Health

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Brief Report

Background Elderly patients frequently experience dete- riorating health after critical illness, which may threaten their independence and predispose them to unplanned hospital readmissions and premature death. Objectives To evaluate the operational feasibility of a 90-day home-based palliative care intervention in multi- morbid elderly Veteran survivors of critical illness. Methods A multidisciplinary home-based palliative care intervention was provided for multimorbid elderly veter- ans who were discharged home after admission to the intensive care unit for sepsis, pneumonia, heart failure, or exacerbation of chronic obstructive lung disease. Results Fifteen patients enrolled in the study, 11 (73%) of whom completed all visits; thus the prespecified goal of >70% completion was met. Median (interquartile range [IQR]) age of the patients was 76 (69-87) years. Participants had a median (IQR) of 8 (7-8) concurrent chronic health conditions, were moderately debilitated at baseline, and were all male. The median (IQR) time to the first study visit was 8 (5-12) days. Patients had a median (IQR) of 8 (5-11) in-home visits and 6 (3-7) telephone encounters during the 90-day study period. Nurses spent a median (IQR) cumulative time of 330 (240-585) minutes on home visits and 30 (10-70) minutes on telephone visits. The median (IQR) time per home provider visit was 90 (75-90) minutes. We estimated the median (IQR) cost per patient to be $2321 ($1901-$3331). Conclusion A comprehensive home-based palliative care intervention is operationally feasible in elderly multi- morbid survivors of critical illness and may result in improved physical functioning and quality of life and fewer unplanned emergency department visits. (American Journal of Crit- ical Care. 2021;30:e12-e31)

Feasibility oF a Home- based Palliative Care intervention For elderly multimorbid survivors oF CritiCal illness By Florian B. Mayr, MD, MPH, Judith L. Plowman, MD, Sandra Blakowski, MD, Kimberly Sell-Shemansky, MSW, Joleene M. Young, CRNP, and Sachin Yende, MD, MS

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Home-based care is an attractive alternative after discharge when patients are most vul- nerable and caregivers are the least prepared.

E ach year, 2 million elderly Americans are treated in intensive care units (ICUs).1 Long- term outcomes after critical illness vary, but one-third of patients who survive to hos- pital discharge die during the following year, and one-sixth have severe persistent impairments for which they require ongoing medical care. Most ICU survivors who are discharged home return to their primary care physicians and subspecialists for aftercare.

Alternative care models exist, such as ICU survi- vor clinics that provide integrated care at a single location focused on treating sequelae of critical ill- ness.2 However, both of these care models are clinic-based and require patients to travel, which may be burdensome for some patients or unfeasible for patients who are debilitated or have poor social support. In addition, these aftercare models often do not include palliative care interventions. Home- based care is an attractive alternative after hospital discharge, a period when patients are vulnerable and caregivers feel unprepared and overwhelmed.3 The feasibility of implementing a home-based care model in critical illness survivors has not been stud- ied. Therefore, we conducted a quality improvement trial to test the operational feasibility of a 90-day, home-based palliative care intervention in elderly veteran ICU survivors.

Methods Project Design and Inclusion Criteria

We assessed operational feasibility by conducting a prospective study of a multidisciplinary, home-based palliative care intervention in 15 patients who were discharged home after treatment in the ICU for community-acquired pneumonia, heart failure exac- erbation, chronic obstructive pulmonary disease (COPD), or sepsis. This project was reviewed and

approved by the institutional review board at VA Pittsburgh Healthcare System as a quality improve- ment project.

Intervention Our intervention included at least 2 scheduled

in-home visits and 2 follow-up telephone visits in 90 days, delivered by a multidisciplinary team of pallia- tive care, geriatric, and critical care nurses, nurse prac- titioners, and physicians; physical therapists; and social workers (see Figure, part A; home visit data collection form: Supplement 1). Eligi- ble veterans were identified during hospitalization. The first home visit was sched- uled within 72 hours of hospital discharge, and the final visit was scheduled 90 days after hospital discharge. Scripted telephone calls were planned at weeks 4 and 8 (telephone visit data collection form: Supplement 2). The team met weekly to discuss the patients’ prog- ress and to develop, monitor, and refine care plans.

Home and Telephone Visits The care team assessed patients’ physical, medi-

cal, psychological, social, and spiritual needs during the 2 home visits with a multidisciplinary approach involving physicians, nurse practitioners, nurses, and social workers. The team assessed baseline physical function and symptom burden with the Palliative Performance Scale (PPS) and simplified Edmonton Symptom Assessment System (sESAS; Supplemental Tables 1-3), which have been extensively validated in cancer and noncancer populations.4-6 The partici- pants completed a perception-of-care questionnaire after the final home visit (Supplement 3). Telephone visits were conducted to provide scheduled updates on new health events including changes in symptoms, new medical problems, unplanned rehospitalizations, and emergency department visits. A team member was available 24-7 via an emergency telephone num- ber to help manage new symptoms that required immediate medical attention.

About the Authors Florian B. Mayr is a staff physician, Critical Care Service Line, VA Pittsburgh Healthcare System, and an assistant professor, Clinical Research, Investigation, and Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. Judith L. Plowman is a staff physician and Kimberly Sell-Shemansky is a vice-president, Community Based Care Service Line, VA Pittsburgh Healthcare System. Sandra Blakowski is a section chief, Medicine Service Line, Division of Palliative Care and Hospice, VA Pittsburgh Healthcare System. Joleene M. Young is a nurse practitioner, Critical Care Ser- vice Line, VA Pittsburgh Healthcare System. Sachin Yende is a vice-president, Critical Care Service Line, VA Pittsburgh Healthcare System, and a professor, Clinical Research, Investigation, and Modeling of Acute Illness Center, Depart- ment of Critical Care Medicine, University of Pittsburgh.

