Elderly patients with four or more chronic conditions represented about 14% of Medicare beneficiaries in 2010, but accounted for 70% of the 1.9 million hospital readmissions, according to a 2012 CMS report. Nearly two-thirds of patients did not receive any home healthcare visits that year, and hospice care remained underutilized.
But when should providers switch from treatment to hospice, or even begin to dial back on the tests, drugs and procedures they prescribe for the frail elderly?
“This population is in the gray zone between treatable and terminal, and that gray zone is expanding really rapidly,” said Dr. Brad Stuart, former senior medical director of Sutter Visiting Nurse Association and Hospice.
“In that gray zone, it's often not appropriate to just stop treatment and go straight to hospice,” he said. “But at the same time, it's also not appropriate to just throw the whole nine yards of treatment at everybody every time, which is what we tend to do in traditional care.”
Stuart was instrumental in helping Sutter develop its Advanced Illness Management (AIM) program, an integrated delivery model that advises patients and their families on how to make the transition to hospice while still delivering desired healthcare services in a home setting.
The program begins with a team of staffers consisting of home health and hospice nurses, physicians and social workers asking patients about their treatment.
Those targeted for entry into the program are usually chronically ill patients who have the possibility of dying within a year and have yet not chosen to enter hospice.
Once patients have been identified, AIM staff works on a plan for the next steps in managing their care. AIM's goal is to coordinate care for these patients before they reach the terminal stage to smooth the transition into hospice.