Media Relations

October 10, 2009

By JoAnn Kowalski

The United States ranks between 24th and 36th among the world's nations in qualitative measures of health care. Yet we're No. 1 in health care expenditures.

Why? Because our system of health care reimbursement is based on productivity rather than quality.

Without coordination of care, patients may visit several specialists, receive multiple medications that may not work well together, or ignore early warning signs until a crisis lands them in the emergency room.

In short, the health care system is not a system. It is an often haphazard, arbitrary consumption of health care resources that contributes to decreased quality of life, a shorter life expectancy and rising costs. Without coordinated case managing of patient appointments, treatments and prescriptions, the "system" becomes a liability, not a benefit.

Our current state of health is a direct result of a broken Medicare system. That "system" pays providers on a productivity and intensity basis. The more they see, treat or medicate the patient, the more providers are paid. And the more intense the services, the more they're paid.

If we give providers incentives to do more, more often, in more complex or intense ways, why would they change? We need to stop paying for quantity and start paying for quality.

Overlaying a benefit for the uninsured on top of a productivity-based system will only compound the problem. To make health care coverage possible for the uninsured, we must address this underlying conflict of interest.

Cost savings naturally flow from a model based on quality. HospiceCare provides an example. A quality-based system, HospiceCare is reimbursed a flat per-diem rate with clear expectations for numbers of visits based on the needs of the patient.

In 2008, HospiceCare served 2,652 patients. During this time, 130 emergency-room visits and 158 hospitalizations occurred. HospiceCare prepares patients and families for what to expect with the disease and its symptoms.

HospiceCare also becomes a patient's first call with rapid response nurses who provide in-home assessments to manage pain and symptoms. If the issues are unmanageable at home, the HospiceCare inpatient unit, a hospital or 24-hour crisis care are options.

Keeping 665 patients a day out of emergency rooms improves quality of life and saves Medicare and Medicaid money. Recent studies estimate each hospice patient saves Medicare about $2,300 by providing crisis care in homes.

Because this community has excellent health care providers who we partner with daily, HospiceCare has asked the Centers for Medicare & Medicaid Services to base a quantitative and qualitative demonstration study in Madison.

Specifically, HospiceCare has suggested that CMS analyze the 13 percent of HospiceCare patients discharged annually because they no longer meet the six-month-or-less prognosis required for hospice eligibility. Their conditions improve because HospiceCare's comprehensive case management involves limiting treatments and medications to just those that improve quality of life.

Lawmakers must focus on a fix for our current system by basing it on quality before even considering increasing coverage for the uninsured.

Kowalski is vice president of quality and compliance for HospiceCare Inc. in Madison; www.hospicecareinc.com.

As reported in the Wisconsin State Journal: http://host.madison.com/wsj/news/opinion/column/guest/article_30d46698-b5bb-11de-99b9-001cc4c03286.html

Monday, Sept. 28, 2009

By SHELLY BIRKELO

JANESVILLE — This year's Rock County Women's Expo will benefit nonprofit groups and provide women with free opportunities to attend classes, demonstrations and vendor displays, hear a guest speaker and visit a food court.

"It's a hodgepodge, fabulous event," said Rita Key, coordinator.

Key, 45, of Beloit, founded the women-only event three years ago after becoming aware of nonprofits in the community during the last year of her husband's life.

"There had to be a way these organizations could be better exposed to raise awareness, funds and support to help them keep going," she said.

Plus, Key said, she needed an outlet to keep her active after she quit school and her job to care for her husband, Ray, who was diagnosed with nonsmoking lung cancer in 2002 and died in 2008.

The first expo featured only vendors and was attended by 500 women. Last year's event was highlighted by a total image makeover and attracted 1,200 ladies.

Key attributed growth to word spreading about the expo and adding something new each year. This year, she said, classes have been added: yoga, identity theft and prevention, common legal concerns and women's self-defense.

Key is most excited about the new pole-exercise classes and demonstrations that were added to draw younger women even though the expo's primary demographic is those ages 30 to 55, she said.

"Pole exercise is an aerobics class that is a fun way to shed extra pounds, gain muscle tone and explore one's femininity and sensuality. It's also for women of all shapes and sizes, who will develop skills and gain self-confidence while getting the ultimate workout," according Miss Pole, the Madison/New Berlin-based business that will be present at the expo.

