I need conclusion paragraph for this paper.Use at least 1-2 peer reviewed articles for citation.mn507_unit_9_assignment.docxRunning head: ABSTRACT AND POSITION PAPER
Abstract and Position Paper
Group E:
Yailin Saab Leon
Andrea Small
Sherry Valverde
Kathy Verdes
Christine Weiss
Kaplan University
1
ABSTRACT AND POSITION PAPER
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Abstract and Position Paper
Current Situation Necessitating Change
Currently Medicare is the most influential insurance plan for end of life care, accounting for
80% of the 2.3 million people who died in 1997. End of life care accounted for 10-12% of all
health care spending (Round, Jones & Morris, 2015). Of the 554 billion dollars spent by
Medicare in 2010, 28% or 170 billion was spent on patients last 6 months of life (Raphael,
Ahrens & Fowler, 2001). It has been estimated that 20 to 30 percent of these medical
expenditures may have had no meaningful impact. Without any changes to the cost of end-of-life
care as the nation’s elderly population grows Medicare will be bankrupt sooner than anticipated
(Round, Jones & Morris, 2015).
Originally the Affordable Care Act (ACA) had included a provision where Medicare would
reimburse physicians for end of life care but the provision was removed. This provision would
allow physicians and other healthcare providers to take the time and properly educate patients on
what would happen and what they can do to ensure their loved ones comfort during their last
moments alive. This policy change will promote awareness that aggressive intervention at the
end of life often does not lead to a better outcome or quality of life. By providing the education
needed patients will die with peace and dignity.
Studies have found that about 4 in 10 Americans ages 65 and older do not have advanced
directives or have not written down their own wishes for end-of-life medical treatment. By
emphasizing communication, Medicare may possibly be able to reduce the number of hospital
stays and physician visits at the end of life in a way that individual beneficiaries value and want,
thereby reducing spending. This policy would reimburse physicians and other health-care
professionals for talking to patients about their end-of-life options.
ABSTRACT AND POSITION PAPER
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Taking a stand against the unnecessary costs of end-of-life care, and encouraging a policy
change to provide further education to patients and family members on the choices of treatment
for end-of-life care such as palliative care, hospice and advance directives; the policy would
ensure that end-of-life care is compassionate, affordable, sustainable, and of the best quality
possible.
The Proposed Policy Change
The proposed policy change is the use of the Physician Order for Life- Sustaining
Treatment (POLST) document in planning for end of life care. The POLST document conveys
patient’s medical treatment preference into a physician order: the document expresses patient’s
wishes regarding life-sustaining treatment, limited life-sustaining treatment and comfort
measures (Florida State University College of Medicine, 2016). In the Unites States a significant
amount of dollars are spend yearly on unwanted end of life care: it is estimated that nearly 27%
or 327 billion of the Medicare’s budget pays for patient’s final year of life (Nakhoda, 2010)..
Recent studies have concluded that end of life conversation such as the POLST document have
lowered end of life care expenses by 36%, a significant saving to healthcare especially when life
prolonging measures are most often associated with worse quality of death and typically not
resulting in longer life (Nakhoda, 2010).
Agenda Setting
With healthcare reform and budget in the recent spotlight, the introduction of a cost
saving notion should grab elected official’s attention. It is also most imperative to add the stress
attached to end of life care decisions to the conversation. Dying in itself is not an easy process:
although, the patient may have an idea in mind of how he or she wants to proceed: family, loved
ones and providers may have a different perception. End of life care decisions can be
ABSTRACT AND POSITION PAPER
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overwhelming to anyone who is not prepared. Bakitas, Kryworuchko, Matlock, & Volandes
(2011) mentioned the pressure of end of life care on patient and families cannot only be
overwhelming but can also cause “decision paralysis” often affecting patient’s wishes and
deferring the decision to providers as they feel it is too complicated.
The POLST document would ensure patients are prepared and their wishes are followed.
In today’s healthcare nurses and other health professionals are prominent in numerous policy
discussions (Nickitas, Middaugh, & Aries, 2016). Nurses are in a perfect position to initiate
discussions about the POLST document at any time during a patient’s life and care (Hickman,
Keevern, & Hammes, 2015). It is also important to note that providers hold positive views
towards the POLST document and would be a great asset to any end of life care policy
discussions (Hickman, Keevern, & Hammes, 2015). The Florida POLST headquarters is
currently located at the Florida State University Center for Innovative Collaboration in Medicine
and Law (Florida State University College of Medicine, 2016).
