 Aloha welcome to health care in Hawaii. I'm your host Josh Green senator from the Big Island as you can see I'm in my scrubs today and Also a worker in the ER. I'm welcoming a good friend today to our show. I'm Mr. Ken Zerry Who is the hospice Hawaii president been that for many years nurse for 33 years was on the national board of? Hospice nurses national hospice and palliative care organization board member also founding board member at Kukua Mal I am good to see you. Thanks Josh. Thanks for having me on boys for being here So we're gonna talk about a very very important issue which is hospice care today And we've entitled our show at your recommendation the myths of hospice care, right? Why don't you unpack that for me just a little bit Josh? I think that one of the phenomenon that we run into when we talk to folks about hospice It's actually all summed up in the most common complaint Which is why didn't I know about hospice sooner when you kind of unpack that to use your word you really do come into? Understanding that there are all sorts of barriers of emotional Misunderstanding barriers about people getting access to hospice sooner Yes, what we do know is that when you can have hospice in the last two or three months of life It can be almost miraculous and what we can hopefully try to achieve with that patient and their family And the beauty of it is it's generally covered a hundred percent. That's it's really important So as a part of the larger dialogue of health care, we know we have an aging population Right, we have people with severe chronic illness. We have people with very advanced cancers that lived a long time But at some point people have an option to go into hospice care. Does everyone go into hospice care? No, no actually Nationally between 45 and 50 percent of all Medicare beneficiaries Which is our largest biggest piece of data about half of all Medicare beneficiaries have hospice care in America About about 10 or 15 of percent of those are discharged alive. They graduate. They actually get a little better And here in Hawaii, we're at about a 45 to 47 48 percent probably at this point in time of all deaths That occur in the state have hospice care. That's amazing to me So that means a person has gotten very very ill and how do they qualify for hospice? How does how does a patient even contact you? Does it always have to go through their doctor or through their nurse? How do they get to you? So the the first simple question to ask is the question we like is would you be surprised? So Josh if you were making a referral for a patient to me and you said I don't know if this gentleman who's got a chronic debilitating Set of conditions. I don't know if he's eligible for hospice I might say well Josh would you be surprised if he was alive next spring because it's the fall right now, right? That's kind of a nice six-month window. Yes And if you would think about this person you think you know He's got heart disease and he's got kidney disease and he's got some some pulmonary issues Yeah, I don't really think he's gonna make it past the new year then we need to talk about hospice care for him Okay, so simply that kind of an initial screening is the first way to start now Anybody can make a referral to hospice Hawaii for hospice care Yes, and they just call our number at nine two four nine two five five It's you know Google hospice Hawaii right and you and you make that call Are you are you just on a wahoo or are you do you have affiliates? How does that work just so people know sure hospice Hawaii is one of nine providers and nine hospices in the state We serve the island of Oahu and then we also serve Moldakai for about 20 years Oh, that's right 15 years and about two years ago at the request of the folks at Pulama Lanai We began a hospice program on Lanai So we're really proud of those folks as well. That's see that's extraordinary. Now. Let me take a half step back a patient like you said has been referred for hospice assessment and It's because that they are felt by their provider To probably be somewhere near the last six months of life because that's the qualifying sure credential it seems now How do you then proceed you have an individual that's been referred to you? I say this individual is This wonderful person. They've got say bad cancer. They're very sick It's you know, it's a worry. Why even bother? Why can't I just take care of them as their primary care physician or send them a somewhat rhetorical question, of course Yeah, or send them to the hospital Down, you know in the last few months of their life. Why use hospice? Well Josh, so you're not going to be able to keep them in your ER, right? That's the truth of it right sure, I mean unless somebody is really in the last hours of life Yes, and frankly most people don't want to be in your ER. It's not about your ER They're smart Most people don't want to be in any hospital when they reach the end of their life Hospice care as a philosophy was created 4045 years ago to say how do we care for people in their last months of life in Their own homes as an alternative to being in the hospital Yes So when you make that call or when when an ER physician on a while who makes that call Then we'll go and see that patient and