Archive for the ‘Palliative Care’ Category

Infographic: Palliative Care Ensures Value

December 30th, 2019 by Melanie Matthews

Strong evidence exists proving the value of palliative care’s impact on quality, satisfaction, consumer demand, and cost. Because it focuses on the highest need and highest cost patient segment, palliative care is an essential strategy for population health management, according to a new infographic by the Center to Advance Palliative Care.

The infographic examines the impact of palliative care on quality of life, symptom burden, patient satisfaction and experience and healthcare spending and utilization.

When the prestigious Memorial Sloan Kettering Cancer Center (MSKCC) began to face tougher competition from hospitals with managed care contracts and limited networks, the state-of-the-art specialty hospital decided to implement a team-based care coordination approach to attract and retain healthcare payors focused on value-based care.

Integrated Case Management: Elevating Quality and Clinical Metrics with Multidisciplinary Team-Based Care details the framework and implementation of the service-based multidisciplinary program MSKCC adopted to demonstrate that the care it provides to more than 25,000 admitted patients each year is both cost-effective and cost-efficient.

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Guest Post: Innovative, Specialized Palliative Care Programs Help ACOs Improve Patient Care, Achieve Success in Medicare Shared Savings Program

September 13th, 2018 by Greer Myers

Home-based Palliative Care

A structured, systematized approach to home-based palliative care: One of the most effective ways to manage and enhance care delivery for vulnerable, costly populations.

Under the new Medicare Shared Savings Program (MSSP), Accountable Care Organizations (ACOs) will be required to take on more risk as a rule of engagement and participation. The Centers for Medicare & Medicaid Services (CMS) is also shrinking the amount of time ACOs can be in an upside-only model to two years, putting additional pressure on ACO leaders to initiate changes. Currently, 82 percent of ACOs participating in the MSSP are in an upside-only model.

This has prompted many organizations to seek innovative strategies that will enable them to remain in the program and achieve success. One proven approach involves the adoption of a structured and systematized home-based palliative care program designed to identify patients with serious or advanced illness earlier in the disease process and offer them services outside of the hospital setting.

The palliative care team, primarily specially trained nurses and social workers, addresses the unique needs of the patient and family, taking into consideration their culture and values when developing a patient-centered approach to care. The team coordinates patient care across the continuum, which may include specialty care, acute, post-acute and community-based care needs.

For ACOs facing tight timeframes for implementing programmatic changes, this structured approach to community-based palliative care can be rapidly deployed in any geographic area and quickly scaled for larger populations.

Supporting the Medical Home

Home-based palliative care programs align with the medical home model through the provision of specialized care for people living with serious or advanced illness. Sharing priorities with the medical home, both emphasize the importance of care in the home, providing appropriate social services, clinical assessments and referrals, and partnering with physicians to deliver a solution that is patient-centered, data-driven and evidence-based.

A structured, systematized approach to home-based palliative care is one of the most effective ways to manage and enhance care delivery within this vulnerable, costly population. Quality controls and reporting are essential to improving quality and decreasing cost. Programs offering modular continuing education to palliative care team members, as well as guided tools and electronic patient assessments, enable highly skilled clinicians to maximize the impact of member outreach, enrollment and engagement.

Palliative care teams extend the reach and frequency of patient engagement, establishing collaborative relationships and reporting with the medical home that further strengthen care coordination. This level of connectivity and interaction with the medical home represents a significant opportunity to affect quality and cost.

Advantages for Patients and ACOs

Populations burdened by a serious or advanced illness place incredible strain on ACO resources, compromising the organization’s ability to improve care while generating shared savings under the MSSP model. By adopting the medical home/home-based palliative care approach, ACOs can turn this high cost population into an opportunity: improving quality and patient satisfaction while reducing cost and generating shared savings through reduced unnecessary hospital admissions, readmissions and ICU stays. Furthermore, this approach avoids over-medicalized care and high-cost services that may not align with the patient’s goals of care.

Integrating home-based palliative care within the medical home model ensures that each member is treated with respect, dignity, and compassion. This leads to a better quality of life, thanks to strong and trusting engagement with specialized palliative care professionals. Overall, this integrated model aims to improve quality and care coordination, so that individuals access care in the right place, at the right time, and in the manner that best suits a patient’s goals of care.

