death
• Care not consistent with wishes and values
• Greater healthcare utilization
• Less hospice use and shorter length of stay
• Higher healthcare cost
3. Traditional
Care
Hospice
Death
Decreased
Value

30. Index presentation and
hospitalization introduce natural
disease history and concept of
advance care planning
Acute exacerbations, including
ED visits and hospitalizations,
ongoing disease education, and
help to complete an ACP
Annual
Wellness Visit
Assists in
timely
transition
to hospice
Advance
Care
Planning
(ACP)
Conversations should occur throughout the natural
history of serious illness
Quality
of
Life

31. Supports the
Triple Aim
Increased Satisfaction With Care on CAHPS
Greater Goal-Concordant Care
Fewer Hospitalizations
Fewer ICU Days
Fewer ED Visits
Lower Healthcare Cost
Greater Hospice Utilization
Die in Preferred Care Setting
Patel, M., et al. (2018). Effect of a Lay Health Worker Intervention on Goals-of-Care Documentation and on Health Care Use, Costs, and
Satisfaction Among Patients With Cancer: A Randomized Clinical Trial. JAMA Oncolology, 4(10):1359-1366.
El-Jawahri, A., et al. (2016). Randomized, Controlled Trial of an Advance Care Planning Video Decision Support Tool for Patients With
Advanced Heart Failure. Circulation, 134(1):52-60.
Advance Care Planning Evidence Base

32. Hospice
Enrollment
and Hospital
Readmissions
Holden, T., et al. (2015). Hospice Enrollment, Local Hospice Utilization Patterns, and
Rehospitalization in Medicare Patients. Journal of Palliative Medicine, 18(7), 601-612.
Kaplan-Meier survival curves for hospice enrollees and
non-enrollees demonstrating the proportion of patients remaining
out of the hospital in the 30-day post-discharge period.

33. 0.00
0.10
0.20
0.30
0.40
0.50
In-hospital deaths ICU admissions 30-day hospital
readmissions
Incremental
reduction
in
various
outcomes
(proportion)
53-105 days
15-30 days
8-14 days
1-7 days
Hospice
Enrollment
Hospice Use
Decreases
Acute-Care
Utilization
Kelly, A. (2013). Hospice Enrollment Saves Money and Improves Quality. Health Affairs, 32 (3):552–561.
0
2
4
6
8
10
Hospital Days ICU days
Hospital
and
ICU
days
avoided
53-105 days
15-30 days
8-14 days
1-7 days
Hospice
Enrollment

34. Hospice
and Medicare
Cost Savings
Kelly, A. (2013). Hospice Enrollment Saves Money and Improves Quality. Health Affairs, 32 (3):552–561.
0
2,000
4,000
6,000
8,000
53-105 Days 15-30 Days 8-14 Days 1-7 Days
Total
Medicare
Savings
($)
Hospice Enrollment Range

35. Case of AF
• 76 y/o, 6-year history of HF, relatively stable
until past 6 months, secondary to ischemic
cardiomyopathy
– Presents to ED with third exacerbation
in 6 months
– Recent EF 23%
– Long-standing ACE inhibitor, B-blocker,
and diuretic
– ICD placed several years ago
– Dopplers negative DVT, CXR HF
– PMH: s/p CVA, HTN, DJD, hard of hearing
• Admitted to hospital with HF exacerbation,
unclear reason

36. Case of AF
(cont.)
• Admitted to hospitalist service
– IV diuresis
– Optimization of BP medications
– Education about HF
• Patient had cut back on diuretics
due to functional urinary incontinence
• Start considering discharge process
• Prior to admission, ambulates with
assistance, shortness of breath
with minimal exertion

37. Heart Failure
(HF)
Trajectory
Function
Death
Low
Multiple hospitalizations Death after exacerbation
High
NYHA Class III/IV
Hospice-Eligible
NYHA Symptoms:
Shortness of breath
Fatigue
Chest pain
Palpitations

38. Hospitalizations
and End of Life
Dunlay, S., et al. (2015). Care in the last year of life for community patients with heart failure. Circulation: Heart Failure, 8(3):489-96
• 80% HF patients hospitalized
last 6 months of life
• 28% died in the hospital
• Mean number hospitalizations
last 6 months 2.5-3.6;
LOS 11-13 days
0
50
100
150
200
250
300
350
331-365 301-330 271-300 241-270 211-240 181-210 151-180 121-150 91-120 61-90 31-60 0-30
Number
of
Hospitalizations
Days Prior to Death
Hospitalizations Days in Hospital