Model Used to Bring About Change
The Kingdon model for policy development and implementation would be one of the best
ways to initiate change in regards to the exorbitant cost for end-of-life care. The model has three
phases, namely, the problem phase, the proposal phase, and the political phase. These three
phases must be completed for a policy to be adopted (Bradford, 2003, para 2). Agenda setting is
the first stage of the policy process where the problem is identified, namely, the exorbitant cost
of end-of-life care and the policy decision makers must deem it important enough to pay
attention to the issue. It is important that the policy change being advocated should have a hook
to grab the legislative’s attention because there are many other services vying for a finite amount
ABSTRACT AND POSITION PAPER
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of tax dollars. Thus the policy with the most problem recognition factor may rise to the top of
the agenda for legislative consideration.
In this case, millions of dollars would be saved if end-of-life costs could be reduced
with the introduction of the POLST (Physician Orders for Life Sustaining Treatment) document.
The next phase, the proposal phase, represents the process by which policies are generated,
debates, revised, and adopted for serious consideration. This process may be time consuming as
competing proposals may be attached to the same problem. Proposals are more successful if
they are practical, less expensive, and appealing to the public. The political phase in this
proposal refers to political factors that influence agenda, namely, political climate, mood, and the
elected officials. As we are in the arena of health care reform, introduction, and widespread use
of the POLST document, could be introduced as a means of cutting the costs of end-of-life care
by eliminating expensive and therapies that will not help patients with terminal illnesses in the
last year of their lives.
Design Strategy
Discussing end-of-life issues and code status is one of the hardest tasks that any health
care team must undertake, but it is a necessary one. Once it is deemed that a patient’s condition
is terminal, then that conversation between doctor, patient, and their family, should be
encouraged. For the proposed policy change to be effective, the above mentioned conversation
must be initiated. The POLST document must be discussed at length. Every patient facing endof-life issues must have the document at an easily acceptable section of the chart or in the EHR.
All staff must be introduced to the POLST document and educated on its use. Physicians and
hospitals should be granted incentives for introducing the POLST document to the patient and
their family.
ABSTRACT AND POSITION PAPER
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In a similar manner, providing financial incentives for services such as home health care
rather than emergency and acute care services at the end-of-life will help reduce the overall cost
of expensive hospitalization and treatment for terminally ill patients. Lin et al (2014) state “HSC
[hospice share care] is associated with significant medical expenditure savings and reduced
likelihood of intensive medical utilization. All types of HPC are associated with medical
expenditure savings” (p. 1908). These strategies will not only save taxpayers millions of dollars,
but helps to prevent physical, emotional, and financial distress to the patient and their family, at
that point in time, when end of life decisions have to be made. This policy change will
undoubtedly reduce and/or eliminate spending on expensive testing and treatments that are futile
and reduce the exorbitant cost of end-of-life care.
Implementation Strategies
Implementing strategies to help reduce the high cost of end-of-life-care and change the
current policies has a chance to make a significant impact on the future of healthcare. Palliative
care should be accessible and affordable to anyone who needs it. Advanced acre decisions and
the implementation of Physician Ordered Life Sustaining Treatment (POLST) have helped
providers to give competent, coordinated and compassionate end-of-life-care. (Wholihan & Pace,
2012).
The framework of the Kingdon Model suggests that policies move forward when the
three streams come together. The first stream is the definition of the problem ( high cost of end
of life care). The second stream is the development of potential policies to solve the problem
(financial incentives for palliative care; implementation of POLST document). Finally, the third
stream is the role of the public opinion and the politics of initiating the policies ( interest groups
ABSTRACT AND POSITION PAPER
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and organizations representing healthcare professionals). The implementation of high quality
end-of-life-care involves a support system of providers who have the knowledge and skills for
treating individuals with advanced serious illness who are at the end of their life. According to
the Institute of Medicine, ” Professional societies and other organizations that establish quality
standard should develop standards for clinician-patient communication and advance care
planning that are measurable, actionable, and evidence based”(2015). This begins with providers
working together as a palliative care team to discuss end-of-life-care with an emphasis on values
clarification and care planning. Multistep care processes and end of life transition levels make
the process more efficient (Wholihan & Pace, 2012)
There also needs to be the implementation of federal, state and private insurance
companies to provide the financing of quality care that is consistent with the values and
preferences of those at the end of life. “Changes are needed throughout the healthcare system to
incentivize the provision of comprehensive palliative care”. (Meghani & Hinds, 2015)
In order to implement the strategy to reduce the high cost of end-of-life-care there needs
to be public education and engagement regarding end of life care issues. The Kingdon Model
distinguishes between the “conditions” that people are aware of and “problems” that cause
policymakers to act (Cohen & McKeown, 2015) It is up to the health community and leaders to
make the knowledge available and transform the “condition” into a policy problem for action.
