Hospice in Oregon 2008: a historical perspective March 4, 2008

1. Hospice in Oregon 2008:a historical perspectiveMarch 4, 2008 Ann Jackson, MBA Executive Director/CEO Oregon Hospice Association

2. History • 1977: OHA and first hospices established • 1980: Accreditation standards developed • 1981: First hospice accredited • 1982: Medicare Demo • 1987: Oregon’s hospice laws pass unanimously • 1988: TA grant • 43 hospices; 4 Medicare certified; 22 OHA accredited • 1990: All hospices in compliance • 1992: All hospices Medicare certified • 1998: All Oregonians have hospice • 2007: Oregon’s hospice laws amended to require both certification and accreditation

3. Evolution(1981-2007) • Goals focused on optimal standards • Medicare minimal • NHPCO optimal • OHA special focus • Volunteer peer review shifted to OHA staff review • Arms length relationships with hospices • Quality primary goal

4. Benefits to Hospices • Hospices have “benevolent” support • Use OHA accreditation as quality indicator • Enjoy more frequent surveys and feedback • Enjoy access to best practices and consultation • Measured against high quality standards • Able to compare themselves with peers • Troubleshoot problems at arms length • Refer difficult community issues • Protect themselves against potential PR nightmares

5. A Perspective • 270,000 Oregonians died between 1998 and 2006 • 292 used physician-assisted suicide • 269,718 did not

6. History: The Early Years • 1987 • ORS.443:850-870 • Senator Roberts introduces “Death With Dignity” legislation • 1988 • OHA has new chief executive • Meyer Memorial Trust awards grant to implement hospice law • 1989 • OHA adopts resolution opposing PAS • 1990 • OHA decides to join public debate • 1994 and 1997 • OHA opposes ODDA legislation; supports repeal • OHA recommends hospice referrals to people who ask for prescription; urges hospices to admit dying Oregonians who intend to use ODDA

7. Lessons Learned: Hospice & ODDA • 86% of Oregonians who died using Oregon’s Death with Dignity Act were hospice patients

8. Lessons Learned:Hospice and ODDA One of 200 individuals who consider a request uses a prescription One of 25 individuals who formally make a request uses prescription One of 1,000 individuals who die in Oregon uses a prescription Tolle et al, Characteristics and Proportion of Dying Oregonians Who Personally Consider Physician-Assisted Suicide, J Clin Ethics 15:2(111-122) 2004

9. Oregon Death Rates • 84% of Americans prefer to die at home • > 50% of Americans die in hospital • Oregon’s hospital death rate lowest • Oregon’s hospice general inpatient rate lowest • Oregon’s home death rate highest • Oregon’s cost of EOL care lowest • Oregon’s satisfaction with EOL care equal or better than states with high cost of care • Cost of care correlated with # of hospital beds

10. Advanced Planning RateOHSU Center for Ethics in Health Care

11. Advanced Planning Rate • 100% of Oregon’s hospices used POLST in 2006

12. Hospice Penetration Rates Admissions/Deaths Oregon • 57% in 2005 • 53% in 2004 • 40% in 2000 • Arizona • 81% in 2005 • 71% in 2004 • 55% in 2000 • Florida • 57% in 2005 • 43% in 2000 • Maine • 34% in 2005 • 11% in 2000

13. % Change in Hospice Penetration 2000-2005 (Medicare)

14. Hospice Lengths of Stay • Hospice LOS peaked in 1994, fell until 2000 • LOS is impacted by • Regulatory scrutiny • Hospice in nursing homes • Competition and marketing • Changes in treatment methods • Disease mix • 50% of Oregon hospice patients were admitted within 17 days of death in 2006

15. Days of Care: Oregon 2006 Routine home 50.1 GIP .5 Respite .1 Total 50.8 1999 Routine home 41.7 GIP .2 Respite .3 Total 42.2

16. MedPac 2006

17. Hospice Deaths: Oregon 2006 Home 53% Hospital 2% Inpatient hospice 5% FH/RC/ALF 27% NF as resident 12% NF as hospice admit 1% 1999 Home 66% Hospital 2% Inpatient hospice 1% FH/RC/ALF 19% NF as resident 12% NF as hospice admit 2%

18. Oregon Hospice Registry 1988 16% providing services to public are Medicare certified 48% accredited or certified 43 hospices on Registry 7 certified by Medicare 11 accredited by OHA 10 accredited by JCAHO 1 IP/residential hospice 1 IP hospice wing 1 residential hospice

19. Oregon Hospice Registry 1991 57% providing services to public are Medicare certified 40 hospices on Registry 3 certified by Medicare and accredited by OHA 8 certified by Medicare and accredited by JCAHO* 10 accredited by OHA 1 JCAHO* 12 Medicare 6 developing services No operating inpatient or residential hospices JCAHO dropped hospice accreditation 1990 90% members of OHA in 1991

20. Oregon Hospice Registry 2006 99% providing services to public are Medicare certified 66 hospices on Registry 6 certified by Medicare and accredited by OHA and JCAHO 23 certified by Medicare and accredited by OHA 21 certified by Medicare and accredited by JCAHO 3 developing services 2 are accredited by OHA 1 is federal 4, 2 in WA, have IP hospices 4 are developing IP hospices 2 have residential hospices 8 hospices licensed in WA, CA, ID 86% members of OHA in 2006

21. Oregon Hospice Registry 2007 99% providing services to public are Medicare certified 73 hospices on Registry 5 certified by Medicare and accredited by OHA and JCAHO 26 certified by Medicare and accredited by OHA 19 certified by Medicare and accredited by JCAHO 4 developing services 2 are accredited by OHA 1 is federal 4, 2 in WA, have IP hospices 2 operating; 6 developing IP hospices 2 have residential hospices 10 hospices licensed in WA, CA, ID 95% members of OHA in 2007

22. Quality of EOL Care in Oregon • 1998: “Oregon leader in nation’s end of life care” • Oregon ranks first • (Robert Wood Johnson, State Initiatives) • 2002: Means to a Better End • Oregon ranks second • (Robert Wood Johnson, Last Acts) • 2005: “Best places to die in America” • Oregon ranks second • (Forbes Magazine)

23. Conclusion: 2002 • An explanation for “very low rate” of assisted death may be the high quality of care provided by Oregon’s hospices • Ganzini et al, “Experiences of Oregon nurses and social workers who requested assistance with suicide”, NEJM 8/22/02

24. Conclusion: 2008 • “Interventions that help patients maintain control, independence, and self-care in a home environment may be effective means of addressing serious requests for PAD” • Ganzini L, Goy E, Dobscha S, “Why Oregon patients request assisted death: family members’ views”, J Gen Intern Med. 2007 Dec 15; : 18080719 www.oregonhospice.org

25. Data Sources • Jay Cushman • OHSU Center for Ethics • CMS • DOJ • OHA • Forbes • Robert Wood Johnson Foundation