39. HF and
Hospice
• Symptoms w/ minimal exertion or rest
(NYHA Class III/IV) despite standard
of care
• Inability to tolerate standard of care
medical therapies
• Recent history of cardiac arrest or
recurrent syncope
• Inotropic support required and not
LVAD/transplant candidate
• Oxygen requirement secondary to
poor cardiac function
• ED visits and hospitalizations from
HF exacerbations

40. HF Functional Status and Survival (cont.)
Creber, M., et al. (2019). Use of the Palliative Performance Scale to estimate survival among home
hospice patients with heart Failure. ESC: Heart Failure, 2019;6:371-378
Patients with a PPS score of ≤ 50 are generally hospice-eligible; some
patients with a higher PPS may also be eligible.
PPS
Score
Ambulation
Activity and
Evidence
of Disease
Self-Care Intake
Conscious
Level
60 Reduced
Unable to do
hobby/housework
Significant disease
Occasional
assistance
necessary
Normal
or
reduced
Full or
confusion
50 Mainly sit/lie
Unable to do
any housework
Extensive disease
Considerable
assistance
required
40 Mainly in bed
Unable to do
most activities
Extensive disease
Mainly assistance
Full or
drowsy +/-
confusion
30
Totally
bedbound
Unable to do
any activities
Extensive disease
Requires total care

41. HF Location
of Death
2006–2015
Al-Kindi, S., et al. (2017). Where patients with heart failure die: trends in location of death of
patients with heart failure in the United States. Journal of Cardiac Failure, (9):713-714.
Hospital 32.3%
Home 24.4%
Nursing Home/LTAC 28.8%
Hospice 5%
ED/Outpatient 4.9%
Other/Unknown 4.2%
2015 Location of Death
0%
5%
10%
15%
20%
25%
30%
35%
40%
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Inpatient Emergency Room Home Hospice Nursing Home/LTAC

42. Heart Failure
Symptom
Burdens
Allen, L., et al. (2012). Decision making in advanced heart failure: a scientific statement
from the American Heart Association. Circulation, 125(15), 1928-1952.
Outcome
Heart Failure
EF < 30%
Heart Failure
> 30%
Advanced
Cancer
Number of Physical
Symptoms
9.4 (1.1) 8.7 (1.2) 8.7 (1.5)
Depression Score 3.6 (0.6) 4.3 (0.6) 3.2 (0.8)
Spiritual Well-Being 35.2 (1.8) 36.3 (1.9) 39.1 (2.3)
No significant difference between any of the groups

43. Most
Common
HF Symptoms
> 50%
• Lack of energy
• Pain
• Feeling drowsy
• Dry mouth
• Shortness of breath
• Depression
Blinderman, C., et al. (2008). Symptom distress and quality of life in patients with advanced
congestive heart failure. Journal of Pain and Symptom Management, 35(6), 594-603.

44. Pharmacologic Treatment HF
Class Name Indication Adverse Effects Comments
Aldosterone Blocker Spironolactone NYHA III or IV
• Hyperkalemia
• Renal dysfunction
Monitor hyperkalemia
ACE Inhibitor
Enalapril
Lisinopril
Ramipril
HF Stage B-D
• Hyperkalemia
• Renal dysfunction
• Hypotension angioedema
• Cough First line for systolic HF
Beta-Blockers Carvedilol
Metoprolol
• Fatigue
• Hypotension
• Depressed mood
ARBs
Losartan
Valsartan
Candesartan
• Hyperkalemia
• Renal dysfunction
• Hypotension
Substitution for ACE
inhibitors, not with ACEI
Loop Diuretics
Furosemide
Torsemide
Bumetanide
Volume overload
• Renal dysfunction
• Frequent urination
• Increase thirst
IV or Sub Q admin
Cardiac Glycosides Digoxin
Symptomatic
HF after 1st line
• Cardiac arrythmias
• Ventricular hypertrophy
• Nausea
• Delirium
Monitor toxicity closely

45. HF and Hospice Reduce
Hospital Readmissions
Kheirbek, R., et al. (2015). Discharge hospice referral and lower 30-day all-cause readmission in
Medicare beneficiaries hospitalized for heart failure. Circulation: Heart Failure, 8(4):733-40.
Approximately 10%
of HF patients who
were admitted to
the hospital and
died within the next
6 months were
referred to hospice.
Hospice-eligible HF
patients who enroll
were 88% less likely
to be re-hospitalized
compared to
non-enrollees.