Corresponding author: Florian B. Mayr, MD, MPH, VA Pitts- burgh Healthcare System, University Drive C, Bldg. 1, Rm 5A112, Pittsburgh, PA 15241 (email: [email protected]).

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Outcomes The primary outcome was the operational fea-

sibility of conducting this trial.7 We aimed to enroll 1 to 2 patients per month for 12 months and com- plete at least 70% of all prespecified home and tele- phone visits within the proposed time windows. Secondary outcomes included (1) PPS score at day 90, (2) sESAS score at day 90, (3) patient/caregiver satisfaction, and (4) number of unplanned hospital readmissions and emergency department visits within 90 days.

Statistical Analysis We present categori-

cal data as count and per- centage and continuous data as median and inter- quartile range (IQR). We refrained from formal statistical testing because

of the limited sample size. We estimated resource utilization by applying current procedural terminol- ogy billing codes for in-home, telephone, and care coordination visits (Supplemental Table 4). We compared the number of unplanned readmissions and emergency department visits during the study period with the number in the 3-month period

preceding the index hospitalization. Data manage- ment and analyses were performed with Stata/SE 15.1 (Stata Corp).

Results Patient Characteristics

Patient characteristics are summarized in the Table. Median (IQR) age was 76 (69-87) years, and all participants were male and multimorbid (median [IQR] number of chronic health conditions, 8 [7-8]). Patients were moderately debilitated at baseline (median [IQR] PPS score, 60 [60-70]; median (IQR) sESAS score, 4 [2-7]). The reasons for the index hospitalization were heart failure exacerbation (67%), community-acquired pneumonia (20%), sepsis (7%), and COPD exacer- bation (7%). Ten patients required organ support, 8 received noninvasive or invasive positive pressure ventilation, and 3 received vasopressor support. The median (IQR) APACHE score at admission was 15 (13-18). The most common reasons for nonenroll- ment were a dependent living situation before hos- pitalization, transfer from an outside hospital, or residence more than 25 miles from our institution.

Feasibility Outcomes We enrolled 15 patients in 12 months. Ninety-day

follow-up was available in all 15 patients; 11 patients

Figure (A) Schematic overview of home-based palliative care intervention and (B) comparison of unplanned hospital readmissions and emergency department visits for each patient during the 90-day period immediately preceding enrollment (before) and during the study period (after).

B No. of readmissions before and after initiation of program

5 6

5 4

4 3

2 2

1 1

0 0

Hospital discharge

Initial home visit

Telephone visit 1

Telephone visit 2

Final home visit

12 ± 2 weeks8 ± 1 weeks4 ± 4 days72 hours

Before Before AfterAfter

No. of emergency department visits before and after initiation of program

90-day study period

Our intervention resulted in improved symptom

control and quality of life, which contributed to high

patient satisfaction.

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(73%) completed all study visits (see Table). Two patients (13%) died before study completion, and 2 patients did not complete all visits because of pro- longed rehospitalization.

The median (IQR) time to first study visit was 8 (5-12) days. Each patient received a median (IQR) of 8 (5-11) in-home visits during the 90-day study period: 4 (3-6) visits by nurses, 3 (2-4) visits by physicians, and 1 (1-1) visit by a social worker. In addition to home visits, patients had a median (IQR) of 6 (3-7) telephone encounters during the study period (see Table).

Each patient was visited at home by nurses for a median (IQR) total of 330 (240-585) minutes and was visited by telephone for a median (IQR) cumu- lative time of 30 (10-70) minutes (see Table). The median (IQR) time for each home visit was 90 (75- 90) minutes. We estimated the median (IQR) cost per patient to be $2321 ($1901-$3331), which is in stark contrast to the average cost of $31 679 per ICU admission for the very elderly.8 We refrained from formal cost-benefit analysis at this early stage of fea- sibility testing, but we estimate that the intervention was cost-neutral in our setting.

Clinical Outcomes Median PPS scores at day 90 (n = 11; median [IQR],

70% [50%-80%]) were slightly higher than the initial PPS scores (n = 15; median [IQR], 60% [60%-70%]; see Table). Consistently, median sESAS scores were slightly lower at day 90 (n = 11; median [IQR], 3 [2-4]) than the initial scores (n = 15; median [IQR], 4 [2-7]). Of the 11 patients who completed all visits, 3 (27%) were readmitted within 30 days and 7 (64%) were readmitted within 90 days. The median number of unplanned hospital admissions during the project period (median [IQR], 1 [0-2]) was similar to that of the 3-month period preceding index hospitaliza- tion (median [IQR], 1 [0-3]), whereas unplanned emergency department visits were lower during the project period (median [IQR], 1 [0-2]) than they were during the 3-month period preceding index hospitalization (median [IQR], 2 [2-4]); see Figure, part B). Patients rated their overall satisfaction with this intervention with a median (IQR) score of 4.5 (4-5) (n = 11) on a 5-point Likert scale.

