Embracing End-of-Life Plans Can Lead to Better Skilled Nursing Care — While Reducing Unnecessary Costs

For nursing home owners and operators, having frank conversations about residents’ end-of-life intentions, and organizing the associated paperwork proactively, is a potential way to avoid unwanted hospitalizations and the sizable costs that come with it — especially if it’s not in line with the patient’s wishes.

Nursing homes are faced with tough decisions when the end of a resident’s life comes sooner than expected, or if the resident never had conversations about their choices with loved ones. For these reasons, several experts say that the skilled nursing sector cannot afford to put off uncomfortable conversations — and one major provider in the Northwest says that aside from the human benefits, the cost savings could total in the millions.

In 2016, Medicare introduced a new payment structure for end-of-life conversations with numerous codes and detailed instructions, incentivizing operators and clinicians to formalize the process and encourage more of these discussions.


In addition to face-to-face interventions, new tech solutions have emerged to ease the end-of-life planning process.

Vynca, for instance, markets itself as a digital advance care planning company with an integrated IT platform that holds care planning paperwork in the cloud. And with some studies pointing to increased and unnecessary hospitalizations for patients at the end of life, IT platforms such as these may continue to decrease hospitalizations and reduce anxiety for patients and families in need of clearer guidelines during this difficult process.

The Palo Alto, Calif.-based Vynca has a presence in 11 states with 660,000 advance care planning documents, including Physician Orders for Life-Sustaining Treatment (POLST), health proxy forms, goals of care notes, and several other advance directive documents, according to CEO Ryan Van Wert.


The company has also attracted attention from one post-acute and long-term care heavyweight in the Pacific Northwest: Phil Fogg, CEO of skilled nursing and senior living operator Marquis Companies, who has invested in Vynca in addition to using its services.

Vynca began as a post-doc project out of Stanford University known as Biodesign when Van Wert, who was an ER physician, observed patients receiving aggressive care as a default when POLST documents were not readily available.

“In many of these emergency situations, when the advance directive or POLST documents were not available, patients ended up admitted to hospitals on ventilators when it was later discovered they had clear preferences to avoid these treatments,” he said.

In addition, several studies emphasize that most Americans prefer comfort-focused measures at the end of life, according to Van Wert.

“But in the absence of clear documentation, it is difficult to ensure these preferences are honored,” he said.

The failed dissemination of information often occurs when a patient is traveling from one site of care to the next — from post-acute care to a hospital, or from home to a hospital.

“There’s a breakdown in how that information travels, or whether it is available to direct care,” Van Wert said.

Due to the difficult nature of the conversation, people often “aren’t having it — or there are errors on the document created. There’s also a quality issue in terms of how many discussions are going on and how accurately the talks are being completed,” Van Wert said.

Vynca strives to help post-acute facilities work with larger health record systems in a more integrated way. Company goals look to reduce error rates through digital completion of the forms, which include embedded error-checking features, multi-language functionality, and the option to apply digital signatures, said Van Wert. The platform also includes guides, educational materials, and videos that help patients and clinicians understand their choices, he added. 

Oregon Health and Science University and the state of Oregon initially created the framework for POLST documents in paper form. The documents are typically used when a patient becomes very ill or weak at the end of life, and “gives medical orders to emergency personnel” based on their given medical circumstances, according to the national POLST website. The POLST paradigm has been adopted by the majority of states across the nation, Van Wert said.

Vynca’s team worked with the Oregon POLST Registry to create what he calls a “bi-directional link.” The partnership allows Oregon providers to submit and query documents automatically from within their electronic health records (EHR). To date, Vynca has established connections with several acute and post-acute EHR vendors to facilitate clinical integration; the company partners with more than 80 hospitals, health plans, ACOs, and additional state registries.

A handful of studies highlighted by Van Wert illustrate that the use of POLST forms correlates with greater adherence to resident choice. One study in the Journal of the American Geriatrics Society, for instance, determined that the majority of individuals with POLST forms chose comfort-focused care; among these people, only 6% died in a hospital.

In the same study, when a patient opted for all possible treatments on his or her POLST paperwork, the results pointed to a higher in-hospital death rate at 44% — whereas without a POLST form, in-hospital death rate was decreased to 34%. Those results, Van Wert said, suggest that having a POLST form makes it more likely to have one’s care preferences honored.

Another study revealed a 43% reduction in hospitalization rates when an advance directive program was carried out at a skilled nursing facility.

However, a recent controversial study points to a higher rate of hospitalizations with Medicare Advantage patients who underwent advance care planning. The study, however, contains certain limitations, such as leaving out reasons for hospitalization and not knowing the severity of the patient’s illness at the time.

The research involved 18,500 patients who were also “more likely than those without these encounters to receive hospice services and less likely to receive any intensive therapies, such as chemotherapy,” according to the study.