The expo will provide women other experiences the community has to offer, Key said.

Fifty-three vendors have signed up to be involved in the expo, themed "Wisconsin-Owned and Grown." But Key is hoping to add at least 17 more. Vendor areas will focus on education, nutrition, in-home parties and home maintenance, she said.

The expo gives educational display space to different nonprofits each year.

This year they are the American Red Cross, HospiceCare Inc. of Janesville, Big Brothers Big Sisters, Sexual Assault Recovery Program, Family Respite Care Service and Transitions, an extension of Beloit Regional Hospice.

The groups will split profits made by food vendors, who also will be provided space at no cost, Key said.

Flu shots, gift bags stuffed with coupons and demonstrations also will be given throughout the day.

"It is time just to take a break and have some leisure fun," Key said. "And it doesn't cost you anything."

As published at: http://www.GazetteXtra.com/news/2009/sep/28/expo-lets-women-take-break-have-some-fun/

September 1, 2009

HospiceCare nurse Kristin Keir provides at-home care to William "Mac" McCullough, one of her 15 patients she has under her charge.

"You've got five percent less lung capacity from the latest test," HospiceCare, Inc. nurse Kristin Keir, 34, tells her patient, "but, here you are!"

Defying all the odds, she means.

It's a sunny, summer day, and Keir visits her patient, William "Mac" McCullough, an 80-year-old gentleman with a diagnosis of COPD (Chronic Obstructive Pulmonary Disease). In 2005, McCullough was given six months to live and his family called HospiceCare. There have been several scares since then, but McCullough keeps battling through. Keir has worked with him for the last two years, checking in on a weekly basis, in his home, the way he prefers it.

His condition meets the numeric criteria of HospiceCare, and because he's dependent on oxygen, his hospice benefits continue. But having a two-year relationship with a hospice patient is a rare occurrence.

"So, your lungs are operating at about 20% capacity," Keir tells McCullough, sitting comfortably in a corner of his long-time family home, just steps away from the Lake Mendota shoreline. With oxygen piping into his nostrils, McCullough reacts, "So I don't have much more to go, in other words?"

Keir nods. She takes his vitals. His blood pressure is 110 over 70. "Pooping and peeing okay?" she inquires. He nods. She checks his heart, lungs, and stomach. "I think you're good!" she says, packing up her stethoscope.

This is not a depressing visit. McCullough is charming, witty, and, as we quickly learn, once held a two-year post on Madison's city council. "I've been busy!" he says of his life. His memory is sharp as he recalls controversial votes he made in that capacity. "I got quite an education, and had a great time!"

With a twinkle in his eye, he chides his nurse about a long-standing joke — something about a skinny-dipping party he intends to throw. They banter back and forth playfully. "I'd love to have another cigarette," he suddenly announces, knowing full well those days are behind him.

Within arm's reach are nebulizers McCullough uses to aid his breathing. As Keir checks the apparatus, the patient's mischievous side reappears. With laughing eyes, he jokes about lighting and passing the nebulizer tube around like a marijuana cigarette. Asked how he would know about such things, he just grins, "I've seen it on TV!" he insists. The room brightens.

"Kristin's a good gal," McCullough says. "She takes her job seriously." Keir stays for another half hour as we all learn a bit more about McCullough's life. For those few moments, it's hard to imagine the fate that awaits this proud man and his loving family. McCullough's daughter Sherry, visiting from Colorado, is also present this day. Her mother Betty, McCullough's wife of 56 years, is asleep upstairs.

Keir is one of 134 registered nurses employed by Dane County's HospiceCare, Inc. It is a salaried job she calls her "soul-work." Prior to joining HospiceCare, Keir was an OB/GYN nurse for a multi-disciplined physicians practice. "When I saw the ad for Hospice, something kicked in," she said, admitting that for the first time, she's really happy. "I know that I'm in the right place."

Keir, with HospiceCare since December of 2005, admitted she felt like a novice in the beginning. "I was a pretty big sponge for the first year," she recalled, adding that her previous jobs had not required a lot of physical assessments, or critical thinking related to medication choices. The day she lost her first hospice patient, she remembers going home, standing on her porch and crying.

