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EndofLife Care in the Department of Veterans Affairs

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Discuss recent mandates related to end-of-life care in the VA ... FANTASY DEATH EXERCISE. Mandates and other Pressures. Millennium Bill ... Good News! ... – PowerPoint PPT presentation

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Title: EndofLife Care in the Department of Veterans Affairs


1
End-of-Life Care in the Department of Veterans
Affairs
  • Jon Fuller, MD
  • James Hallenbeck, MD
  • James Breckenridge, PhD
  • VA Palo Alto HCS

2
Purpose
  • Discuss recent mandates related to end-of-life
    care in the VA
  • Present recent data showing where veterans die
    and how much this costs
  • Suggest ways facilities can come into better
    compliance with mandates, save money through
    cost-shifting and facilitate better care

3
Key Points
  • Veterans are dying in record numbers
  • End-of-life care as currently provided is very
    expensive
  • Too many veterans are dying in ICUs and acute
    care
  • Too few veterans are receiving good end-of-life
    care in dedicated palliative care beds or home
    hospices
  • Shifting patients into better, less expensive
    venues of care can save money

4
Questions for VA Facilities
  • Should the VA invest more in palliative care?
  • Is such care cost-effective?
  • Could adequate dollars be cost-shifted or avoided
    to justify such an investment?

Is palliative care a luxury the VA cannot afford,
or can the VA not afford not to have palliative
care?
5
FANTASY DEATH EXERCISE
6
Mandates and other Pressures
  • Millennium Bill
  • Palliative Care Consult Memorandum
  • Call for dedicated Palliative Care Beds (GEC
    Strategic Plan, National Policy Board 2/12/02)
  • Lots of very sick and dying veterans on your
    doorstep
  • ICU and acute care bed pressure
  • Not enough money

7
Good News!
  • Shifting workload out of acute care into
    dedicated palliative care beds, HBPC or community
    hospices can
  • Help you meet Millennium Bill targets
  • Meet evolving mandates for palliative care
    services
  • Save you money
  • Increase high VERA reimbursement
  • Create excellent PR for your facility
  • Help veterans exercise choice in where and how
    they die

8
Veteran Deaths Basic Facts
  • 29 of Americans dying each year are veterans
  • The majority of dying veterans are not enrolled
    for by care by VA
  • A majority of enrolled veterans do not die in VA
    facilities
  • A small shift of very sick and dying veterans not
    currently served by VA into the VA could swamp
    the system

9
Annual Veteran Deaths
A small percentage of veterans die as inpatients
in VA facilities
10
(No Transcript)
11
Demographics and Associated Costs of Dying for
Enrolled VeteransPreliminary Findings
  • James Breckenridge, PhD
  • James Hallenbeck, MD
  • Co-Principal Investigators
  • VA Palo Alto HCS
  • Susan Ettner, PhD, UCLA,
  • Karl Lorenz, MD, West LA VA
  • - Co investigators

Preliminary data do not cite
Funded by the Robert Wood Johnson Foundation
12
Dying Veterans over 3 Fiscal Years
  • Identified 148,122 veterans who died nationwide,
    who had at least 1 inpatient stay
  • Identified last inpatient stay
  • ICU, Acute Care (non-ICU), Nursing Home, Other,
    Dedicated Palliative Care Bed
  • Calculated how many veterans died, associated
    costs and related statistics

13
Patients dying during last institutional stay
  • 79, 216 (53 ) died in an institutional setting
    at some time over three year period

41 of VA acute care deaths in ICU as compared
to 16.9 under Medicare
14
Costs of Terminal Stays
  • Annual direct cost of terminal admits
    387,367,000
  • 67 of costs in acute care

15
Cost per Day and Average LOS
16
Average Cost Per Day for Terminal Stays
Direct DSS Cost
17
ICU Deaths by VISN
18
ICU Deaths as General Medicine Unique Patients
19
ICU Utilization in Last Six Months of Life
20
VISN 21
VISN 22
21
Direct Costs of Care for Last Six Months and Last
Year of Life
22
VA Cost per Veteran for Last Year of Life
ESTIMATED DIRECT AND INDIRECT COST 1,749,608,000
Estimated total VA cost per veteran in last year
of life 44,124
Comparison Medicare Claims Data age 65-74
31,800 /year
Hogan et al. Health Affairs 2001, based on 1997
claims data
23
What percent of the VHA Budget is Spent on the
Last Year of Life?
Of approximately 17,000,000,000 allocated per
year by VHA for clinical care 10 is for care
in the last year of life
For 1.3 of enrolled veterans
24
The question is not whether or not we should
provide end-of-life care we already are
  • The question is whether we are using resources
    wisely in the provision of this care
  • And
  • Whether or not we can honor veterans preferences
    as to where they wish to die

25
(No Transcript)
26
Things to consider
  • Develop palliative care consult teams
  • Identify a palliative care coordinator to help
    with
  • Community hospice referrals
  • Staff education regarding palliative care options
  • Liaison to the community
  • Develop dedicated bed programs, where not present

27
SUMMARY
  • Veterans are dying in record numbers
  • End-of-life care as currently provided is very
    expensive
  • Too many veterans are dying in ICUs and acute
    care
  • Too few veterans are receiving good end-of-life
    care in dedicated beds or home hospices
  • Shifting patients into better, less expensive
    venues of care can save you money
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