Hospital 30 Day Readmission Reduction With Hospice Admission 'Literature Review' chapter

Excerpt from 'Literature Review' chapter :

Hospice care is a kind of philosophy and care that centers on the palliation of a patient who is seriusly or terminally ill. Hospice care includes tending to the patient's pain and symptoms as well as their emotional and spiritual needs. The proposed research examines how referral and admission to hospice care can lead to a reduction in hospital re-admissions. This author proposes to look at current hospital referrals to hospices in 2013 (control) and hospital 30 day re-admission rates of current local level II trauma center for patients with chronic disease. The Proposal is to add "Hospice and Palliative medicine consult" to current standing orders. This literature review will focus on eight articles/reports that recommend palliative care among other things to achieve a high quality of care.

In an article by Smith et al. (2012), the writers address the integration of palliative care services into standard oncology practice during a patient's diagnosis of metastatic or advanced cancer. The article discusses how the perceived notionS of palliative care include the same as end-of-life care. But, it argues that "palliative care is focused on the relief of suffering, in all of its dimensions, throughout the course of a patient's illness" (Smith et al., 2012, p.1-9). The articles shares how hospice is typically only reserved for the last three weeks of a patient's life. This period of treatment in turn nullifies the possible benefits the patient could receive from said treatment.

Smith et al. state improvements in quality of life, survival rates, and cost of care will greatly decrease patient readmission rates as well as provide much needed chances of recovery for these terminally ill or seriously ill patients. The article brings up an important point with regards to the possible revision in treatment protocol for hospice and palliative care, "Until recently, data from randomized controlled trials (RCTs) demonstrating the benefits of palliative care in patients with metastatic cancer who are also receiving standard oncology care have not been available" (Smith et al., 2012, p.1-9). It is only till recent times that people have realized the importance and need for hospice and palliative care to include improvements in quality of life, cost of care, and survival rates.

They utilized seven published RCTs in order to form the basis of the recent data for this PCO or Provisional Clinical Opinion. The evidence they gathered led to the conclusion that: "patients with metastatic non-small-cell lung cancer should be offered concurrent palliative care and standard oncologic care at initial diagnosis" (Smith et al., 2012, p.1-9). Even though there has been some recent attempts at researching palliative care including higher survival rates of cancer patients in conjunction with early palliative care and standard cancer care, there is still not enough information on demonstrated in other oncology settings. As it pertains to certain results, earlier palliative care diminishes chances for wasted intensive care as well as better patient and caregiver outcomes that include appropriate referrals and use of hospice care. The most significant point the paper makes is no excessive costs or harm to patients and caregivers when appropriating improvements to delivery of palliative and hospice care. Therefore it would benefit every part to create strategies to optimize concurrent palliative care and standard oncology care.

In an article by Temel et al. (2010), they examine the effect of introducing: "palliative care early after diagnosis on patient-reported outcomes and end-of-life care among ambulatory patients with newly diagnosed disease" (Temel et al., 2010, p. 733-42). As with most people who suffer from terminally ill diseases, metastatic non-small-cell lung cancer brings a host of consequential and painful symptoms along with aggressive care towards the end of life period. The authors believe early use of palliative care services will allow for a better outcome. Patients were randomly assigned either standard oncologic care or standard oncologic care combined with early palliative care. They measured quality of life and mood through a twelve week period with the Functional Assessment of Cancer

Therapy -- Lung (FACT-L) scale and the Hospital Anxiety and Depression Scale.

The results of the 151 patients who underwent randomization were: 27 died in the twelve week time period with 107 patients finishing assessments. "Patients assigned to early palliative care had a better quality of life than did patients assigned to standard care (mean score on the FACT-L scale [in which scores range from 0 to 136, with higher scores indicating better quality of life], 98.0 vs. 91.5; P = 0.03). In addition, fewer patients in the palliative care group than in the standard care group had depressive symptoms (16% vs. 38%, P = 0.01)" (Temel et al., 2010, p. 733-42). Although the article did a great job in revealing concrete evidence that early palliative care led on average to longer median survival rates among terminally ill patients, the lack in detail of what was done during early palliative care and how patients responded specifically to certain areas of the care remain. It is important to research how patients act when terminally ill and when they receive treatment in order to give treatment even earlier than normal or deny treatment if patient is recovering.

Some patients do not need early palliative treatment because they are dying regardless. Consulting with patients thoroughly in order to identify who needs early intervention or standard treatment is important in relation to time and resources spent. The study however, did reveal that early palliative care led to less aggressive treatment at the end of life coupled with longer survival rates making early palliative care a useful and cost-effective method of care. More research is needed t identify responses of patients receiving palliative care.

As mentioned before, there is limited evidence on the impact of early treatment measures, though research and studies done on this topic have shown favorable results. There is also limited evidence on the impact of advance care planning or ACP on patient outcomes. In a recent study by Abel, Pring, Rich, Malik, & Verne (2013), the authors conducted a "retrospective cohort study on deaths of all patients known to a hospice in a 2.5-year period to see if use of ACP affected actual place of death, hospital use and cost of hospital care in the last year" (Abel, Pring, Rich, Malik, & Verne, 2013, p. 168 -- 173). From a total f 960 patients, the results were: "550 (57%) people completed ACP. 414 (75%) achieved their choice of place of death. For those who chose home, 34 (11.3%) died in hospital; a care home 2 (1.7%) died in hospital; a hospice 14 (11.2%) died in hospital and 6 (86%) who chose to die in hospital did so. 112 (26.5%) of people without ACP died in hospital" (Abel, Pring, Rich, Malik, & Verne, 2013, p. 168 -- 173).

A strength of this study was the inclusion of mean cost of hospital treatment which was: "for those who died in hospital was £11,299, those dying outside of hospital £7,730 (p<.001). Mean number of emergency admissions for those who died in hospital was 2.2 and who died elsewhere was 1.7 (p<.001)" (Abel, Pring, Rich, Malik, & Verne, 2013, p. 168 -- 173). This demonstrated that patients who died in the hospital cost more than those who died outside. Allowing them time to make the decision where to pass on, which is typical in an ACP, allows for efficient cost allocation; more times than not, more people choose dying at home rather than in the hospital, therefore reducing cost of care. Inclusion of ACP in a hospice setting along with the measures described in this paper will not only reduce cost of care, but also give patients more choice, more time to choose, and better treatment options.

Cost is always something that must be handled effectively. In an article by Brown, Peikes, Peterson, Schore, & Razafindrakoto (2012), an examination of Medicare spending reveals the need for focused attention on beneficiaries with multiple chronic conditions. Although the studies researched in this paper reveal coordinated care management programs such as integration of early palliative care have revealed positive results, this study says these types of programs have not been successful. "Many care coordination and disease management programs designed to improve beneficiaries' care and reduce their need for hospitalizations have been tested, but few have been successful" (Brown, Peikes, Peterson, Schore, & Razafindrakoto, 2012, p. 1156-1166). The ones that did however, were analyzed by this study revealing four of the eleven observed programs were successful through six approaches: "The six approaches practiced by care coordinators in at least three of the four programs were as follows: supplementing telephone calls to patients with frequent in-person meetings; occasionally meeting in person with providers; acting as a communications hub for providers; delivering evidence-based education to patients; providing strong medication management; and providing timely and comprehensive transitional care after hospitalizations" (Brown, Peikes, Peterson, Schore, & Razafindrakoto, 2012, p. 1156-1166). This study revealed what kind of approaches must be taken in order to ensure success in a managed care program. It also showed how these…

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