life and decrease the number of readmissions and the overall cost of care. Examples of Policy Levers: • Expand or fund the use of evidence-based care-transition models through demonstration programs. • Setting targeted readmission reduction goal for skilled nursing facilities. • Eliminating Medicare’s three-day prior hospitalization requirement for coverage of post-acute skilled nursing facility care. • Counting all days in the hospital including those spent in observation status towards the Medicare three-day requirement. Active Organizations: American Healthcare Association, Center for Medicare Advocacy, American Medical Association Addressing the Health Needs of an Aging America | 24 Evidence Searching for Policy Levers Since 2010, biomedical and health services research has produced a wealth of potentially effective policy interventions that have received less attention from stakeholders and policymakers. In many cases, the staggering number of research studies, researchers’ ineffective dissemination of findings to policymakers, and policymakers’ limited capacity to routinely scan the evidence base, have combined to make it difficult to scale these interventions into actionable policy recommendations. The Stern Center research team found this pattern to be particularly evident in the fields of patient self-care, as well as palliative and end-of-life care. In these areas especially, researchers, stakeholders, and policymakers should collaborate to identify ways that public policy can better apply the insights of effective interventions. Supporting Palliative and End-of-Life Care Palliative care is a holistic approach to care that focuses on relieving symptoms and easing stress for patients with serious illness. Hospice care is similar to palliative medicine, in that it focuses on managing the symptoms and reducing the suffering of a patient at the end-of-life. Hospice care can take place either in an individual’s home or in an institutional setting. About 70 percent of Americans would prefer to die at home,10 but only about 25 percent actually die at home.11 Approximately one-third of Medicare spending is on patients in their last two years of life. Conversations about preferences for end-of-life care are difficult and many Americans do not have an advanced directive expressing their preferences for care at the end-of-life. As a result, many patients at the end-of-life receive costly and painful healthcare interventions that do not truly respond to individual needs or wishes. Focus Area: Palliative Care A few studies have revealed that integrating palliative care into usual care settings can result in improved health outcomes, patient satisfaction, and cost. One pilot study of integrating on-site palliative care advanced practice nurses in the community oncology setting found significant decreases in hospitalization and mortality. A nationwide study also revealedthat hospice-provided palliative care results in lower costs for terminal geriatric hepatocellular carcinoma patients. There is a small but emerging evidence-base for the effective deployment of palliative care programs in nursing home and community settings. Remaining policy challenges include misaligned payment incentives and a lack of insurer coverage and reimbursement for palliative care, the failure of major quality metrics to include palliative care, financial barriers to third party payments for such care, and statelevel policies that create barriers to essential pain medications in end-of-life settings. 9 J. Cloud, A Kinder, Gentler Death, Time, September 18, 2000, available from: 10National Center for Health Statistics, Health, United States, 2010, With Special Feature on Death and Dying, available from: http://www.cdc.gov/nchs/data/hus/hus10.pdf Addressing the Health Needs of an Aging America | 25 Focus Area: Advance Care Planning Patients often lose their capacity or ability to communicate their preferences on end-oflife care goals. Systematic reviews have suggested that written directives or nonresuscitate orders hold promise for addressing this problem and improving the quality of end-of-life care. Policies that support patients’ preferences, however, will likely encompass more than written directives alone, however, and further research is