Evaluation Strategies
When evaluating the strategies implemented for reducing the high cost of end-of-lifecare, it is important to remember that there is more than one component being evaluated. There
are a number of different stakeholders and evaluation needs to be both an individual and
ABSTRACT AND POSITION PAPER
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collective action. Nursing, as one of the most trusted health disciplines, can help ensure the
existence of advance care planning and other critical components of palliative care and use those
to influence stakeholders (Meghani & Hinds, 2015). The cost saving benefit in end-of-life-care
is mostly due to improved decision making and earlier end of life discussions among patients,
families and providers (Wholihan & Pace, 2012). Unlike hospice care which requires a
prognosis, non-hospice palliative care can be incorporated into the continuum of care and has
been associated with lower cost and higher quality of life. Another way of evaluating a policy’s
effectiveness is the extent to which it has reached the intended populations. Policy stakeholders
bring different perspectives which is imperative for change to come about in the healthcare
arena. As a community there needs to be an end to the perception of “cure at all costs” and with
the evaluation of the strategies that are being implemented, the emphasis on value based care is
becoming a realizable goal.
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Journal Link
http://edmgr.ovid.com/jhpn/accounts/ifauth.htm
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References
Bakitas, M., Kryworuchko, J., Matlock, D. D., & Volandes, A. E. (2011). Palliative Medicine
and Decision Science: The Critical Need for a Shared Agenda to Foster Informed Patient
Choice in Serious Illness. Journal of Palliative Medicine, 14(10), 1109-1116.
doi:10.1089/jpm.2011.0032
Bradford, S. (2003). The kingdom policy window model and its application to the new york
public smoking ban. Retrieved from: ttps://www.scottbradford.us/2003/12/04/thekingdon-policy-window-model-and-its-application-to-the-new-york-public-smoking-ban/
Cohen, S. & McKeown, K. (2015). Public policy, public health, and health policy. Oncology
Nursing Society.
Florida State University: College of Medicine. (2016). POLST. Retrieved from
http://med.fsu.edu/?page=innovativeCollaboration.POLST
Hickman, S. E., Keevern, E., & Hammes, B. J. (2015). Use of the Physician Orders for LifeSustaining Treatment Program in the Clinical Setting: A Systematic Review of the
Literature. Journal of the American Geriatrics Society, 63(2), 341-350 10p.
doi:10.1111/jgs.13248
Lin, W., Chiu, T., Ho, C., Davidson, L. E., Hsu, H., Liu, C., . . . Lin, C. (2014). Hospice sharedcare saved medical expenditure and reduced the likelihood of intensive medical
utilization among advanced cancer patients in taiwan–a nationwide survey. Supportive
Care in Cancer, 22 (7), 1907-14.
ABSTRACT AND POSITION PAPER
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Meghani, S. & Hinds, P. (2015). Policy brief: The institute of medicine report dying in america:
improving quality and honoring individual preferences near the end of life. Science
Direct. Retrieved from: www.nursingoutlook.org.
Nakhoda, Z. (2010). End-of-Life Care and the Medicare Hospice Benefit: The High Cost of Endof-Life Care. Journal of Financial Service Professionals, 64(2), 24-28.
Nickitas, D, Middaugh, D, & Aries, N. (2016). Policy and Politics for Nurses and other Health
Professionals. (2nd ed.). Burlington, MA: Jones & Barlett
Raphael, C., Ahrens, J. & Fowler, N. (2001) Financing end of life care in the USA. Journal of
Royal Society Medicine.
Round, J., Jones, L., & Morris, S. (2015). Estimating the cost of caring for people with cancer at
the end of life: A modeling study. Palliative Medicine, 29(10), 899-907.
doi:10.1177/0269216315595203
Wholihan, D.& Pace, J. (2012). Community Discussions: A vision for cutting the costs of endof-life -care. Nursing Economics, 30(3), 170-178
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