What’s more, specially trained palliative clinicians act as an extension of the primary treating physician and strengthen the medical home. The palliative nurses and social workers establish goals of care, provide supportive home-based care and assess patient and caregiver status, reporting relevant information to the primary treating physician to fill gaps in care and better align goals with care received.

Innovation in the Real World

Let’s consider a typical patient experience that is all too familiar: An 89-year old man with congestive heart failure (CHF) experienced five emergency room visits and five hospital admissions in one year before his condition worsened and he was intubated in the ICU. Prior to this, he had been seeing his cardiologist and primary care provider for adjustments to his medications, which he was unable to manage at home.

Now consider the vastly better approach of in-home palliative care: This same patient would have informed providers he did not want to go to the hospital or have intubation. When his health deteriorated, his social worker would have met with him and his family to discuss palliative care and supportive care options. He would have also been placed on the palliative care program with home visits made by palliative care specialists as needed. When the time came, his palliative care specialist would have evaluated hospice options with the patient and his family, and he would have died in the manner of his choosing – peacefully at home.

An innovative palliative care approach provides specialized patient/caregiver support and enhances communication with the primary treating physician. This facilitates a shared decision-making model, which results in better congruence between a patient’s individual goals of care and medical care received. It is a recipe for improving quality of life and satisfaction with the care that is delivered.

Greer Myers

Greer Myers

About the Author: Greer Myers is the president, Turn-Key Health and executive vice president, chief development officer, Enclara Pharmacia. With more than 20 years of healthcare experience, Mr. Myers joined Enclara Healthcare in 2014, and maintains dual roles as its President of Turn-Key Health and its EVP of Corporate Development of Enclara Pharmacia. Bringing strengths in post-acute operations, mergers and acquisitions, pharmacy benefits management, strategy and business development, he also has strong vertical experience in payer, provider and healthcare IT verticals.

MSKCC Integrated Case Management Enhances Efficiency, But Never At Patients’ Expense

August 29th, 2017 by Patricia Donovan

MSKCC’s service-based interdisciplinary team adheres to the four C’s of team-based care.

With a reputation synonymous with state-of-the-art cancer care, Memorial Sloan Kettering Cancer Center (MSKCC) shouldn’t have much to prove.

But like most healthcare providers, with the dawn of value-based care, MSKCC began to face tougher competition from hospitals with managed care contracts and limited networks. To attract and retain payors, MSKCC had to demonstrate that its care was both cost-effective and cost-efficient.

“Under managed care, you had to be able to prove your worth,” explains Laura Ostrowsky, MSKCC’s director of case management. “And worth was more than just best care, it was best care in a quality-effective manner.”

To accomplish this, MSKCC adopted a multidisciplinary, team-based care coordination approach, Ms. Ostrowsky explained during Integrated Case Management: A New Approach to Transition Planning, an August 2017 webinar now available as an on-demand rebroadcast.

Transition planning used to be referred to as discharge planning, she noted.

Integrated case management is at the heart of MSKCC’s service-based strategy, with MSKCC case managers  assigned by service. “That means that if a case manager is based on the tenth floor, which houses breast and GYN services, and one of those patients is in the ICU, they’re still being followed by the breast or GYN case manager.”

The variety of care settings is one of a half dozen reasons integrated case management is necessary, Ms. Ostrowsky added.

Communication among all team members is key, she continued, outlining the four ‘C’s’ of team-based care—so much so that some scripting has been created to keep all team members on message with patients.

However, a commitment to standards in communication and other areas should never override a patient’s need. “The clinical issues should always take priority,” Ms. Ostrowsky emphasized.

A day in the life of an MSKCC inpatient integrated case manager runs the gamut from reviewing and assessing new patients to orchestrating transition planning. “Our patients go out with all kinds of services, from infusion care to home chemotherapy to wound VACs.” Some patients are transferred to post-acute facilities, while others face end-of-life issues that include hospice care, which could be inpatient or home.

