A New Model for Advanced Illness Management – Daniel Hoefer

Daniel R. Hoefer, MD, Outpatient Palliative Care and Hospice, Sharp HospiceCare

The vast majority of healthcare is paid for by a model called fee for service. The physician is paid once a procedure or event occurs. This became the foundation for Medicare reimbursement. At Medicare’s inception this was an acceptable model. Life expectancy was about 68 on average and the cost of care was limited by knowledge and relatively few available services.

Fifty years later however, technology and knowledge have dramatically increased. Unfortunately the culture of care and management of the elderly has not kept pace. (This includes the culture of reimbursement.) The fastest growing segments of the US population are over age 70 – 80. Yet, research historically deliberately excluded these demographics. We now know that the psychosocial needs of patients and families, goals of care and human physiology change as people live longer: http://www.nxtbook.com/nxtbooks/nhpco/newsline_201204/#/0.

We furthermore know that originally we had a reactive model of care, both medical and psychosocial. However, when 90% of patients in this country die from the predictable end stages of chronic illness a reactive model achieves inferior results. The hospital unnecessarily becomes a tool to manage late-stage disease.

Since 2007 Sharp Health Care through Sharp HospiceCare has embraced these changes. They have developed a model of transitional care which provides concurrent traditional and palliative management. Patients have complete access to traditionally aggressive treatment strategies but as their disease progresses can participate in aggressive palliative and then aggressive hospice strategies. The course of treatment is guided by the goals of care of the patient, including the fact that most persons do not want to be institutionalized and prefer to stay at home.

By providing a concurrent model of care patients have better quality of life, and their goals of care are respected at decreased cost. Hospitalizations are dramatically decreased. Caregiver and families as well have better outcomes. Sharp HospiceCare is decreasing the cost curve of healthcare, not by decreasing care but by dramatically improving the way it is delivered.

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