MediCaring demo to be launched; VA has a role

Phase I of the Medicaring National Demonstra tion Project, developed by the Center to Improve Care of the Dying at George Washington University in Washington, DC, soon will be launched. While one or more hospices may serve as demo sites, many others are acutely interested in seeing how this experiment in redeploying Medicare resources for incurable, chronically ill patients might reshape hospice care, even as hospice provided its model for interdisciplinary end-of-life care. MediCaring would provide coordina- ted, comprehensive care using advanced practice nurses or physicians for primary care. The program also includes early intervention to prevent disease complications and tailored life-prolonging, palliative, and supportive services.

A projected six to eight demo sites, along with six more within the Veterans Affairs health system, likely will be selected within the next few weeks for participation in the three-year pilot project. Data from the first year would be used to request a coverage waiver from the Health Care Financing Administration to help pay for the second phase, perhaps using a capitated reimbursement rate.

A meeting of potential demonstration sites was planned in conjunction with the Institute for Healthcare Improvement's national end-of-life Congress in St. Louis in late July, to find out which institutions are able to make the commitment. Actual sites would be signed on over the next two months, says MediCaring creator Joanne Lynn, MD. "I'd be quite disappointed if there wasn't a hospice among them; a number of hospices are in the group interested in trying to pull it off."

According to a report in the May 20 JAMA,1 participating sites would commit to enroll at least 100 patients annually with chronic heart failure or chronic obstructive pulmonary disease. "However, that could change once we have representatives from all 12 sites sitting around the table," Lynn tells HMA. Other appropriate conditions would be stroke and dementia, but the project would use measurable disease severity rather than a numerical life expectancy as the basis for eligibility. Demonstration sites would commit to uniform data collection and a rigorous research design.

The JAMA article about MediCaring has generated a new round of phone inquiries. In that article, Lynn states, "Hospice has set the standard for good end-of-life care through the use of interdisciplinary teams that coordinate care and manage costs; a focus on patient and family as the unit of care; and reliable and effective service delivery. The program has enjoyed widespread approval." However, there is a need for new end-of-life models that are not burdened by hospice's six-months-or-less hurdle and sharp distinction between palliative and curative care, and can thus avoid "the'toxicity' of the hospice label, which many people resist," she observes. "It is perceived as a harsh turning away from treatment and as a marker for imminent death."

The VA is moving forward to identify sites for the MediCaring demo, confirms Bonnie J. Ryan, VA's chief of community-based care in the Office of geriatrics and extended care. MediCaring operating costs would come out of existing budgeted funds, with no additional appropriations, while the research component of the project would be funded by the VA's health services research and development department.

Meanwhile, the VA is finalizing its national strategy for improving care at the end of life, building on a National Strategic Summit held May 10-12 in Warrenton, VA, Ryan says. The strategy will outline concrete actions that can be implemented at all levels within the VA to improve care at the end of life. It also plans another pilot project similar to MediCaring, for Alzheimer's patients, in collaboration with the Alzheimer's Association in Chicago.

As required by the Veterans Health Care Elig ibility Act of 1996, the VA completed its Hospice Study in April and submitted it to Congress. Among its findings, 98% of 148 VA medical centers had implemented hospice programs serving 11,000 veterans in 1996. VA centers referred veterans to non-VA community hospices or directly provided inpatient hospice care, or both. The combined approach was viewed as having the greatest potential for meeting veterans' needs. While satisfaction with hospice care is high throughout the VA system, three main barriers were identified:

o inadequate integration of the hospice program with other medical center services;

o inadequate coordination between VA medical centers and community hospices;

o inadequate follow-up on veterans referred to hospices.

The VA also received a grant for nearly $1 million from the Robert Wood Johnson Foundation in Princeton, NJ, to develop a faculty fellowship program in end-of-life and palliative care. A faculty fellow will be named at each of 30 VA-affiliated internal medicine training programs across the country. These fellows will come together in October to develop and implement a curriculum for state-of-the-art care for patients through the end of life. They also will seek innovative ways to implement this curriculum with medical residents, Ryan says. The program also will be collaborating with hospices in arranging placements. The VA plans to eventually share its end-of-life curriculum with other medical residency programs.


1. Skolnick AA. MediCaring project to demonstrate, evaluate innovative end-of-life program for chronically ill. JAMA 1998; 279:1,511-1,512.