Gerald Chinchar isn't quite at the end of life, but there have been times when it seemed that it might not be far away. The seventy-six-year-old fell twice last year, shattering his hip and femur, and now he navigates his San Diego home in a wheelchair. He has multiple conditions, including diabetes, chronic obstructive pulmonary disease, and congestive heart failure, all of which increase his chances of landing in the hospital.
Chinchar says the hospital is the last place he wants to be. He still likes to watch his grandchildren's sporting events and play blackjack at the casino. "If they told me I had six months to live or go to the hospital and last two years, I'd say leave me home," Chinchar proclaims. "That ain't no trade for me."
Like Chinchar, most elderly people would rather avoid the hospital in their last years of life. But for many, it doesn't work out that way: they are in and out of the ER, getting treated for flare-ups of various chronic illnesses. Often, they spend the last few days or weeks of their lives in hospital beds undergoing unpleasant treatments and procedures that have little or no chance of extending their lives in a meaningful way. It's a massive problem that has galvanized health providers, hospital administrators, and policymakers to search for solutions.
Some seniors repeatedly land in the hospital because they are seriously ill and can't get care at home that could have prevented a trip to the emergency room. They are not ready for hospice care, which is limited to those expected to live less than six months. But they could still benefit from the type of services hospice provides, including home visits by health providers and medications aimed at relieving pain and other symptoms. Those services not only help improve quality of life; they also keep people out of expensive emergency rooms and inpatient units.
Fortunately for Gerald Chinchar, he landed in one of the few programs set up for people like him. Sharp HealthCare, the nonprofit San Diego health system where Chinchar receives care, has devised a way to fulfill his wishes and reduce costs at the same time. It's a "pre-hospice" program called Transitions, designed to give elderly patients the care they want and need at home and to help them avoid the hospital.
Through Transitions, social workers and nurses from Sharp regularly visit patients in their homes to explain what they can expect in their final years, help them make end-of-life plans, and teach them how to better manage their diseases. Physicians track the patients' health and scrap unnecessary medications. Unlike in hospice care, patients don't need to have a prognosis of six months or less and can continue getting treatment for their diseases.
Before the Transitions program started, the only option for many of its patients in a health crisis was to call 911 and be rushed to the emergency room. Now, they have round-the-clock access to the program's nurses, just a phone call away. "Transitions is for just that point where people are starting to realize they can see the end of the road," said San Diego physician Dan Hoefer, one of the creators of the program. "We are trying to help them through that process so it's not filled with chaos."
The chaos for patients and the expense for Medicare that programs like Transitions seek to address is likely to grow in coming years--10,000 Baby Boomers turn sixty-five every day, and many of them have multiple chronic diseases. Transitions was among the first of its kind when it started ten years ago, but several such programs, formally known as "home-based palliative care," have since opened around the country. They are part of a broader push to improve people's well-being and reduce spending through better coordination of care and more treatment outside hospital walls.
Health policymakers increasingly recognize that to control health care costs, they must target the sickest patients. About a quarter of all Medicare spending for beneficiaries sixty-five and older is to treat people in their last year of life, according to a report by the Kaiser Family Foundation.
Another expensive group includes those who are seriously ill but not necessarily at the very end of life. People who are chronically ill and have functional disabilities (like the inability to walk or bathe themselves) make up about 14 percent of the population but account for 56 percent of health care costs, according to a 2014 Institute of Medicine report, Dying in America.
But one huge barrier stands in the way of home-based palliative care: Medicare and private insurers have not traditionally paid for it. Under regular fee-for-service Medicare, the federal government reimburses health providers for office visits and procedures, and hospitals for patients in their beds. The...