we'll look and see what's going on with that individual So while we use the general term, would you be surprised we actually have some specific guidelines from Medicare that we have to follow And it's we have to demonstrate that there's a medical necessity for hospice care So we know how to look at conditions in the individual. So for instance As a health care provider, I would say How many of their activities of daily living do they need assistance in right the ability to bathe yourself the ability to Feed yourself the ability to make your own meals and if they need help in two or three of those Then are that's a sign that this person is kind of debilitated. We also look and see Have they lost weight? Do they have progressive infections? Are they going in and out of the ER a lot? Those kind of some of the criteria that we look at to say is this person going to be medically eligible for hospice care? Yes, certainly with a cancer patient. We might say well, what's the progression of their cancer? But with the cardiac patient, we might say what's the functionality of their heart? So our medical director in concert with you in collaboration with you it's gonna as their PCP, right? It's gonna say yeah, we think that this person has got about six months or less to live And we're gonna do that. That's our job at hospice Hawaii to make sure that we we demonstrate that Yes a question about why can't you just take care of them in the clinic or why can't they go to the hospital? So you know as well as I do that hospitals don't have the space for this They hospitals need to have those beds moving for people that are really sick And if you've got somebody that's had an immediate heart attack you want that hospital bed for them and the person who? So has got just heart disease and Needs a lot of help doesn't really necessarily need to be in the hospital and frankly It's not the best place to be right and you can't go to their homes Yeah, well that was that was where I was kind of headed so hospice is you use the word philosophy Which I really liked a lot where it's a philosophy about getting people more comfort more care that they need While in concert with being in the last six months of life based on the best expectation that an assessment can do my uncle died at home and home hospice hospice care in Philadelphia some places have hospice centers right their facilities could you distinguish a little bit about what you do and what's done in Hawaii so Hospice when it was designed was really designed to be care-based at home Actually, the the principles of hospice came over from England and it married up with our visiting nurse associations in America And hospice became a home care-based model of care So primarily what we're doing is we're sending a team of professionals to that patient's home to help that family care for them Yes in Hawaii We see care for hospice being done in patients own homes We see it done in nursing homes that so hospice Hawaii has a couple dozen nursing home contract partners Yes, so we can go to the nursing home and provide care to that because that's a place of residence for that individual right We see care being done in some foster homes and care homes Wow, and then we do have a couple of inpatient units in Hawaii that we call them hospice inpatient units Or hospice residential units hospice Hawaii has our Kailua home Which is kind of in just one of the neighborhoods in Kailua. It's been there for 20 years five bed You just walk in and it's such a place of powerful spirit. It's just the mana is terrific there And we care for people in the last months of life around the clock with our nursing staff in our Kailua home That's it's really exceptional. Okay, so I'm gathering And I've experienced some hospice care because I over the years on occasion I was asked to be supportive as a doc for patients Especially when I was a primary care physician that we're very near the end of life and helping with orders a patient Is felt to be in need right they get referred to you and they get accepted into your program in this case You've done the assessment at home then what happens next do they suddenly get I'll toss out a couple myths or questions here. They suddenly get a lot of medications to make them comfortable. Is is it meant to? Help them to the end of life. Is it meant to make them comfortable? What's really the approach that that happens at the clinical the clinical level sure So the first thing that will happen is we'll ask the patient and families to sign consents and to To sign paperwork that says Medicare can pay us because we're gonna get paid by Medicare HSA Kaiser Right medicaid so that that's what covers it then the clinical team the doctor the nurses the social workers are going to Assess this patient completely and say ask a simple question What does this family need to be successful in taking care of their loved one in their own home? Free of pain and suffering as best we can do Yes Surrounded by the loved ones that are coping well and really to to live out the rest of their life in a way that reflects their values We've been doing this thing called their bucket list. Yes, right to say how do they do the things that are important in whatever time? They have left be it a