Hospice care was one area of focus for MSKCC—in particular, getting providers to speak frankly with patients about hospice and incorporating those services earlier on in the patient’s diagnosis when appropriate, both of which required a cultural shift. “Our patients didn’t come to Memorial to be told that there’s nothing that we can do for them,” she explained. “And our doctors didn’t come to work at Memorial to send people to hospice. They came here to cure cancer.”

In taking a closer look at end-of-life services, Ms. Ostrowsky found that physicians tended to refer to hospice later than she hoped that they would. “I wanted to really look at our length of stay in hospice as a way of identifying the timeliness of referral.” A longer hospice stay allows the patient to form relationships with their hospice caretakers rather than feeling abandoned and “left to die,” concluded Ms. Ostrowsky.

By placing case managers in inpatient areas and encouraging key case management-provider conversations that she shared during the program, MSKCC improved hospice referral timeliness and grew hospice length of stay. In turn, these quality improvements correlated with higher patient (and family) satisfaction.

Integrated case managers have also been key in identifying patients who can benefit from LTACH services and moving them there sooner, she added. “We can decrease length of stay within the hospital and get [patients] that kind of focused care that they need sooner.”

Listen to Laura Ostrowky describe the surprise question that can improve timeliness of hospice referrals.

Infographic: Medicare and End-of-Life Care

November 23rd, 2016 by Melanie Matthews

Although Medicare spent significantly more on care for people at the end of life who died in 2014 ($34,529 per person) than for other beneficiaries that year ($9,121 per person), the share of total Medicare spending for people at the end of life decreased from 18.6% to 13.5% between 2000 and 2014, according to a new Visualizing Health Policy infographic by the Kaiser Family Foundation.

The infographic also examines Medicare spending for end of life care by age, Medicare spending on hospice and the impact of Medicare reimbursement to discuss end of life care, which began in January 2016.

Medicare and End-of-Life Care

Care Coordination in an ACO: Population Health Management from Wellness to End-of-LifeWhen acknowledging its position as a top-ranking Medicare Shared Savings Program (MSSP), Memorial Hermann is quick to credit its own physicians—who in 2007 lobbied for a clinically integrated network that formed the foundation of the current Memorial Hermann accountable care organization (ACO). Now, eight years later, collaboration and integration continue to be the engines driving the ACO’s cost savings, reduced utilization and healthy patient engagement rates associated with Memorial Hermann ACO’s highest-risk population.

Care Coordination in an ACO: Population Health Management from Wellness to End-of-Life details Memorial Hermann’s carefully executed journey to quality and the culmination of the ACO’s community-based care management program.

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6 Population Health Strategies to Set Stage for Physician Reimbursement

May 12th, 2016 by Patricia Donovan

Robert Fortini, PNP

A team-based, top-of-license approach is key to population health success, says Robert Fortini, PNP, Bon Secours Medical Group chief clinical officer.

In the last six years, Bon Secours Medical Group (BSMG) has deployed a half-dozen population health strategies as groundwork for its Next Generation Healthcare offering. Here, Robert Fortini, PNP, BSMG chief clinical officer, identifies the tactics his organization leverages to effect health behavior change.

The specific population health strategies Bon Secours has deployed over the last six years start with the patient-centered medical home (PCMH) concept. I’m an avid believer in the concept of a team of professionals working together, along with that ‘top of license’ aspect, where it’s not just the sole domain of the independent ‘cowboy’ physician taking care of the patients. It’s pharmacists, nurses, social workers, and registered dietitians. It’s the entire team, with everyone having a vested responsibility for practicing to the top of his or her license.

Next, access is huge. It is ridiculous to think we can manage chronic disease in four 15-minute visits a year scheduled between 8 a.m. and 5 p.m. Monday through Friday, while closing at lunchtime. It’s absolutely ludicrous. We are blowing that up by opening weekends and evenings and using technology to expand access, which is critical to affecting that behavioral change.

Third, know your population. Identifying effectively those who are most at risk with advanced analytics to make your efforts more efficient is very important.

