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September 24, 2018

Providence St. Joseph's CEO saw his father endure unwanted end-of-life care. Now, he wants to protect his patients from a similar fate.

Daily Briefing

    After Rod Hochman, a physician and CEO of Providence St. Joseph health system, watched his father endure unwanted, aggressive medical interventions at the end of his life, Hochman launched an effort to ensure patients at his own health system didn't meet a similar fate, Brian Stauffer reports for Politico.

    Download URMC's conversation prompts to start improving end-of-life care for patients

    Hochman's father spent his last hours in a hospital enduring aggressive end-of-life care. Hochman watched as his 78-year-old father, who'd suffered a stroke, lay in the ICU connected to a ventilator and an intravenous drip. This was not what Hochman's father had wanted for his final days—and it was only later that Hochman realized that, in any event, the efforts to save his father were unlikely to keep him alive.

    Costly, unwanted end of life care all too common in the US

    As CEO of Providence St. Joseph health care system, one of the largest nonprofit health systems in the country, Hochman understands that his father's experience is not uncommon.

    For doctors and patients, conversations surrounding end-of-life care can be sensitive, emotionally taxing, and have "no single template," Stauffer writes. The conversations can involve discussions about religious views, values, and medical terminology and last anywhere from one visit to a few months.

    In addition, doctors are not well compensated for the conversations that advanced directives require. Until 2016, Medicare didn't reimburse doctors for the time it took to have discussions about advance-care planning. Even now, looking at billing data show not even one in 100 Medicare beneficiaries had end-of-life-planning conversations with their doctors in the first six months of 2017.

    According to Stauffer, unwanted end-of-life care also strains the Medicare system. About 25% of Medicare spending is for end-of life care—much of which is unwanted, Stauffer reports.

    A deceptively easy goal—and the big effort behind it

    This year, Hochman is aiming to increase by 2% the number of patients at his 51-hospital health system who have advanced directives and designated decision-makers for end-of-life care. While that might seem like a modest target, Stauffer writes, "it's proving to be an ambitious and resource-intensive effort."

    Broadly speaking, Providence is working toward its goal by changing its culture and operations, Stauffer reports.

    For instance, Providence created a new internal agency called the Institute for Human Caring in an effort to integrate "whole-person care" into the system's culture, according to Stauffer. The agency aims to improve communication between patients and physicians, and it provides "advanced communication training" for physicians and nurses. 

    Providence also offers digital and printed guides, available in multiple languages, that explain advance-care planning documents to patients and families as well as videos that explain processes and treatments such as dialysis, CPR, and hospice care.

    To ensure that the patients' preferences are carried out, Providence EHRs now contain information about a patient's end-of-life preferences, their designated decision-maker, and wishes for their final days, according Matthew Gonzales, the chief medical information officer of the Institute for Human Caring. If physicians begin a treatment that the patient, or their designated decision-maker, did not approve, the system sends the physician an alert.

    Medicare is contributing to some of Hochman's efforts as well: It offers financial incentives for doctors and hospitals to manage the cost and quality of end-of-life care. In addition, Providence has tied part of doctor compensation to advanced directive completion rates. "That got their attention," said Ira Byock, who leads the whole-person care initiative.

    What's working

    More than 13% of the 125,314 Medicare patients who were discharged from Providence hospitals this year completed advanced directives—and about 38,000 patients who came to Providence hospitals had advanced directives scanned in their EHRs, Stauffer reports.

    Health care staff at Providence hospitals have noticed a positive change as well. "Two years ago, only the palliative care team was putting in the notes on goals of care [in patient records]," said Christina Rothans, a social worker on the palliative care service. "Now it's nurses, social workers, primary care. There's been a culture change."

    Providence also has found that patients who have conversations with health care providers about end-of-life care report higher satisfaction—which may ultimately result in a financial return to the hospital. "We think it's a good return on investment and it's better care for our patients," Hochman said, adding, "But here's a secret. We would do it anyway. It's the right thing to do."

    The beginning of change across the US?

    The efforts of Providence health system can serve as a "trial run" for other hospitals that seek to manage the costs and consequences of aggressive, high-tech end-of-life-care, Stauffer writes.

    According to Stauffer, very few U.S. health systems have made the effort to manage the cost and processes of end-of-life care, but experts think it is a worthwhile investment.

    "There is a sense of calm and peace when you are being rolled in to know, if something were to happen, my wishes would be honored," said Lindsey Burrell, an ICU nurse at a Providence hospital. "It decreases anxiety—and for the surrogate, too" (Stauffer, Politico, 9/12).

    Oct. 24 webconference: Improve end-of-life care for cancer patients

    Over the past few years, there have been increased conversations about end-of-life care in America driven by numerous books, films, and newspaper articles.

    Join us on Oct. 24 to learn how your peers have improved end-of-life care—from activating patients to providing care team training to finding hospice partners with a shared vision for patient care.

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