VITAS Advantage: Case Study on Open Formulary for Hospitals
Case Study: Patient with Heart Failure
AF*, a 68-year-old female, visits her primary care physician after discharge for her third hospitalization in six months for worsening heart failure (NYHA Class III) and a fall. She also has underlying chronic obstructive pulmonary disease (COPD) and early-stage dementia.
AF’s primary care physician refers her to hospice care after a goals-of-care conversation with AF’s daughter, who is also her primary caregiver.
The care plan by her hospice nurse and physician relies heavily on the VITAS open formulary, including continuation of cardiac medications for symptom management, increased diuretics for fluid management, home oxygen for COPD symptoms, low-dose, long-acting opioids as needed for shortness of breath, and Ativan for anxiety and insomnia.
Additional care from the hospice team includes personal hygiene, proactive wound care, education for the daughter on oxygen use and energy-conversation techniques, and ongoing goals-of-care conversations and decisions.
Three weeks later, AF died peacefully at home with her daughter at her bedside.
*These initials represent an anonymized patient and are used for the purposes of education only.
Open Formulary Ensures Patient Access to Medications and Therapies That Improve Their Symptoms
Even in patients with severe underlying disease, such as cardiac disease, palliative care can be introduced to provide support while also providing compassionate end-of-life care to avoid costly hospitalizations/readmissions.
This is according to the authors of an article published in Cardiology Magazine, a publication of the American College of Cardiology.
If a hospice provider offers an open formulary, it gives severely ill patients choices about how to be cared for and where, especially during a pandemic, when care in a hospital might not be the best or safest option. Half of US hospitalizations and intensive care unit (ICU) admissions and 80% of deaths related to COVID-19 have occurred among patients 65 and older.
An open formulary ensures the continuation of disease-directed medications/treatments that provide comfort, address pain, and support quality of life without curing or reversing the underlying disease. Care goals include optimal symptom control and improved quality of life.
“Palliative care can guide, educate, comfort, and aid in complex medical decision-making,” the authors write. “Patients and families can be given several options for the course of care,” including the choice to be at home with palliative or hospice care for symptom management.
With the support of hospice that is not consigned to a limited list of medications and therapies, hospitals can send their severely ill patients home, freeing up beds, easing burdens on staff, and ensuring that patients receive the goal-concordant care they prefer. This is particularly important during COVID-19, the authors point out, with many hospitals stretched to capacity and hospitalized patients isolated from family and friends.
The authors urge clinicians to accelerate palliative care consultations “to ease suffering and provide comfort to patients and families during the COVID-19 pandemic.”
The researchers advise clinicians to help patients complete advance care planning forms so their values and care preferences are documented, including whether they want medical interventions in certain circumstances. The advance care planning tool known as POLST (Physician Orders for Life Sustaining Treatments) is a portable document that can be revised or rescinded by the patient at any time.
“The COVID-19 pandemic has resulted in significant consequences for patients who require complex medical decisions in a resource scarce health care environment,” they write. “Palliative care provides assistance to providers to integrate planning and comfort into care.”
The VITAS Open Formulary for Hospitals
In partnership with specialists and hospitalists, the VITAS open formulary simplifies the conversations that lead to timely, patient-preferred referrals to hospice care. Reassured by the availability of disease-directed medications that manage symptoms/pain, provide comfort, and improve quality of life, patients feel confident in the transition to hospice.
Hospitals benefit from:
- Lower Medicare spending per beneficiary and reduced hospital readmissions
- Improvements in length-of-stay metrics and CAHPS/HEDIS scores
- Enhanced quality of life and higher satisfaction with care among patients and their families/caregivers
Source: Mulrow, J. & Doherty, C. (2020). Palliative Care Considerations for Patients with Cardiovascular Disease Under COVID-19. Cardiology Magazine, April 9, 2020, American College of Cardiology