Discussion We demonstrated operational feasibility of a home-

based multidisciplinary intervention in multimorbid ICU survivors and reached our predefined goals of enrolling 15 patients within 12 months and complet- ing at least 70% of prespecified visits. The importance of palliative care is highlighted by the fact that 1 patient

transitioned to hospice during during the 90-day study period and 2 additional patients transitioned to hos- pice shortly after the 90-day study period. We observed

Clinical characteristic

Table Clinical characteristics, study visits, and outcomes of 15 patients enrolled in the study

Age, median (IQR), y

Male sex, No. (%)

APACHE score, median (IQR)

Marital status, No. (%) Married Divorced or widowed Single

Body mass index,a median (IQR)

Health behaviors, No. (%) Past or current smoker Past or current alcohol use

No. of comorbidities, median (IQR)

Comorbidity, No. (%) Hypertension Diabetes Coronary artery disease Heart failure Pulmonary disease Renal disease Malignant neoplasm Anemia

Caregiver, No. (%) Spouse Other

Palliative Performance Scale score, median (IQR), %

Simplified Edmonton Symptom Assessment System score, median (IQR)

Study visits Days in hospital before enrollment, median (IQR) Days to first study visit, median (IQR) Number of in-home visits, median (IQR) Number of phone calls, median (IQR) Duration of in-home provider visits, median (IQR), min Total nurse time spent per patient on home visits,

median (IQR), min Total nurse time spent per patient on phone visits,

median (IQR), min

Outcomesb

No. of emergency department visits, median (IQR) No. of unplanned readmissions, median (IQR) Palliative Performance Scale score, median (IQR) Modified Edmonton Symptom Assessment System score,

median (IQR) Overall patient satisfaction on 5-point Likert scale, median (IQR) 90-Day mortality, No. (%)

76 (69-87)

15 (100)

15 (13-18)

9 (60) 4 (27) 2 (13)

22.3 (19.1-26.3)

14 (93) 13 (87)

8 (7-8)

14 (93) 9 (60)

11 (73) 15 (100) 12 (80) 10 (67) 6 (40) 10 (67)

9 (60) 6 (40)

60 (60-70)

4 (2-7)

9 (5-16) 8 (5-12) 8 (5-11) 6 (3-7) 90 (75-90) 330 (240-585)

30 (10-70)

1 (0-2) 1 (0-3) 70 (50-80) 3 (2-4)

4.5 (4-5)

2 (13)

Value

Abbreviations: APACHE, Acute Physiology and Chronic Health Evaluation; IQR, interquartile range.

a Calculated as weight in kilograms divided by height in meters squared.

b Study outcomes were assessed in 11 patients who completed the intervention. The denominator for 90-day mortality included all 15 study participants.

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improvements in physical functioning, quality of life, and symptom control, which contributed to high patient satisfaction. This intervention was time inten- sive and required multiple in-person and telephone visits by nurses, physicians, and social workers. Differ- ent models of care may be appropriate for different ICU survivors, and a resource-intensive intervention like this may be appropriate only for a subset of high- risk patients. On the basis of this experience, we recom- mend that future studies test efficacy, generalizability, and scalability; optimize efficiency by incorporating novel technology (telehealth visits); test alternative follow-up periods (eg, 60 days vs 90 days); and iden- tify subgroups of ICU survivors who are most likely to benefit from home-based care interventions.

Our project has several limitations. First, it was designed as a quality improvement study to test the operational feasibility of implementing compre- hensive home-based palliative care in multimorbid veterans. Although we were able to meet our enroll- ment criteria, the scalability of interventions like this will depend on the ability to automatize study proce- dures, for example, through EHR-prompted screen- ing. Second, the median time to the first home visit was 8 days although it was planned to be 72 hours. Future studies of home-based interventions should aim to complete initial home visits as early as possi- ble because the period immediately after hospital discharge is the most stressful and vulnerable time for patients and caretakers. Third, our project was conducted in the unique environment of the largest integrated health care system, and our findings may not generalizable to other more diverse settings. Fourth, we did not evaluate caregiver satisfaction during this project.

In conclusion, we successfully demonstrated the operational feasibility of a comprehensive

home-based palliative care intervention in multimor- bid elderly veteran survivors of critical illness at high risk of hospital readmission.

ACKNOWLEDGMENTS The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

FINANCIAL DISCLOSURES This work was supported with resources from and the use of facilities at the VA Pittsburgh Healthcare System. Flo- rian B. Mayr is currently supported by a VA VISN4 Com- petitive Career Development fund and National Institutes of Health K23GM132688.

REFERENCES 1. Sjoding MW, Prescott HC, Wunsch H, Iwashyna TJ, Cooke CR.

Longitudinal changes in ICU admissions among elderly patients in the United States. Crit Care Med. 2016;44(7): 1353-1360.

2. Lasiter S, Oles SK, Mundell J, London S, Khan B. Critical care follow-up clinics. Clin Nurse Spec. 2016;30(4):227-237.

3. Choi J, Lingler JH, Donahoe MP, Happ M, Hoffman LA, Tate JA. Home discharge following critical illness: a qualitative analysis of family caregiver experience. Heart Lung. 2018; 47(4):401-407.

4. Anderson F, Downing G, Hill J, Casorso L, Lerch N. Palliative perfor- mance scale (PPS): a new tool. J Palliat Care. 1996; 12(1):5-11.

5. Bruera E, Kuehn N, Miller M, Selmser P, Macmillan K. The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Pal- liat Care. 1991;7(2):6-9.

6. Hui D, Bruera E. The Edmonton Symptom Assessment Sys- tem 25 years later: past, present, and future developments. J Pain Symptom Manage. 2017;53(3):630-643.

7. Eldridge SM, Lancaster GA, Campbell MJ, et al. Defining fea- sibility and pilot studies in preparation for randomised con- trolled trials: development of a conceptual framework. Plos One. 2016;11(3):e0150205.

8. Chin-Yee N, D’Egidio G, Thavorn K, Heyland D, Kyeremanteng K. Cost analysis of the very elderly admitted to intensive care units. Crit Care. 2017;21(1):109.

To purchase electronic or print reprints, contact American Association of Critical-Care Nurses, 27071 Aliso Creek Road, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362- 2050 (ext 532); fax, (949) 362-2049; email, [email protected].