In other words, although the patients opted not to seek comprehensive therapies, “patients who did have the end-of-life conversation were both more likely to enroll in hospice and be hospitalized, including using intensive care units,” researcher Dr. Deepshikha Ashana of the Perelman School of Medicine at the University of Pennsylvania told SNN. 

Those intensive therapies are defined as artificial nutrition, such as a tube in the stomach, a breathing tube, chemotherapy, and dialysis, and were not connected to hospitalization because, most likely, “those kinds of therapies don’t need to be delivered in the hospital.”

Van Wert agreed with the researchers’ analysis of the findings, concurring that the results “may be confounded by the fact that the group with advance care planning may have had more acute illnesses, which may explain the apparent higher healthcare utilization.”

Fogg, the Marquis CEO, told SNN that he invested in Vynca because the frail senior population benefits from having these documents for all providers in one accessible interface.

That integration takes on even greater importance because the company also operates an Institutional Special Needs Plan (I-SNP), a specialty Medicare Advantage plan for long-term care residents. Not only is Marquis on the hook for rehospitalization penalties under value-based payment models, the I-SNP must shoulder the costs of enrolled residents’ hospital stays.

“Ensuring that plan members have their end-of-life choices documented not only honors their decisions but also saves medical expenses for the Medicare Advantage plan, since they don’t have to pay for unnecessary hospital admissions or readmissions,” Fogg said.

Emergency services such as fire, ambulance, and acute care providers and others also need to have this information, he added.

From a cost savings perspective, Fogg said that hospital admissions and readmissions range from $12,500 to $25,000 on average. Every time staff can stop an unnecessary readmission or admission, the Medicare Advantage plan benefits, he said.

“If a 20,000-member Medicare Advantage Plan reduced admissions and/or readmissions by 1%, it would result in a $2,500,000 annual savings, assuming all hospital admissions and readmission cost of $12,500 on the low end,” Fogg said in an e-mail.

In an ongoing ethical debate between intense medical intervention or stepping back for a more peaceful death, Fogg falls on the side of respecting a patient’s wishes instead of what he says the medical community is focused on, which is keeping people alive.

“They are not equipped at helping people die well,” he said. “They make bad unintended decisions through actions or inactions at the detriment of our society.”

More specifically, Fogg noted troubling conversations with nurses who work with patients in long-term care facilities.

“You learn that there’s nothing worse than giving CPR just to break someone’s ribs or do something painful, and that person should not be resuscitated — someone who we should be letting peacefully pass away. Being compassionate and helping people die with dignity should be the priority instead of keeping people breathing,” Fogg said. “It’s OK to let someone go, and to be thoughtful about how they want to do it.”

It’s important to be honest and talk about what someone’s last two to 12 months will look like, said Fogg, adding that sometimes you have to let the patient know that while you could save them and offer a few extra months, at that point, they may not be able to say their goodbyes or be alert.

Terry Holecek, vice president of operations for major hospice player VITAS Healthcare, assists in creating strategic partnerships with nursing homes. SNN spoke to Holecek in September to learn how partnerships between hospice care and nursing homes are deepening.

This week, Holecek outlined the formal steps of end of life care for SNN.

VITAS, which operates hospice programs in 14 states and the District of Columbia, works in tandem with its nursing home partners to facilitate conversations between residents and their families regarding their wishes and values near the end of life, known as a goals-of-care conversation.

A common barrier to this process is identifying patients in the early stages, “because patients are generally referred to hospice late in the process of nearing the end of life or not at all,” Holecek said.

The conversation includes the patient’s feedback based on the type of care they would like to receive, as well as their values and wishes. After the conversation, the team decides on the right available resources to match the patient’s needs for care and the most appropriate setting, Holecek said in a statement.

When partnering with a nursing home, the company helps educate clinicians around hospice eligibility through continuing education and a mobile app with an interactive tool to identify patients with a prognosis of six months or less, if their particular illness runs its usual course.

“We provide those discussions wherever the patient resides, whether at the nursing home, hospital, assisted living facility, or private residence,” Holecek said.

Once a resident is identified, he or she receives a referral to see an advanced practice registered nurse or physician who conducts an evaluation in the skilled facility — the preferred setting — or after the patient is discharged home.

Clinicians also undergo additional communication training to further their understanding of a patient’s health status, and how it has changed over the last year to six months.

“We ask about changes to the patient’s nutritional status, functional status, cognitive status, healthcare utilization, and uncontrolled symptoms,” Holecek said in the e-mail. “Our clinicians can link these changes to the patient’s current condition, and then explore other topics, based on what the patient is open to talking about.”

The final step examines the patient’s expressed goals and preferences for end-of-life care within the context of the patient’s current health status, and then the next best transition in care is determined.

“A patient may benefit from palliative physical or occupational therapy to help them transition back to their home environment. Additional therapies that are not traditionally covered by hospice — such as high-flow oxygen to help patients with advanced lung disease breathe easier, or certain medications to relieve the burdens of advanced heart disease — can support quality of life and reduce the stigma surrounding hospice,” Holecek said in a statement.  

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