Next is managed care contracting—aggressively coming to the table with our payors to help guide the conversations and craft the contracts and benefit designs that are attainable and achievable. That has been a new experience for Bon Secours in the last five years in particular. We have a CMS-based Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) covering about 30,000 attributed lives. We also have a number of commercial ACO-type contractual relationships with our commercial payors.

Fifth on the list: aggressive growth for palliative and hospice. We have invested very significantly in management of advanced illness that occurs at the end of life. The Medicare numbers around that are staggering: 40 percent of Medicare spend occurs in the last two years of life, and the pain, suffering, and emotional angst that occurs for patients and their families is incredible. Investing in the resources necessary to manage that effectively has been our strategic initiative at Bon Secours. We have a very large, well-versed palliative program that provides inpatient, outpatient and even home-based palliative services. And our hospice agency, which I am responsible for in addition to our medical group, has quadrupled in size in the last two years alone.

Then, finally, we manage the white space with powered care coordination, which includes health promotion, chronic disease management, care transition management, and more.

Source: Physician Reimbursement in 2016: 4 Billable Medicare Events to Maximize Care Management Revenue and Results

Physician Reimbursement in 2016: 4 Billable Medicare Events to Maximize Care Management Revenue and Results details the ways in which Bon Secours Medical Group (BSMG) leverages a team-based care approach, expanded care access and technology to capitalize on four Medicare billing events: transitional care management, chronic care management, Medicare annual wellness visits and advance care planning.

End-of-Life Care: Infographic

June 3rd, 2015 by Melanie Matthews

Only 27% of Americans report having talked with their families about end-of-life care, according to a new infographic by Vitas Healthcare.

The infographic examines the need for a living will and a medical power of attorney and the communication needs about these documents.

Case Management for Advanced Illness: Best Practices in End-of-Life CarePoor prognoses, the loss of functional capabilities, and the need for advanced care planning are just some of the emotionally charged challenges of caring for individuals with advanced illness.

Case Management for Advanced Illness: Best Practices in End-of-Life Care examines Aetna’s Compassionate Care program, a case management approach for this population. The payor’s initiative breaks down barriers commonly encountered in this highly sensitive stage of the health continuum while positively impacting both healthcare utilization and spend.

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Infographic: Decision-Making in Cancer Care

March 6th, 2015 by Melanie Matthews

Cancer patients should be involved with decisions about their care and should understand the goals of treatment and prognosis of their disease, according to a new infographic by the National Coalition for Cancer Survivorship.

The infographic examines the current state of prognosis and end-of-life care discussions.

2014 Healthcare Benchmarks: Palliative CareWhile the word ‘palliative’ literally means to cloak or conceal, healthcare is taking the wraps off this critical service — in spite of provider resistance. Recent data increasingly supports the thesis that a well-timed palliative care consult can enhance the patient experience and foster appropriate use of healthcare resources.

2014 Healthcare Benchmarks: Palliative Care documents emerging trends in palliative care at 223 healthcare organizations, from the timing for initial palliative care consults to individuals on the palliative care team to the impact this specialized care is having on healthcare utilization and the patient experience — two critical markers of healthcare performance.

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10 Healthcare Trends Measured in 2014: Medical Neighborhoods, Data Analytics Flourish

January 13th, 2015 by Patricia Donovan

2014's HINtelligence Reports captured trends in healthcare delivery, technology and utilization management.

Each year, the Healthcare Intelligence Network’s series of HINtelligence Reports pinpoint trends shaping the industry, from cutting-edge care collaborations to remote patient management connections to tactics to reduce avoidable utilization.

HINtelligence Report benchmarks are derived from data provided by more than one thousand healthcare companies.

Here are 10 highlights from 2014 HINtelligence Reports that support Triple Aim goals of improving population health and the patient experience while reducing the per capita cost of healthcare.