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Notice to CE enrollees: This article has been designated for CE contact hour(s). The evaluation demonstrates your knowledge of the following objectives:

1. Describe some of the disadvantages of clinic-based aftercare for critical illness survivors. 2. List patient-centered outcomes that may improve in critical illness survivors with home-based palliative care

interventions. 3. List topics that future research in this area should address.

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Supplement 1

HBPC MD/CRNP VISIT NOTE

Visit Date / Visit Number:

PATIENT INFORMATION

Name: Age: Date of Birth: / / Gender: ■ Male ■ Female Last # 4 soc sec : Primary Care Physician: Primary Care Office Contact Person and Phone Number:

CHIEF OBJECTIVE ■ Symptom Management ■ Other ■ Goals of Care REFERRING DIAGNOSIS / Discharge Diagnosis

■ Congestive Heart Failure ■ Sepsis ■ CAP ■ ICU admission ■ COPD ■ Other HISTORY OF PRESENT ILLNESS

PAST MEDICAL HISTORY

■ DM ■ Lung Disease ■ Blood Disorder ■ HTN ■ Liver Disease ■ Cancer ■ CVD ■ Kidney Disease ■ Psychiatric Disorder ■ Thyroid Disease ■ TIA/Stroke ■ Other Specifics: ED visit since last home visit? Hospital admission since last visit?

PAST SURGICAL HISTORY

ADVANCE CARE PLANNING

Existing Documents: ■ Living Will Reviewed: Date Created: ■ POLST Reviewed: Date Created: Patient Identified Surrogate Decision Maker (name/relationship):

Contact Information for Surrogate Decision-maker: Phone: HPOA: Yes No

FAMILY HISTORY ■ Done Previously ■ CAD ■ Drug Abuse ■ Reviewed, Not Pertinent ■ Cancer ■ Other ■ DM ■ Alcohol Abuse SOCIAL HISTORY

Marital Status ■ Single ■ Widowed ■ Married ■ Divorced ■ Other

Living Situation ■ Independent ■ Adult Home ■ Nursing Home ■ With Family ■ Assisted Living ■ Other

Prior Occupation: Military History: Yes Branch of Service: Enrolled in other Healthcare at this time: Yes No Description of Spirituality & Religion:

Tobacco Use Alcohol Use Other Drug Use ■ Current ■ Current ■ Current (type, amt.) (type, amt.) (type, amt.) ■ Past ■ Past ■ Past (type, amt.) (type, amt.) (type, amt.) ■ Age of onset 16-45 years ■ Never ■ Never ■ Never ■ Unknown ■ Unknown ■ Unknown ■ Family History ■ Family History

Continued

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Supplement 1 Continued

MEDICATIONS AS REPORTED BY THE PATIENT

Preferred Pharmacy (name/phone): 24H Oral Morphine Equivalent (OME): mg On Laxatives if Opiates prescribed: Yes No If no, why:

ALLERGIES/TYPE OF REACTION

■ No Known Drug Allergies ■ Drug Allergies:

REVIEW OF SYSTEMS

Constitutional Skin HEENT ■ Weight loss or gain ■ Rashes ■ Pain (describe below) ■ Change in appetite ■ Lumps ■ Decreased hearing ■ Fatigue ■ Itching ■ Ringing in ears ■ Fever or chills ■ Dryness ■ Vision loss/changes ■ Weakness ■ Hair and nail changes ■ Glasses or contacts ■ History of Falls ■ WNL ■ Nasal stuffiness or discharge ■ Trouble sleeping ■ Dentures ■ Ease of bruising ■ Dry mouth ■ Ease of bleeding ■ Sore throat ■ Head or cold intolerance ■ Hoarseness ■ Sweating ■ Lumps ■ Frequent urination ■ Swollen glands ■ Thirst ■ WNL ■ WNL

Respiratory Cardiovascular Gastrointestinal ■ Cough ■ Chest pain or discomfor ■ Swallowing difficultie ■ Coughing up blood ■ Palpitations ■ Heartburn ■ Shortness of breath ■ SOB with activity ■ Nausea ■ Wheezing ■ Orthopnea ■ Change in bowel habits ■ Painful breathing ■ Swelling ■ Rectal bleeding ■ WNL ■ Calf pain with walking ■ Constipation ■ Leg cramping ■ Diarrhea ■ WNL ■ Yellow eyes or skin ■ WNL

Urinary Musculoskeletal Neurologic ■ Frequency ■ Muscle or joint pain ■ Dizziness ■ Urgency ■ Stiffness ■ Fainting ■ Burning or pain ■ Back pain ■ Seizures ■ Blood in urine ■ Redness of joints ■ Weakness ■ Incontinence ■ Swelling of joints ■ Numbness ■ Change in urinary ■ Trauma ■ Tremor ■ WNL ■ WNL ■ WNL

Psychiatric Breasts ■ Nervousness ■ Lumps ■ Stress ■ Pain ■ Depression ■ Discharge ■ Memory loss ■ WNL ■ ADD/OCD/Bipolar/Schizophrenia ■ WNL

EDMONTON SYMPTOM ASSESSMENT SCALE (ESAS)

All Unobtainable due to: Pain: ■ 0 ■ 1 ■ 2 ■ 3 Comments: Anorexia: ■ 0 ■ 1 ■ 2 ■ 3 Comments: Tiredness (fatigue): ■ 0 ■ 1 ■ 2 ■ 3 Comments: Drowsiness (sleepiness): ■ 0 ■ 1 ■ 2 ■ 3 Comments:

Initial Depression Screen: ■ Past 2 weeks, down/depressed/hopeless ■ Past 2 weeks, bring little pleasure/joy ■ Depression rating: ■ Comments:

Continued

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EDMONTON SYMPTOM ASSESSMENT SCALE (ESAS) (continued)