horseback riding or going to the ocean one more time So we we simply ask that question Where is it that there's distress and how can we ease that and where is it that there's opportunity for? Bringing life to a closure And closure not meaning how do we help them die rather? How do we help them live as fully as they can? Yeah, it's great work Josh It really does seem so and you know I've seen a lot of people over the years in the hospital setting where they have told me Doc, please make sure I get home to die at home or please You know, they're very afraid. Please make sure I don't suffer and it sounds like Hospice at least your philosophy of hospice Is it perfect melding of those two? Some people have said If I get put on hospice care, is it to time the time to give up hope? Is that is that an appropriate thing? I don't sound like it from what you're saying It sounds like the opposite. It is kind of a renewed hopes. It is actually it's our mission We have a very simple mission which resonates very powerfully for us. Our mission is to bring hope Yes to reduce fears and to impact lives So hope can be anything as simple as I do want to go to the ocean one more time and see the ocean I want to go to one more roundup over on Molokai Hope can be that I want to have a night where I can sleep the whole night free of pain Yeah, hope can be whatever that person wants it to be see my grandson one more time Reducing of fears is a real important part of what we do I teach our staff that our job is to essentially walk through the Valley of the shadow of death and to shine a Light in the dark places because we have walked that walk so many times So how do I with my experience shine a light so that then you're not afraid? Because we know what we can anticipate and we can really ease that distress sure and then finally when we're able to See help this family care for the loved one at home even as even though it's difficult and hard to do They always remember I kept my promise to dad I kept dad at home and we we took care of many knew that we loved him even in his last seconds of life Yeah, that's our mission. That's very very special I think a lot of the uncertainty for people is the biggest concern that they have Not just when they're sick Because people sometimes need professional help to say how sick am I can I come out of this? What support do I need but also like you said those dark corners of the matter where you just don't know Will I suffer greatly? Yeah at the end will I have access to a nurse will I have access to? a doc or Physician assistant or whomever the right fit is for the for the time And you're able to explain those things. Is that part of the initial assessment? That's all of it It's and it's an ongoing part of how we relate to this family the The the team assesses what the needs of the patient and family are we work to the family to help them address those needs And then we recognize that as time progresses those needs change and they go back and forth That's okay. We've got nurses that are on call 24 7 Right so in the middle of the night a family can call because they have a question about pain Or they can call because someone has died in the middle of night and we're gonna send a nurse to that home Yeah, to ease that family's distress and to do the things that we need to do sure It's not you know, I you've mentioned so many things that I'd like to talk about But I should point out one of them is how valuable what you offer as a service is because many many many times I think people Because of uncertainty, and it's normal and it's reasonable. Don't know should I be going to the emergency room? Should I be in the hospital? Should I be calling my doctor or nurse? Should I be? is this normal and Too often I would say people end up in the emergency department when they don't number one want to be there to When the wait could be quite long and three when they're really gonna get better care And that is something to emphasize better care because it's personalized care It's care that people are familiar with If they're in hospice and we can probably deliver most of the care That's really needed for that individual in their own home with our doctors and our nurses and our AP RNs on call Then they can get in the ER you can do a good job in the ER But we can do it in their home and then they don't have to endure the drive or the ride because that's a big burden My mom had hospice care and the doctor said to mom when she began to care a couple years ago Was we want to have hospice so that you don't have to worry about needing to come back in the hospital And mom did not have to go to the hospital She had mainland did not have to worry about going back in the hospital And that's a promise that we really try to keep now sometimes patients do and that's okay Well, we'll follow them. Well, we'll see how they're doing and we'll get them back home as fast as we can Yes, because there really is no place like home. I hear you. Well, that's I think that's kind of a Perfect place for us to pause. We're about halfway through our program but we're tackling the myths of hospice care as Ken's area who's our expert today on the show says there's no place like home Hospice care is available to people in the state of