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  • Readmissions: More than half of survey respondents participate in post-acute partnerships, with home health collaborations the most common (79 percent). These partnerships serve to streamline processes and care transitions, educate and align staff, and implement changes of value to patients, said respondents to the fourth annual Reducing Hospital Readmissions Survey.
  • Palliative Care: While the majority of respondents (68 percent) administer palliative care on an inpatient basis, more than half (54 percent) say care is conducted on home visits and just under a third offer palliative care at extended care facilities.
  • Patient-Centered Medical Home: Prepared to take their medical homes to the next level of care in the year to come, almost half—48 percent—have joined or expect to join a medical home neighborhood, defined by TransformMed℠ as “a strong foundation of transformed primary care practices aligned with health systems and specialists to insure that care is maximally coordinated and managed.
  • Remote Patient Monitoring: More than half of 2014 respondents—54 percent—have instituted remote monitoring programs, the survey found, which was most often employed for patients or health plan members with multiple chronic conditions (83 percent). Other targets of a remote monitoring strategy included frequent utilizers of hospitals and ERs (62 percent) and the recently discharged (52 percent).
  • Telephonic Case Management: More than 84 percent of respondents utilize telephonic case managers. „One-fifth of telephonic case managers work within the office of a primary care practice.
  • Population Health Management: The last two years reflects a dramatic surge in the use of data analytics tools barely on population health management’s radar in 2012: the use of health risk assessments (HRAs), registries and biometric screenings more than tripled in the last 24 months, while electronic health record (EHR) applications for population health increased five-fold for the same period.
  • Emergency Room Utilization: Among populations generating the majority of avoidable ED visits, dual eligibles jumped nearly 10 percent in the last four years, from 2 to 11 percent, while other populations—high utilizers, Medicare and Medicaid—remained roughly the same. „„Chronic disease replaced pain management as the most frequently presented problem in the ER, at 54 percent.
  • Stratification of High-Risk, High-Cost Patients: The „LACE readmission risk tool (Length of stay, Acute admission, Charleston Comorbidity score, ED visits) is considered the primary indice and screen to assess health risk, according to 33 percent of respondents.
  • Embedded Case Management: Fifty-seven percent of respondents embed or co-locate case managers in primary care practices, where their chief duties are care and transition management, reducing hospital readmissions and patient education and coaching.
  • 2015 Healthcare Forecast: Almost 92 percent of 2015 respondents said the impact of value-based healthcare on their business has been positive, with more than one quarter identifying healthcare’s value-based shift as the trend most likely to impact them in the year to come.

Make your healthcare voice count in 2015 by answering 10 Questions on Chronic Care Management by January 31, 2015. You’ll receive a complimentary HINtelligence Report summarizing survey results.

Caldwell UNC Healthcare Embedded Case Managers Count Outreach, Not Cases

October 2nd, 2014 by Patricia Donovan

embedded case management

Visibility is the embedded case manager's greatest asset.

A frequently sought metric in case management is the optimal case load. However, embedded case managers at Caldwell UNC Healthcare don’t count cases, they count outreach, explains Melanie Fox, director of Caldwell Physician Network’s Embedded Case Management program.

For Ms. Fox’s team of case managers embedded in seven primary care practices and two work sites, outreach is mostly telephonic, but may also include visits to patients’ homes if they see the need.

“We will do anything to make sure patients get to where they need to be. A lot of our home visits occur because of confusion with medications,” she explained during Embedded Case Management in Primary Care and Work Sites: Referral, Stratification and Protocols, a September 2014 webinar now available on-demand.

Typically, the embedded case management team averages about a thousand outreaches per month, Ms. Fox estimates. Telephonically, they reach almost all patients within 48 hours of discharge, and most ED discharges, running down a multi-item checklist, from medication and home health needs to scheduled follow-up appointments and advanced illness management (AIM), formerly referred to as palliative care, which was frequently misunderstood as strictly hospice, she noted.

Caldwell is working to establish that reporting linkage with skilled nursing facilities as well.

Medication is a large part of that telephonic conversation, Ms. Fox adds, as is a focus on new Transition Care Management Codes, where practices can be reimbursed for non-face-to-face care provided when patients transition from an acute care setting back into the community.

The visibility of embedded case managers in a practice is a great asset to both providers and patients, she says. “We seem to be more accepted by providers, staff and patients because they see us as part of the team.”

At the two work sites, the case manager works alongside a nurse practitioner, where the goals are preventive care and chronic disease management.