Initial Anxiety Screen ■ Previous 4 weeks, worried, tense, anxious ■ Freq tense/irritable/trouble sleeping ■ Anxiety rating: ■ Comments:

Nausea: ■ 0 ■ 1 ■ 2 ■ 3 Comments: Shortness of breath ■ 0 ■ 1 ■ 2 ■ 3 Comments: Secretions ■ Yes ■ No ■ Other: Constipation ■ Yes ■ No ■ Other: Delirium ■ Positive ■ Negative ■ Other:

PALLIATIVE PERFORMANCE SCALE (PPS)

FUNCTIONAL ASSESSMENT

Katz Index of independence in Activities of Daily Living1

Use the Katz index to assess independence in activities of daily living: assign 1 point for each activity that the patient is able to com- plete independently (ie, without supervision, direction, or personal assistance):

Bathing _______ Dressing _______ Toileting _______ Transferring _______ Continence _______ Feeding _______

TOTAL POINTS: 6 = High (patient independent), 0 = Low (patient very dependent)

REFERENCE 1. Katz, S, Down, TD, Cash HR, Grotz RC. Progress in the development of the index of ADL. Gerontologist, 1970;10(1):20-30.

PHYSICAL EXAM

Vital Signs: T P R Weight:

GENERAL ■ Alert and oriented ■ Moderate distress ■ No acute distress ■ Severe distress ■ Mild distress ■ Other: Ambulation Status ■ WNL ■ Bedridden ■ Steady gait ■ Wheelchair bound ■ Assistive devices ■ Other:

PPS Level Ambulation

Activity & Evidence of Disease Self-Care Intake Conscious Level

100% Full Normal activity and work No evidence of disease

Full Normal Full

90% Full Normal activity and work Some evidence of disease

Full Normal Full

80% Full Normal activity with effort Some evidence of disease

Full Normal or reduced Full

70% Reduced Unable to do normal job/work Significant disease

Full Normal or reduced Full

60% Reduced Unable to do hobby/housework Significant disease

Occasional assistance necessary

Normal or reduced Full or Confusion

50% Mainly Sit/Lie Unable to do any work Extensive disease

Considerable assistance required

Normal or reduced Full or Confusion

40% Mainly in Bed Unable to do most activity Extensive disease

Mainly assistance Normal or reduced Full or Drowsy ± Confusion

30% Totally Bed Bound Unable to do any activity Extensive disease

Total Care Normal or reduced Full or Drowsy ± Confusion

20% Totally Bed Bound Unable to do any activity Extensive disease

Total Care Minimal to sips Full or Drowsy ± Confusion

10% Totally Bed Bound Unable to do any activity Extensive disease

Total Care Mouth Care only Drowsy or Coma ± Confusion

0% Death — — — —

Continued

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MAHC 10- Fall Risk Assessment Tool

Appearance ■ WNL ■ Emaciated ■ Well nourished ■ Underweight ■ Calm ■ Obese ■ Dysmorphic ■ Unkempt ■ Ill ■ Well developed ■ Malnourished ■ Other: Hydration ■ WNL ■ Severely dehydrated ■ Dehydrated ■ Other: Signs of distress ■ Crying ■ Groaning ■ Difficulty breathing ■ Grunting ■ Grimacing ■ Other:

Skin ■ WNL ■ Cyanosis ■ Anicteric ■ Clubbing ■ Jaundice ■ Edema ■ Normal for ethnicity ■ Pale ■ Acrocyanosis ■ Other:

HENT

■ Normocephalic ■ Neck supple ■ TM’s clear ■ No pharyngeal erythema ■ Normal hearing ■ Hearing grossly normal ■ Moist oral mucosa ■ Ear canals patent ■ No JVD ■ No sinus tenderness

Required Core Elements Assess one point for each core element “yes”

Information may be gathered from medical record, assessment and if applicable, the patient/caregiver. Beyond portals listed below, scoring should be based on your clinical judgment.

Points

Age 65+

Diagnosis (3 or more co-existing) Includes only documents medical diagnosis

Prior history of falls within 3 months An unintentional change in position resulting in coming to rest on the ground or at a lower level

Incontinence Inability to make it to the bathroom or commode in timely manner Includes frequency, urgency, and/or nocturia

Visual impairment Includes but not limited to, macular degeneration, diabetic retinopathies, visual field loss, age-related changes, decline

in visual acuity, accommodation, glare tolerance, depth perception, and night vision or not wearing prescribed glasses or having the correct prescription.

Impaired functional mobility May include patient who need help with IADLS or ALDS or have gait or transfer problems, arthritis, a fear of falling,

foot problems, impaired sensation, impaired coordination or improper use of assistive devices

Environmental hazards May include but not limited to, poor illumination, equipment tubing, inappropriate footwear, pets, hard to reach

items, floor surfaces that are uneven or cluttered, or outdoor entry and exits

Poly Pharmacy (4 or more prescriptions—any type) All prescriptions including prescriptions for OTC meds. Drugs highly associated with fall risk include but not limited

to, sedatives, anti-depressants, tranquilizers, narcotics, antihypertensives, cardiac meds, corticosteroids, anti-anxiety drugs, anticholinergic drugs, and hypoglycemic drugs

Pain affecting level of function Pain often affects an individual’s desire or ability to move or pain can be a factor in depression or compliance with

safety recommendations

Cognitive impairment Could include patients with dementia, Alzheimer’s or stroke, patients who are confused, use poor judgment, have

decreased comprehension, impulsivity, memory deficits. Consider patients ability to adhere to the plan of care.

