January/February 2018

Vintage Voices: Palliative Care at Home: Better Care, Fewer Burdens
By Rhea Go-Coloma, LMSW
Today's Geriatric Medicine
Vol. 11 No. 1 P. 34

The vast majority of Americans want to die at home, yet the care they receive often fails to match their wishes. In California, for example, 70% of individuals surveyed said they wish to die at home, yet 68% are not given that chance.1 In fact, most people with advanced illness die in unfamiliar hospital settings where they are susceptible to overmedication and infection. It should come as no surprise that 72% of physicians choose to die at home.1

Fortunately, palliative care is helping patients receive the care they want where they want it, while also helping them live longer. As published in The New England Journal of Medicine, a study of 151 patients with advanced lung cancer found that those given early palliative care survived 11.6 months, nearly three months longer than those who received standard medical care.2

Community-based palliative care specialists are trained to ensure that patients who live at home receive the care they need to avoid unnecessary or unwanted care. This approach helps to lower the cost of care by reducing visits to the emergency department, ICU days, and in-hospital stays. As a result, Medicare beneficiaries and family caregivers avert high out-of-pocket expenses.

Improving Care at Home
The best way to optimize the palliative care opportunity is by using a specialized and process-driven care model that deploys dedicated teams of nurses and clinical social workers and provides them with training, oversight, and support. It also makes available to them health assessment tools to guide and document all home and telephonic visits and includes the proper infrastructure, staffing, and resources to intervene prior to exacerbations in advanced illness. This model serves as an important bridge to the medical home to address medical, emotional, and social issues that occur during the last 12 to 18 months of life.

Reducing Emotional and Economic Burdens
This model relies on predictive analytics to identify patients who are high opportunity, not simply high cost. The palliative care teams review a patient's symptoms, perform medication reconciliation, discuss and document goals of care, and create a palliative plan of care based on the needs and goals of the patient and family. By providing ongoing home-based support, patient education, and assistance with medical decision making, this approach results in improved care quality, lower economic burdens, and enhanced quality of life for members and family caregivers.

Essentially, this model provides an extra layer of support that improves the experience of care for patients and family caregivers who need greater emotional, psychosocial, and spiritual support during this difficult time of life. The focus is on the person—not the disease process—and recognizes quality over quantity.

— Rhea Go-Coloma, LMSW, is chief administrative officer for Hospice of the West in Phoenix.

References
1. MacPherson A, Parikh RB. Most people want to die at home, but many land in hospitals getting unwanted care. The Washington Post. December 9, 2017. https://www.washingtonpost.com/national/health-science/most-people-want-to-die-at-home-but-many-land-in-hospitals-getting-unwanted-care/2017/12/08/534dd652-ba74-11e7-a908-a3470754bbb9_story.html?utm_term=.a74a8ab0d64d. Accessed December 11, 2017.

2. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.