With extensive RN experience in home health and schooled in the Geisinger Healthcare System model of embedded case management known as ProvenHealth Navigator℠, Ms. Fox joined Caldwell three years ago to develop and launch the program. Referrals to embedded case managers come from hospital discharge and ED reports, as well as provider and even self-referrals.

Although relatively new, Caldwell’s embedded case management approach has helped to halve 30-day hospital readmissions in its Medicare population— from 19.16 percent in second quarter 2012 to 9.09 percent in fourth quarter 2013, she said. Buoyed by this success, Ms. Fox’s team is targeting ED visits as its next metric.

During the program, Ms. Fox also shared six qualities of an effective embedded case manager, advantages of embedding case managers in care sites, and tactics for engaging physicians and staff in the embedded model.

Click here for an interview with Melanie Fox.

Aetna Compassionate Care: “Advanced Illness Care Coordination Can’t Be Measured by Numbers Alone”

September 30th, 2014 by Patricia Donovan

In its new report, “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life,” the Institute of Medicine recommends the development of measurable, actionable, and evidence-based quality standards for clinician-patient communication and advance care planning to reflect the evolving population and health system needs.

Aetna’s Compassionate Care program, a case management approach for individuals in advanced stages of illness, breaks down barriers commonly encountered in this highly sensitive stage of the health continuum while positively impacting both healthcare utilization and spend. Here, Dr. Joseph Agostini, senior medical director, Aetna Medicare, shares some best practices from Aetna’s Compassionate Care Program.

There are several best practices. First, there is training, which is integral to the success of the Aetna Compassionate Care program.

Second, there is the proper selection, mentoring and ongoing learning opportunities for nurse case managers. These include such things as ongoing online tutorials, in-person training, where everyone gets training in change management and motivational interviewing techniques, regular ‘lunch and learns,’ medical director sessions including case-based rounds of cases that are in progress right now and feedback sessions. We bring in external entities to provide specialized expertise as necessary so that nurses get continuing education throughout the process.

Another best practice for us is having Aetna case managers manage all types of members. We don’t have a specialized unit that just specializes in advanced illness care needs. We think all of the nurse case managers should have developed this critical skill of being able to manage those with advanced illness, but also be able to identify support and be advocates for patients in all phases of their lives.

We also use a variety of functional status and prognosis tools. Many of these rating scales are scores focused on functional status. That’s important to follow over time, and can be predictive of outcomes. In our program we don’t necessarily use all of these scales, but we always capture some basic functional status over time and it’s useful and necessary to view that longitudinally.

A real-life example captures the heart of what we do. A case manager writes:

‘Wife stated member passed away with hospice. Much emotional support given to spouse, she talked about what a wonderful life they had together, their children, all of the people’s lives that he touched. They were married 49 years last Thursday and each year he would give her a piece of jewelry. On Tuesday when she walked into his room he had a gift and card lying on his chest, a beautiful ring that he had their daughters purchase. She was happy he gave it to her on Tuesday; on Thursday he was not alert. She stated through his business that he touched many people’s lives and they all somehow knew he was sick and he has received many flowers, meals, fruits, cakes. She stated her lawn had become overgrown and the landscaper came and cleaned up the entire property, planted over 50 mums, placed cornstalks and pumpkins all around. She said she is so grateful for the outpouring of love. Also stated that hospice is wonderful, as well as everyone at the doctor’s office and everyone here at Aetna. She tells all of her friends that when you are part of Aetna, you have a lifeline.”

And the case manager concludes, “Encouraged her to call with ongoing issues or concerns and closed to case management.”

You can really feel the depth of connection that develops between the Aetna member, or the family caregiver and the case manager. You can’t really make this happen; it occurs over time and I would suggest to everyone that advanced illness care coordination can’t be measured by numbers alone or on hospital admissions or the length of time in hospice. We need to develop quality measures that capture the degree of family, caregiver and patient support that a program like this engenders.

advanc care planning
Dr. Joseph Agostini is the senior medical director for the Aetna Medicare team. He is responsible for medical management strategy, clinical initiatives, and provider collaboration oversight for Aetna Medicare members.

Source: Case Management for Advanced Illness: Best Practices in End-of-Life Care