A score of 4 or more is considered at risk for falling TOTAL

Continued

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Supplement 1 Continued

HENT (continued)

Eye ■ PERL ■ Icteric ■ Intact ■ Anticteric ■ EOMI ■ Other: ■ Normal conjunctiva ■ Other: Mouth ■ WNL ■ Dentures ■ Decreased oral secretion control ■ Teeth ■ Retrognathia ■ Lips ■ Drooling ■ Palate ■ Tongue ■ Other: ■ Gingiva Mucosa ■ Dry ■ Leukoplakia ■ Erythematous ■ Papilloma ■ Tacky ■ Other:

RESPIRATORY

■ Lungs CTA ■ Symmetrical expansion ■ Nonlabored respirations ■ No chest wall tenderness ■ BS equal ■ Other: CARDIOVASCULAR

■ RRR ■ No gallops ■ Normal S

1 , S

2 ■ Not examined

■ No murmur ■ Other: ■ No rubs GASTROINTESTINAL ■ Soft ■ No organomegaly ■ Nontender ■ Rectum/anus ■ Nondistended ■ Other: ■ Normal bowel sounds Abdomen ■ Lower quadrant ■ Guarding ■ Firm ■ Suprapubic ■ Rigid ■ Soft ■ Periumbilical ■ Tenderness ■ Nontender ■ Epigastric ■ Rebound tenderness ■ Nondistended ■ McBurney’s point ■ Stoma ■ Normal active bowel sounds ■ WNL ■ Liver ■ Bowel sounds absent ■ Flat ■ Spleen ■ Left ■ Distended ■ Hernia ■ Right ■ Obese ■ Drawing abdomen (f) ■ Bilateral ■ Ecchymotic ■ Other: ■ All found quadrants ■ Omphalocele ■ Upper quadrant ■ Surgical scars ■ Wound Mass ■ Firm ■ Fixed ■ Mobile ■ Tender ■ Pulsatile ■ Size cm ■ Soft ■ Other: Bowel sounds ■ Left ■ Lower quadrant ■ High-pitched ■ Right ■ Present ■ Hyperactive ■ Bilateral ■ Absent ■ Hypoactive ■ All found quadrants ■ Diminished ■ Bruit present ■ Upper quadrant ■ Dull ■ Other: NEUROLOGIC ■ Alert ■ CN II-XII intact ■ Sensory ■ Oriented ■ Gag reflex normal ■ Cranial nerves ■ Normal sensory ■ Normal DTR’s ■ Other ■ Normal motor ■ Normal gait ■ No focal defects ■ Nonfocal exam

Continued

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Supplement 1 Continued

PSYCHIATRIC

Other: General Appearance:

Constitutional Behavior ■ Acutely ill ■ Agitated ■ Comfortable ■ Appropriate ■ Debilitated ■ Combative ■ Frail ■ Cooperative ■ Generally unwell ■ Excessive mannerisms ■ Uncomfortable ■ Hostile ■ Other: ■ Incongruous ■ Relaxed ■ Other

Attitude Grooming ■ Angry ■ Appropriate ■ Cooperative ■ Not washed ■ Easily engaged ■ Disheveled ■ Guarded ■ Unkempt ■ Suspicious ■ Other ■ Other Mood ■ Euphoric ■ Nervous ■ Angry ■ Fearful ■ Overwhelmed ■ Anxious ■ Frustrated ■ Panicked ■ Apathetic ■ Grieving ■ Sad ■ Calm ■ Happy ■ Tense ■ Comfortable ■ Hopeless ■ Worried ■ Depressed ■ Irritable ■ Other ■ Distinguished ■ Moody ■ Elated Affect: Other: Mood Quality: ■ Elated ■ Moody ■ Angry ■ Euphoric ■ Nervous ■ Anxious ■ Fearful ■ Overwhelmed ■ Apathetic ■ Flat ■ Panicked ■ Belligerent ■ Frustrated ■ Sad ■ Calm ■ Grieving ■ Tense ■ Comfortable ■ Happy ■ Worried ■ Depressed ■ Hopeless ■ Other ■ Disgusted ■ Hostile ■ Irritable Appropriateness: Stability: ■ Appropriate ■ Constricted ■ Inappropriate ■ Labile ■ Congruent ■ Stable ■ Incongruent ■ Other: ■ Other:

Intensity: Range: ■ Normal ■ Full range ■ Blunted ■ Restricted range ■ Exaggerated ■ Other: ■ Flat ■ Overly dramatic Reactivity: ■ Restricted ■ Reactive ■ Other: ■ Nonreactive ■ Other:

Thought content: Attention/concentration: ■ Confabulation ■ Decreased ■ Confused ■ Normal ■ Irrelevant ■ Other: ■ Other:

Orientation: Language: ■ Person ■ Naming ■ Place ■ Repetition ■ Time ■ Reading ■ Other ■ Comprehension

Continued

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Supplement 1 Continued

PSYCHIATRIC (continued)

Memory: Fund of knowledge: ■ Recent ■ Current events ■ Remote ■ Past history ■ Other: ■ Vocabulary

COGNITIVE EVALUTION

Cognitive Assessment not complete because not clinically relevant:

Mini COG: Ask patient to remember three words (eg, apple, baby, car) and repeat them to you.

Ask patient to put numbers on clock face, and then draw hands of the clock to read 11:20.