Hawaii to ease their suffering to ease their concerns and really to give them Hope in the final stages of life. We'll be back in a moment Hello, this is Martin to Spain. I want to get you get excited I'm about to say For Hawaii and beyond we're gonna broadcast on Tuesdays 5 p.m. Here on think tech Hawaii For global connections, you can find me here live every Thursday at 1 p.m We'll be talking to people around the islands or visiting the islands who are connected in various aspects of global affairs So please tune in and aloha and thanks for watching Aloha, my name is Danelia D. A. N. E. L. I. A. And I'm the other half of the duo John Newman welcome we are co-hosts of a Show called keys to success which is live on the think tech live network series weekly on Thursdays at 11 a.m We're looking forward to seeing you then Aloha Aloha, welcome back to health care in Hawaii I'm your host Josh Green senator from the big Island Conan Kau and ER physician today. I'm joined by Ken Zerry who's an excellent guy I really like him very much He laughs, but he is doing just really blessed work. He is a leader here in hospice care He's the president of hospice Hawaii has been a nurse professional for many years And in our first segment was able to explain kind of what hospice care is we've discussed some of the myths about hospice It is a place that you get care usually in your home. It is something that can restore hope It's meant for people toward the end of life in the last six months of life And we're gonna unpack that a little bit more as well but Ken said many things about what hospice is and One of the things it is is a way to alleviate fear and suffering Yeah, some of the other myths here hospice is only for the last days of life So that indeed is a myth hospice was designed to be for the last six months of life And and it's about a 40 44 year old Way of delivering care in America that think the Medicare Hospice benefit. It's about 40 years old. I'm sorry. It's about 35 years old Yes, and and it's never been designed for the last days of life The reality of it is is that we can't do the great things in three days, right? Unfortunately though, Josh what we see is that 25% of our patients die in the first seven days 30% of our patients die in the first 10 days. Is that because they get you too late because we didn't get them into the system? because people are afraid of hospice sometimes hospice means I'm giving up or It used to be that physicians would tell patients old days would say there's nothing more I can do for you. It's time for hospice and that's gosh No, we would want hospice for them right because it feels like you're being abandoned and you're not yeah The care is being the focus of your care is being shifted onto a different goal so so We don't want hospice to be the last week of life. We still struggle with that here and on the mainland Yeah, I see that a lot. I you know, I've referred many individuals to hospice care and for full disclosure Probably I don't know probably to your hospice although. I'm on the neighbor islands as a clinician, but I've seen a lot of people Come into the ER several times even though they have a like usually it's a severe lung or heart problem or cancer and I finally mentioned to them, you know, there is this service called hospice care where I think you might get better care at home Not that you can't still come in if if God forbid it's you know, you're very scared or we need to give even more services I don't know what they might be but even more services than hospice might offer at that moment and they didn't know about it right and Then they realize oh, I'm gonna have a home care team a team, you know, and that's incredible You had mentioned some people worry that they can't keep their own doctor when they go into hospice. Is that a myth? It's a myth. Okay, so we we do want people to keep their own physician So if you were a primary care physician for a patient and you've been there PCP for 10 years, right? You may have a relationship with them that you want to sustain You want to be able to be a part of this part of the reason you got into medicine was to care for people Even in the midst of their dying and so we want to work with you in much the way that you want to Some physicians really prefer to hand it off to the experts at hospice and palliative care at hospice Hawaii To just say once you handle this and let us know what I can do Others say you know what I want to stay engaged and it's our job to ask that physician How do you want to be engaged right and they and they know them very well? I remember I'll tell you this kind of funny story. I was in Ka'u on big Island providing hospice care for a patient of mine very very sweet guy who had came to me With an advanced lung cancer and he was not that old he was in his late 60s he had been a Worker in the nuclear field checking warheads actually and He had PhD his wife had a PhD and they lived in the very rural parts of the state He knew he was gonna die and I would through hospice be able to get extra services to him Right and get him medicines at home and get him oxygen at home And I just remember when this guy Right before he died he his wife made a lasagna dinner for me and the local Catholic priest