"I allow myself that every now and then," she said, adding that she also receives a lot of support from family and friends. "It's okay to let people see you be emotional. That's normal and natural. People say, 'Oh, it gets easier,' but I hope I'll never be that nurse that says that. I want to keep everyone special."

Keir describes her hospice duties as holistic. "[My job is to] make sure my patients are comfortable physically. I work with pharmacists, doctors, and families, of course, but part of what I do is bear witness with [my patients] and guide them spiritually and emotionally." Of the 15 patients currently under her care, she says McCullough is in the best condition. He still gets out for dinner twice a week — with the help of a 24-hour live-in assistant — to his favorite haunts: the Avenue Bar and The Esquire Club. [The family pays separately for two assistants not affiliated with HospiceCare.]

"I don't feel like a rare bird," Keir says of her job choice. "[Our patients] are the remarkable ones. They let total strangers in and allow us to help them. At the end of the day, I count myself really privileged to do this work. These are precious times, and many don't have this opportunity. I help people meet some of their end-of-life goals."

The work is hard, she says, and intense sometimes. But the support system she receives from the HospiceCare staff, including other RNs, LPNs, social workers, chaplains, volunteers, and grief counselors, allows her to prioritize her days efficiently.

For the most part, each day is dictated by her patients and their families, though she also works fairly independently. "I'll call doctors to suggest what might work for my patients, and nine times out of 10, they'll just say 'do it.'"

Sometimes, she admits, there is some pushback from physicians who might lack end-of-life experience. Then there are the days where she wishes she could be in five homes at the same time. "I'm thankful I have a backup RN and LPN," she said. On-call backup is available around the clock.

Most important, Keir said, is the ability to always focus on the present and the patient in front of her. That, she says, "is really, really important. There are times when [being in the present] is tough to do if there are a million things going on."

One of Keir's biggest frustrations is that people in the end-of-life stage aren't sent to hospice sooner. "It's never too soon," she insists. Indeed, 50% of those served by HospiceCare are admitted just two weeks prior to death. "That's upsetting when you realize what those patients are missing out on," she says, citing satisfaction surveys that show the top regret of families is that they didn't call hospice sooner. "When patients come in within the last few weeks, days, or hours of death, that's such a short period of time for us to help them emotionally and spiritually for their journey."

And when that final moment arrives, Keir says her role often involves watching how the families react, answering questions they may have, offering pointers on keeping patients comfortable, and observing and translating a patient's verbal or nonverbal communications at life's end.

"If I'm not there, I'm on the phone with the family every day." It all comes back to the patient's individualized plan of care.

Keir says the rewards she gains from her job far outweigh the difficult moments. "I learn so much from my patients," she says. "In the end, I feel like I'm a better clinician. I've inevitably learned a new skill, task, or about a new medication, and often feel like I'm a better person. I've heard husbands and wives interact during their last moments, and it's changed my life. It's easier for me not to get caught up in my own rat race."

Her biggest honor, she says, are the connections she makes with patients and their families; the ability to become "a tiny insider into their lives, helping them meet goals, and watching people die comfortably, when they feared they couldn't." If a patient requests a special dinner, HospiceCare will try everything to provide it. "One person wanted to see the ocean," she said, "so we'll find different ways to bring the ocean to them."

In 2008, approximately 37% of HospiceCare patients had cancer, while 63% had a combination of heart, lung, and kidney disease, ALS, AIDS, or Alzheimer's disease. Patients ranged in age from two days to 107 years. On this day, the nonprofit is serving 630 patients, with just a fraction receiving in-patient care at the HospiceCare facility.

Back in the McCullough household, "Mac's" son Clint has walked in. Sherry and Clint are two of four McCullough children. They speak about the peace of mind they feel, knowing their father is well cared for.

"They are all saints," said Clint, of all his father's helpers. "I don't know how we'd do this without them. They are underpaid and overworked. Hospice braces you for what's coming in an open, gentle way. They're there for you and offer reinforcement."

Unable to avoid the elephant in the room, I ask McCullough what it's like knowing his days are numbered? He shrugs matter-of-factly. "I'm gonna die sometime, why worry about it?"

And that is the day's teaching moment.