Ask patient to recall three words. number recalled Decision-making capacity: ■ Yes ■ No

CAM: ■ Acute onset fluctuating course ■ CAM Diagnosis Negative ■ Inattention ■ CAM Diagnosis Positive ■ Disorganized thinking ■ Other:

INTEGUMENTARY

■ Normal ■ No rash ■ No jaundice ■ Not examined ■ Other:

Skin ■ Mottled ■ WNL ■ Pale ■ Cold ■ Pink ■ Cool ■ Warm ■ Cyanotic ■ Rash ■ Dry ■ Other: ■ Hot

Wound ■ Maceration ■ Abrasion ■ Puncture wound ■ Abscess ■ Stab wound ■ Avulsion ■ Surgical incision location ■ Bite ■ Ulcer ■ Burn ■ Vesicle ■ Gunshot wound ■ Other: ■ Hematoma ■ Laceration Wound Location ■ Left ■ Nose ■ Abdomen ■ Right ■ Neck ■ Perineum ■ Bilateral ■ Back ■ Buttock ■ Entire ■ Chest ■ Groin ■ Body ■ Breast ■ Genital area ■ Scalp ■ Axillae ■ Leg ■ Head ■ Shoulder ■ Feet ■ Face ■ Arms ■ Other: ■ Eye ■ Hand ■ Ear ■ Finger Wound Shape ■ Arciform ■ Jagged ■ Symmetric ■ Bull’s eye ■ Linear ■ V-Shaped ■ Circular ■ Multiform ■ Vertical ■ Curved ■ Oval ■ Y-Shaped ■ Diagonal ■ Retiform ■ Zosteriform ■ Geographic ■ Round ■ Other: ■ Horizontal ■ Serpiginous ■ Irregular ■ Stellate

Wound Size and depth ■ Depth cm ■ Healing stage ■ Involving tendon ■ Diameter cm ■ Superficial ■ Involving bone ■ Length cm ■ Involving subcutaneous tissue ■ Other: ■ Width cm ■ Involving muscle ■ Stage Undermining cm at o’clock ■ Other: Tunneling: cm at o’clock ■ Other:

Continued

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Supplement 1 Continued

MUSCULOSKELETAL

■ Normal ROM ■ Normal strength ■ No tenderness ■ No swelling ■ No deformity ■ Normal gait

Spine: Spinal tenderness (location) other Right Ext Exam ■ All other upper ext normal ■ Lower leg ■ WNL ■ Other- ■ Ankle ■ WNL except for ■ Foot ■ Shoulder Left Ext Exam ■ Toe ■ Arm ■ WNL ■ Leg ■ Elbow ■ WNL except for ■ Length discrepancy ■ Forearm ■ Hip ■ All other lower ext normal ■ Wrist ■ Thigh ■ Other ■ Hand ■ Knee ■ Fingers GYN/GU

Voiding: ■ Yes ■ No ■ Other Catheter: ■ Foley ■ Condom ■ Suprapubic ■ Other Nephrostomy: ■ Right ■ Left ■ Bilateral ■ Other Urine: ■ Sufficient ■ Decreased output ■ Anuric ■ Other Vaginal discharge/bleeding: ■ Yes ■ No ■ Other

LYMPHATICS

■ No lymphadenopathy ■ Other

LINES AND TUBES

Other

Vascular catheters ■ Arterial ■ Gastrostomy tube ■ Central venous ■ PEG tube ■ Pulmonary artery ■ Postpyloric tube ■ Peripheral ■ Surgical drain ■ Other ■ Nephrostomy tube ■ Urinary catheter Nonvascular catheters ■ Urinary catheter ■ Chest tube ■ Vesicostomy catheter ■ Nasoenteric tube ■ Tracheostomy tube ■ Gastric tube ■ Other REVIEW / MANAGEMENT

Laboratory Results Test: Date:

Test: Date:

Radiology Results: Test: Date Results : Test: Date Results : Other Diagnostic Findings:

GOALS OF CARE

■ Yes Summary of discussion

With whom

Discussed Prognosis: ■ Yes ■ Not done ■ Patient/surrogate decline Discussed short and long ■ Yes ■ Not done ■ N/A Summary of discussion:

Continued

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Supplement 1 Continued

GOALS OF CARE (continued)

Changes made to existing Advance Care Documents: ■ Yes ■ No POLST created today: ■ Yes ■ No Scan to TCC and PCP: ■ Yes ■ No Comments: IMPRESSION/PLAN

RECOMMENDED FOLLOW UP TO TODAY’S VISIT

Date to review at IDT:

POST VISIT COMMUNICATION

Call to PCP Date/Time: minutes Spoke with:

Other contact(s):

PROFESSIONAL SERVICES

Total Time Spent : minutes Time spent eval/management: minutes Time spent counseling/coordination of care: minutes Counseling/coordination consisted of Start time was End time was

MD/CRNP Signature: Date:

Printed MD/CRNP Name:

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Supplement 2

HBPC MD/CRNP PHONE VISIT NOTE

Visit Date / Visit Number:

PATIENT INFORMATION

Name: Age: DOB: / / Gender: [ ] Male [ ] Female Last # 4 of SSN : PCP: Primary Care Office Contact Person and Phone Number:

CHIEF OBJECTIVE [ ] Symptom management [ ] Other [ ] Goals of care/advanced care planning EVENTS SINCE LAST VISIT

[ ] ED visit [ ] Unscheduled doctor’s visit [ ] Hospital admission [ ] Other [ ] Observation admission [ ] Use of 24/7 hotline

Details: (please provide brief narrative below with referral to original documentation)

ADVANCED CARE PLANNING

Existing documents: [ ] Living will Previously reviewed: [ ] yes [ ] no Any changes? [ ] yes [ ] no [ ] POLST Previously reviewed: [ ] yes [ ] no Any changes? [ ] yes [ ] no

Patient identified surrogate decision maker (name/relationship)

Contact information for surrogate decision maker Phone: HPOA: [ ] yes [ ] no

Patient identified primary caretaker (name/relationship)

Contact information for surrogate decision maker Phone:

SOCIAL HISTORY

Since our last visit, have there been any changes to your social situation: [ ] yes [ ] no

If yes, please continue below:

[ ] Marital status [ ] yes [ ] no details: [ ] Living situation [ ] yes [ ] no details:: [ ] Primary caretaker [ ] yes [ ] no details:: [ ] Occupation [ ] yes [ ] no details:: [ ] Tobacco use [ ] yes [ ] no details:: [ ] Alcohol use [ ] yes [ ] no details:: [ ] Other drug use [ ] yes [ ] no details::

MEDICATION HISTORY

Since our last visit, have there been any changes to medication regimen: [ ] yes [ ] no If yes, please fill in details below

Preferred pharmacy (name/phone): 24-hour morphine equivalent (OME): mg On concurrent laxatives: [ ] yes [ ] no

Continued

Details of medication change:

Medication Current dosing Change/reason for change

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Supplement 2 Continued

REVIEW OF SYSTEMS

Constitutional Skin HEENT [ ] weight loss [ ] rashes [ ] pain (describe below) [ ] change in appetite [ ] lumps [ ] decreased hearing [ ] fatigue [ ] itching [ ] ringing in ears [ ] fevers/chills [ ] dryness [ ] vision change/loss [ ] weakness [ ] hair/nail changes [ ] glasses/contact lenses [ ] falls [ ] WNL [ ] nasal stuffiness/discharge [ ] bruising [ ] bleeding [ ] bleeding [ ] dentures [ ] heat/cold intolerance [ ] dry mouth [ ] sweating [ ] sore throat [ ] frequent urination [ ] hoarseness [ ] thirst [ ] lumps [ ] WNL [ ] swollen glands [ ] WNL

Respiratory Cardiovascular Gastrointestinal [ ] cough [ ] chest pain/discomfort [ ] swallowing problems [ ] hemoptysis [ ] palpitations [ ] heartburn [ ] shortness of breath [ ] SOB with activity [ ] nausea [ ] wheezing [ ] orthopnea [ ] change in bowel habits [ ] painful breathing [ ] swelling [ ] rectal bleeding [ ] change in O2 requirement [ ] calf pain with walking [ ] constipation [ ] bruising [ ] leg cramping [ ] diarrhea [ ] bleeding [ ] WNL [ ] yellow eyes/skin [ ] heat/cold intolerance [ ] dry mouth [ ] sweating [ ] WNL [ ] frequent urination [ ] thirst [ ] diarrhea [ ] constipation [ ] WNL

Urinary Musculoskeletal Neurologic [ ] frequency [ ] muscle/joint pain [ ] dizziness [ ] urgency [ ] stiffness [ ] fainting [ ] burning or pain [ ] back pain [ ] seizures [ ] blood in urine [ ] redness of joints [ ] weakness [ ] incontinence [ ] swelling of joints [ ] numbness [ ] change in urinary [ ] trauma [ ] tingling [ ] WNL [ ] WNL [ ] tremors [ ] headaches [ ] WNL

Psychiatric Breasts [ ] nervousness [ ] lumps [ ] stress [ ] pain [ ] depression [ ] discharge [ ] memory loss [ ] WNL [ ] ADD/OCD/bipolar/schizophrenia [ ] swelling [ ] substance abuse [ ] WNL

REVIEW / MANAGEMENT Laboratory results: test: result: test: result: test: result:

Radiology results: test: result: test: result:

test: result:

Other diagnostic findings: test: result: test: result: test: result: GOALS OF CARE

[ ] yes

Summary of discussion with

Continued

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Supplement 2 Continued

GOALS OF CARE (continued)

Discussed prognosis: [ ] yes [ ] no [ ] patient/surrogate declined

Discussed short- and long-term goals [ ] yes [ ] not done [ ] N/A

Summary of discussion:

Changes made to existing advanced care documents: [ ] yes [ ] no

POLST created today: [ ] yes [ ] no Scan to TCC and PCC: [ ] yes [ ] no

Comments:

IMPRESSION/PLAN

RECOMMENDED FOLLOW UP TO TODAY’S PHONE VISIT

DATE TO REVIEW AT IDT:

PROFESSIONAL SERVICES

Start time of phone call: End time of phone call:

Counseling/coordination consisted of:

MD/NP/RN Signature: Date:

MD/NP/RN Name (print):

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PPS level, %

Supplemental Table 1 Palliative Performance Scale (PPS)a

100

Full

Full or confusion

Full or drowsy ± confusion

Drowsy or coma ± confusion

—

Normal

Normal or reduced

Minimal to sips

Mouth care only

—

Full

Occasional assistance necessary

Considerable assistance required

Mainly assistance

Total care

—

Normal activity and work No evidence of disease

Normal activity and work Some evidence of disease

Normal activity with effort Some evidence of disease

Unable to do normal job/work Significant disease

Unable to do hobby/housework Significant disease

Unable to do any work Extensive disease

Unable to do most activity Extensive disease

Unable to do any activity Extensive disease

—

Full

Reduced

Mainly sit/lie

Mainly in bed

Totally bed bound

Death

Consciousness levelIntakeSelf-careActivity and evidence of diseaseAmbulation

Domain

Supplemental Table 2 Simplified Edmonton Symptom Assessment System

Pain

Anorexia

Fatigue

Drowsiness

Depression

Anxiety

Nausea

Shortness of breath

Secretions (yes/no)

Constipation (yes/no)

Delirium (yes/no)

Summary score

0-3

0-1

0-27

Scoring

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Abbreviation: CPT, current procedural terminology.

CPT code

Supplemental Table 4 CPT codes used to estimate costs associated with home and telephone visits

99496

99347

99350

98966

99367

Transitional care management services

Established patient home services

Telephone assessment and management service provided by a qualified nonphysician health care professional

Medical team conference

Description

Domain

Supplemental Table 3 Original Edmonton Symptom Assessment System

Pain

Tiredness

Nausea

Depression

Anxiety

Drowsiness

Appetite

General well-being

Shortness of breath