actually who used to come and hang out socially and he said green. I'm dying and He was very appreciative of the hospice care and he didn't want to go into the hospital And you know, he was happy that he was able to live out his final Period of time I think he was in for about two and a half three months before he passed and he said there's a present for you in your car Don't shoot yourself and I said well, what do you do it? Turns out he had given he was thankful for the home service and he put a Kayak had his wife who was this little short person I put the kayak on my Jeep and a spear gun and He gave that to me, which I then nothing re-gifted to some nurses on my team Who are just wonderful people but the sense of comfort that he had the sense of being able to live at home To the end of his days in his own bed. Yeah, these are the kind of things you seem to be offering Everybody that needs it. Yeah, Josh So as a physician involved in the care you can say I want him to have these pain medications and I and he needs this medical equipment in the home and he needs oxygen in the home and All of those kind of typical barriers that exist to getting stuff in the home Yes, they just dissolve when hospice is in the way. I'm sorry when hospice is involved, right? We get those out of the way so we we don't need qualifying Oxygen saturations to get oxygen. We say is there distress is the short of breath great get the oxygen out there? Yes, that's simple. So we're able to to put those medications We use we use local pharmacy service that delivers medications And so first of all we're going to pay for that pain medicine. Yes So that pain medicine is costing four thousand dollars a week because it's a very expensive infusion We'll pay for it and there's no cost to the patient and family We'll do what we need to do to keep them at home and comfortable I wanted to ask you about that because it um, we've established very Clearly that hospice is a civilized and compassionate way to provide care that I I like that that I feel strongly about But then we go into these other questions You've described and I've described a lot of services that people might think. Hey, is that expensive? Is that how does that get afforded by a patient? How does the health care system afford that? I mean I've on the show many times had health economists insurers and so on We always seem to be talking about how expensive health care is how is it that you or I Can be providing so much service at home to an individual who is really ill possibly Um without the worry about cost. What is the mechanism? Well, um, so as a president I always worry about the money, but as a nonprofit, we're very generously supported by our community So that the community essentially says to me you don't worry about this. You just provide the care And I love being that kind of a relationship with our community. Yeah Medicare pays a daily amount of money. It's about an average of $195 More or less on a while who it's about that a little bit less on the neighbor islands So we have to make that work So even on the days that we don't see the patient we're still being paid And it's kind of a whole risk model for us So we may have a patient that their care costs thousands and thousands of dollars a week And we may have a patient whose care costs, you know a couple hundred dollars a week We lump it all together and we make it work. Yes I'm really happy to say we've never had to say no to somebody who didn't have insurance and couldn't pay for it That's the beauty of being a local not-for-profit. Yes So for the family though, there's no Payment for this. There's no co-pay for this. They don't have to pay this, right? You know the question is why does it work because this is how I grew up in the world of hospice This is the only reimbursement model we ever had so it works because we make it work You know, it's we know how to live within our our means in general So we do it seems like it also is a very important adjunct to the hospital based healthcare system Again, I on the show I've talked about how we don't have sometimes enough hospital beds or we don't have enough providers in the hospital Or people getting readmitted to the hospital. That's a very big issue now for Medicare, right? And it seems like hospice Care by providing care at home rather than an individual going to the hospital and all due respect to my hospital friends Who I love. I mean they do great work at Queens and Straub and HHSC But it's very expensive to spend a day in the hospital Especially if you have significant health needs could be five six seven thousand or more dollars a day This is way less Is there some kind of balance that's been struck so that some of those resources that are getting saved rather than Having someone number one didn't want to be at the hospital because they were afraid and chose not to be but two You know, if someone who is otherwise sick 85 year olds got bad cancer spends their last month in the hospital that bill could be Hundreds of thousands of dollars hundreds of thousands. So are we saving money as a health care system? By having services like hospice. We are indeed so study after study has demonstrated that for And these have been studies that have been done by