46. Case of AF
(cont.)
• Family meeting with patient and
daughter, who wants to try
skilled rehabilitation
to strengthen patient
• Open conversation with
patient and daughter
– Overall poor prognosis
– Recommend hospice services
to best meet patient goals
– Continue to provide
state-of-the-art HF care
– Open to informational visit
prior to transfer

47. Important
Elements of
Shared
Decision-
Making for
Goals-of-Care
Conversations
– No more hospitals
– Minimal tests
– Improve shortness of breath
– Continue to live in house
– Keep alive as long
as possible
Allen, L., et al. (2012). Decision making in advanced heart failure: a scientific statement
from the American Heart Association. Circulation, 125(15), 1928-1952.
Outcomes
Relevant to
and individual
Patient
Survival
Costs/Burden
Direct Medical Costs
Indirect Costs
Lost Opportunities
Caregiver Burden
Quality of Life
Symptoms
Physical Function
Mental
Emotional
Social

48. Case of AF
(cont.)
• At NH, patient participates in PT/OT and
builds up some strength and endurance
– Able to get out of seated position and
ambulate with quad cane
– Still short of breath with minimal
exertion or at rest
• End of week 1, appears a little confused,
blood work and urine sent for analysis
– At night, develops confusion and agitation
– Sent back to hospital
– Admitted with UTI and delirium

49. 0
1
2
3
4
5
6
7
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Days Following Hospital Discharge
Pneumonia Hospitalization
Dharmarajan, K., et al. (2013). Diagnoses and timing of 30-day readmissions after hospitalization for
heart failure, acute myocardial infarction, or pneumonia. JAMA, 309(4), 355-363.
Percentage of all readmissions, 15.3
Percentage of all readmissions, 33.6
Percentage of all readmissions, 62.6
Days 0-15
Days 0-7
Days 0-3
Heart Failure and Hospital Readmission
0
1
2
3
4
5
6
7
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Days Following Hospital Discharge
Acute Myocardial Infarction Hospitalization
Percentage of all readmissions, 19.1
Percentage of all readmissions, 40.1
Percentage of all readmissions, 67.6
Days 0-15
Days 0-7
Days 0-3
0
1
2
3
4
5
6
7
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Days Following Hospital Discharge
Heart Failure Hospitalization
Percentage of all readmissions, 13.4
Percentage of all readmissions, 31.7
Percentage of all readmissions, 61.0
Days 0-15
Days 0-7
Days 0-3

50. Case of AF
(cont.)
• Hospital plan of care:
– Antibiotics
– Gentle hydration
– Safe and supportive environment
• Cognition improves within 2 days and
PT evaluation recommends skilled facility
• Family elects to return to skilled
facility for PT

51. Case of AF
(cont.)
• Participates in PT/OT and continues
to improve endurance and strength
• Discharge planning initiated with
discussions of home health or hospice
– NYHA Class III or IV
– Daughter wants PT in home
for a couple of sessions when
patient transitions
– Home health aides to help
bathe patient

52. Service Comparison
Service VITAS Home Health
Palliative Care
Physician Support
Yes No
Nurse Frequency
of Visits
Unlimited based
on patient need
Diagnosis-
driven
RT/PT/OT/Speech Yes Yes
Equipment Included Yes No
After Hours Staff
Availability
Yes No
Levels of Care 4 Levels Home
Care Plan Review Weekly Variable
Targeted Disease-
Specific Program
Yes Variable
Bereavement Support Yes No
Service VITAS Home Health
Eligibility • Physician-certified prognosis
< 6 months, if disease runs
normal course
• Hospice prognosis must be
re-certified periodically
• Patient agrees to palliative,
not curative, plan of care
• Plan of care determined
by initial and ongoing
doctor/team assessment,
combined with
patient/family wishes
• Not required to be
homebound
• Must require skilled level
of care and a specific plan
of care confirming need,
frequency, and duration
of visits
• Skilled nursing care need
must be re-certified
periodically
• As skilled needs change,
approved services change
• Must be homebound,
except for short durations
Length of Care Unlimited number of visits
based on patient need, if
prognosis remains 6 months
or less
• Limited number of visits
• Must document progress
within the length of
service allowed
Medications
Included
VITAS provides Rx and OTC
medications related to hospice
diagnosis at no charge to
the patient
Medications are not covered
under the Medicare Home
Health Benefit

53. SNF Use by
Older Adults
in Last 6
Months
of Life 0
10
20
30
40
50
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Adjusted
Prevalence
of
SNF
Admission
(%)
Year of Death
65 - < 75yr 75 - < 85yr ≥ 85yr
Only 1.5% enrolled in hospice at discharge

