ElderBranch, a resource for people looking for senior careproviders, recently published a series of articles regarding end-of-life care: where we are today, innovative models and interviews with experts.

Below is an excerpt from our interview with Susan Enguídanos, PhD, of the USC Leonard Davis School of Gerontology about a palliative care program that she helped design in partnership with Partners in Care Foundation.

ELDERBRANCH: Generally speaking, what’s broken, missing or lacking when it comes to end-of-life care?

SUSAN ENGUIDANOS: One of the biggest problems is that end of life really starts sooner – in terms of the decline. People get end-of-life care usually in the last three weeks of life, which is in hospice, but you really don’t have any other mechanism in our system to address the decline that starts much earlier.

Our whole health care system is designed to cure and provide care for people who are healthy and can navigate the system, but we don’t have anything that provides the other needs that people have as they start to decline and experience serious health problems.

ELDERBRANCH: Can you describe the Kaiser Permanente program that you helped design?

SUSAN ENGUIDANOS: In terms of the model, it looks a lot like hospice. We have physicians, social workers, nurses, homes health aides, chaplains and it’s all home-based. The frequency of it is predicated on the needs of the patient.

One of the other critical components is that they have access to information – medical personnel, 24 hours a day. So if they had a crisis, they could pick up the phone, call somebody, and reach a nurse who can reach a doctor at any time. What we’re finding in some of the work I’m doing right now is [that among] patients that have been readmitted to the hospital, we’re finding that access in a crisis is a key issue as to why people end up back in the emergency room. It’s not necessarily their first choice, but they didn’t feel like they had an alternative.

ELDERBRANCH: Do palliative care programs actually escalate total costs of care?

SUSAN ENGUIDANOS: For the palliative care team, the right decision isn’t around financing, it’s around what does the patient really want in their last years of life. What type of trajectory and care treatment are well-suited, and providing them information about what their trade-offs are. What [are] your options if you decide not to do aggressive care, or what the odds of survival are if you have a heart condition and cancer.

The other research that just came out found that people actually live longer because they make different decisions. They have fewer episodes of chemo and radiation but they live longer. We found that if we gave them more care in the home, they either didn’t need or decided not to pursue aggressive care.

ELDERBRANCH: While there is a Medicare hospice benefit, there isn’t something similar for palliative care. How are palliative care programs being paid for and is that a factor when thinking about broader adoption of these kinds of models?

SUSAN ENGUIDANOS: That has been the primary barrier in disseminating the model and promoting replication. [Given] the Kaiser structure is completely a closed system, they can move funds around to cover whatever they want. In systems that aren’t like the VA or Kaiser, there’s always going to be a winner and a loser, and the loser is the person paying for the services and the winner is the person saving money.

We have to figure out how to reimburse these services in a way that there’s not a “loser.” That’s exactly why a lot of these models don’t have the social worker or the chaplain; they have the nurse practitioner and the physician because they can charge for home visits. So that’s a huge barrier in terms of why we haven’t had better success in getting this replicated.

Elderbranch’s complete interview with Dr. Enguídanos, as well as the complete series on end-of-life care can be found in the following parts: I, II, III, IV.

A report released today by the National Academies paints a dire picture of American health. Not only do people in the United States die sooner than people in other high-income countries, but American health is poorer than in peer countries at every stage of life – from birth to childhood to adolescence, in youth and middle age, and for older adults.

“The problem is not limited to people who are poor or uninsured,” said Eileen Crimmins, AARP Chair in Gerontology at the USC Leonard Davis School of Gerontology and a member of the National Research Council panel that compiled the report. “Even Americans with health insurance, higher incomes, college education and healthy behaviors such as not smoking seem to be sicker than their counterparts in other countries.”

In contrast to prior research on life expectancy that focused on people over 50, the ten-person panel, chaired by Steven H. Woolf of Virginia Commonwealth University, examined potential health disadvantages among younger Americans — and found that Americans are less likely to make it to age 50 at all.

Deaths before 50 account for about two-thirds of the difference in male life expectancy between the United States and other developed countries and about one-third of the difference in female life expectancy, the report found.

Among the 17 peer countries — all high-income democracies with relatively large populations — examined by the panel, people in the United States are much more likely to die of almost everything, including injury, noncommunicable diseases such as diabetes, and communicable diseases such as HIV.

In particular, among the countries studied:

• Americans are the most likely to die in transportation accidents. The rate of violent death is also significantly higher in the United States, especially death from firearms. Overall, the United States had the second highest death rate from injury (behind Finland).

• Americans are much more likely than people in peer countries to die from maternal conditions related to pregnancy. Since the 1990s, among high-income countries, teenagers in the United States have much higher rates of pregnancy and are more likely to acquire sexually transmitted diseases.

• Though the incidence of AIDS has fallen in the last two decades, the United States still has the highest incidence of AIDS among peer countries. Overall, the United States has the fourth highest mortality from communicable diseases (behind Portugal, Japan and the UK).

• The U.S. has the highest prevalence of diabetes and high rates of obesity, starting in childhood. The U.S. has the second highest death rate from noncommunicable diseases such as diabetes or cardiovascular disease (behind Denmark).

“No single factor can fully explain the health disadvantage we have in the United States,” Crimmins said. “But we must start a national discussion about what investments and tradeoffs Americans are prepared to make for health, and encourage research on the causes of the problem and the strategies and approaches adopted by other nations.”For an interactive chart of how the United States stacks up against peer countries in various causes of death, visit http://sites.nationalacademies.org/DBASSE/CPOP/DBASSE_080393#deaths-from-all-causes.

In their report, the expert panel identifies several likely explanations for the unhealthiness of Americans, including high levels of poverty in the United States and a built environment that is designed around automobiles. In addition, while Americans are currently less likely to smoke and drink less, we consume the most calories per person and have higher rates of drug abuse, the report found.

“This is not a contest with other countries, but a tragedy that Americans are dying earlier and suffering from illness and injury at rates that are avoidable,” said Crimmins. “Americans can have better health, with important implications for the economy and competitiveness.”

For a full copy of the report, “U.S. Health in International Perspective: Shorter Lives, Poorer Health,” visit http://sites.nationalacademies.org/DBASSE/CPOP/US_Health_in_International_Perspective/index.htm#.UOytBbZq7x4.