Duke University, right? That says that for the last three months of care Yes, that if the patient has hospice and they're compared to the patient who does not have hospice Then on average Medicare saves 2,900 Change interesting on that individual. So when you look at a million, uh, 1.5 million people Having hospice care Do the math fast billions of dollars are saved. It's over a billion bucks every year at least Yeah, that would be three billion right there, right? Yeah, because we're able to to save that money Now there is a trade-off Um, when you have your loved one in the hospital, then there's nurses around the clock caring for that person When your loved one is at home, you're doing the work as a family member most of the time A hospice team Intermittently visits so the the nurse might visit once or twice a week the nurses aid might visit two three four five times a week But most of the time you're caring for your loved one. So that's the trade-off Yes, and we're going to support you and teach you how to do it Right and and then from time to time if we have somebody who can't do it Then we can bring them into our kailua home, right and we have a copay there. It's more expensive But we also do a lot of charity care there as well. Sure. Yeah, I mean, I think that It is a different system. No doubt. It is but Again, this is just one person's perspective who I'll be very honest. I think that that hospice care is extraordinarily important and valuable to to people and to our state Um, when you go into the hospital There's lots of chaos in mayhem and there's Flashing lights and there's beeps and there's buzzers and it sometimes even drives me baddie in the er And I think that when people are headed towards the end of life There is a special value of tranquility And that's at least it occurs to me that that's what you're offering. So I'm laughing because frankly In my family when when you would come into our family's household There's lots of chaos, but it's it's laughter and love and teasing and and honest expressions of fear and loss And and what you really do see in hospice care is that when you go into home Hopefully the family is living the way they've always lived even in the midst of this love one dying Yes, I've been to to homes where I did a death call as a patient had died I went to their home and it was one of those towers out in Hawaii Kai area right and and I way up to the top of the tower and the trade winds are coming through And there was beautiful jazz music playing and it was such a peaceful and tranquil time that this person had their transition from Life to death in that place and I've been to places where it has been wailing and gnashing of teeth And this is perfect for that family as well And so you get to see Life in its reality at that sacred sacred time and that's what we try to help families achieve Yeah, and you're achieving it in a more natural setting because whatever their home setting is It's their natural setting and frankly the hospital is always A comparatively unnatural setting foreign territory unless you're working there all the time right and Even me I feel more comfortable at home right where the kids are going to be and the dog's going to be on the bed Right or the cat's going to be saying I'm hungry feed me, right? Yeah, that's life I I think you're absolutely on it. So we have only a few minutes left in our show You've touched on many of the myths Hospice care is it for any age or is it just for the elderly hospice care is for any age We have a the state's kind of only formal pediatric hospice program where we can admit Children as young as newborns And as old as 105 years old and everything in between if God forbid a young one's going then they also could get supported home Choosing hospice means giving up all medical treatment. Obviously No, we change the focus of your medical treatment Yes, and it's not just for the end of your last days of life because some people Even graduate from hospice. That's a good thing The bad part about graduating from hospice is all those wonderful wraparound services We have to pull them back So we work hard to to be careful about that and to and to plan it right To to make sure that that transition is smooth and when we need to bring them back on we can indeed Okay, so if I were going to sum up can An important service here in the state of hawaii and in all states hospice care You guys provide it if anybody ever has any questions they call you where hospice hawaii is 924 9255 or hospice hawaii dot Org Okay, and I know we've got many viewers and listeners across the state on the neighbor islands If you call hospice hawaii and you happen to be living in hilo or kona or elsewhere We'll get you in touch. Ken will get you there to the local group. I've been very honored today to have mr. kenzari He's a hospice executive. He runs hospice hawaii has for many years He's on the critical boards across the country and he knows what's happening in this discipline If your family member is suffering or if someone is in need of extra services Toward the end of life. This is a great service to avail yourself of it's a civilized and humane way to get health care So thanks for sharing today. Thanks, josh. The pleasure to be here. You bet