54. Case of AF
(cont.)
• Daughter elects home health, as SNF
believes hospice would not cover PT
• Patient makes a smooth transition home
• 2 weeks later, on Sunday, patient develops
acute shortness of breath
– Calls home health service
– Answering service recommends
going to ED
– HF exacerbation requires IV
diuresis and initiation of inotropes
• In ED, daughter asks what can be
done to keep mom out of the hospital

55. Advanced Therapies in HF
1Harrington, L., et al. (2019). Cardiac Pacemakers at End-of-Life. Palliative Care Network of Wisconsin.
2Balla, C., et al. (2019). Prognosis after pacemaker implantation in extreme elderly. European Journal of Internal Medicine, 65:37-34.
Type Indication Benefits Burdens Comments/Reasoning
Pacemakers/
CRTs
Both:
• Symptomatic bradycardia
• 2○ or 3○ heart block
CRT only:
• NYHA Class III and IV
• Certain Class II patients
Improves:
• Symptoms of heart
disease
• Quality of life
• Cardiac function
All:
• Battery lifespan
• Infection (rare)
• Malfunction (rare)
• Poorer outcomes1:
–Typically placed in patients
who are > 90 y/o, renal failure,
active malignancy, connective
tissue disorder, dementia
cerebrovascular disease,
AICD only:
• Risk of traumatic death
Life expectancy of years
Rare to discontinue–may
result in acute HF exacerbation
Not palliative
Recommend to deactivate when
patient has advanced illness
Defibrillators/
AICDs
High risk of
life-threatening
arrhythmias
Delivers shock
to convert to
normal rhythm
Fewer
hospitalizations
VADs
(LVAD, RVAD,
BiVAD)
Advancing HF despite
maximal medical therapy–
Bridge to transplant/
decision/recovery or
destination therapy
Improves:
• HF symptoms
• Quality of life
Complications:
• Stroke
• Infection
• Sepsis/pneumonia
• Serious bleeds
• Pump malfunction (rare)
External battery must
always be connected
LVAD does not improve 1-yr
survival but does show significant
symptom benefit over OMM
after 1 yr
Improved survival with continuous
flow2:
• 78% at 1 yr
• 45% at 4 yrs

56. Candidate’s
Home
Inotropic
Therapy
• Inotrope provides some symptomatic relief
– Less shortness of breath, more
awake, more able to concentrate
• Maintenance phase and dose,
no active titration
– No previous hypersensitivity
to the agent
• More permanent central venous access
• Agreeable to hospice plan of care
– No monitors, not a bridge to
transplant or LVAD
– Typically discharged on
continuous care for transition
– Do not have to deactivate ICD

57. Inotropes
Outcomes
• Inotropes can be used for symptom control
in patients with advanced HF who are not
candidates for MCS or transplant
– Improved NYHA class (mean difference
0.6 95% CI 0.2–1.0)
– No association with mortality
(0.68 95% CI 0.40–1.17)
– No association with hospital
readmission p>0.10
– ICD shock 2.4 95% CI (2.1–2.8)
• Hospice will cover, since its goal is
improved symptom management
• Overall improvements in survival over time
likely secondary to the incorporation of
improved medical management and ICD
Nizamic, T., et al. (2018). Ambulatory inotrope infusions in advanced heart failure:
a systematic review and meta-analysis. JACC: Heart Failure, 6(9):757-767.

58. Acute
Decompensated
HF and SQ
Furosemide
• Subcutaneous Lasix may eliminate
the need for an IV for patients at home
• Similar outcomes between subq and IV
– Similar diuresis
– No difference in re-hospitalizations
• Dosing has been done in hospice as a
continuous infusion as well as intermittent
• Limited data in severely obese and
end-stage kidney disease patients
• Local side effects can occur: stinging,
burning, swelling
Afari, M., et al. (2019). Subcutaneous Furosemide for the treatment of heart failure:
a state-of-the art review. Heart Failure Reviews, 24(3):309-313.

59. Case of AF
(cont.)
• Elects hospice benefit
• Inpatient hospice, contract bed, or
continuous care at home?
– Continuous care
• Diuresis with subcutaneous furosemide
• Continuation of inotrope
• CHF exacerbation improved; 4 days
later, transitions to routine home care
• Physical therapy assessment initiated
• Dies 5 months later at home with 1
additional episode of acute exacerbation
HF on VITAS Intensive Comfort Care®

60. Summary
• Advanced illness is a common
contributor to hospital readmission
• Hospice helps prevent hospital
readmissions
• Hospice factors associated with
ower hospital readmissions:
– After-hours care
– Availability of continuous care
– Visit frequency
– “Open access”

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