Week 7- Reflections on SB 1004 stakeholder meeting and the Medicaid expansion

This week’s focus includes Medicare, Medicaid and the Affordable Care Act (ACA) as examples of public policy. This provides a prime opportunity to share my experiences participating in a stakeholder meeting for California Senate Bill 1004. As reviewed in previous posts, SB 1004 was passed in the 2014 congressional session. This bill provides a palliative service benefit for all individuals enrolled in the state Medicaid program.

This meeting was preempted by a conference call in which attendees heard from Senator Ed Hernandez who serves as the chair of the Senate Health Committee. The conference call provided stakeholders with the history and broad applicability of this bill. Stakeholders were then invited to join subject matter experts and members of the Department of Health Care Services (DHCS) for a discussion forum at the state Capitol.  While this was clearly a ‘working’ meeting, the dome of the California State Capitol looming across the street lent a heavy weight to the discussion.

The meeting was facilitated by Anastasia Dodson, the Associate Director for Policy at DHCS and Claudia Crist, Deputy Director Health Care Delivery Systems. The director of DHCS, Jennifer Kent, made opening remarks and participated in question and answer sessions. I was pleased to see that many contributors to the health care industry were also represented. The operations and executive officers of many health plans were involved as well as research experts in the field of palliative care. There were also several providers in attendance.

When questioned about the necessity of involving stakeholders in policy development the overarching theme was that this was a critical component to good policy. Stakeholders were asked to “inform” the policy. Ms. Dodson reiterated that policies should be developed in collaboration; they should build on what is currently working. This information is primarily obtained from those working in the field, or the stakeholders.

I had previously been under the impression that once a bill was passed the majority of the work was complete when in fact it appears the work is just beginning! Next steps include drafting documents for public review and holding a second stakeholder meeting to further operationalize the bill.

The passage of SB 1004 rides on the waves of the Medicaid expansion directed by the passage of the ACA in 2010. California is one of the 26 states that have chosen to implement the expansion as of 2012 (McDonough, 2014). According to Medicaid.gov (n.d.) the number of Californians enrolling in Medicaid has grown by 30% since 2013, to reach over 11 million people. The program was designed to reach as many low income individuals and families as possible. The Medicaid expansion coupled with SB 1004 lends itself to a workforce shortage, reimbursement concerns and complicated outcome measurements. The ACA has suffered a tumultuous start as has the Medicaid expansion programs. Regardless of where you land in the political realm it is clear that a cohesive, meticulous roll-out is required when discussing a benefit provided for 11 million people.

This makes the stakeholder process all the more essential. The public are welcomed to these meetings and to comment on the draft documents.  As Ms. Dodson elaborated, the policy should be fully ‘informed’ by the stakeholders to ensure its success. She remarked that we should get the policy right, right out of the gate.

References

California Department of Health Care Services (2015). Palliative Care and SB 1004 [PowerPoint Slides]. Retrieved from http://www.dhcs.ca.gov/provgovpart/Pages/Palliative-Care-Meeting-Material.aspx.

McDonough, J.E. (2014). Health system reform in the United States. International Journal of Health Policy and Management, 2(x), 1-4.

Medicaid.gov (n.d). California. Retrieved from http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/california.html

Miller, B.J. (2015). Palliative Care 101 [PowerPoint slides]. Retrieved from http://www.dhcs.ca.gov/provgovpart/Pages/Palliative-Care-Meeting-Material.aspx

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Week 6- Public Sector Influence on Healthcare Policy: Addressing Disparities

“Social injustice is killing people on a grand scale.”

(WHO, 2008, p 4)

The graphic above, from the United Nations Department of Economic and Social Affairs, should be both sad and startling. It is shocking that in our modern era the average life expectancy can vary from the 40’s to well into the 80’s.  And while global social policy is not the topic of this discussion, the graphic highlights the significant health inequity that exists worldwide. And that perhaps development of sound health policy cannot exist in isolation from good social policy.

Consider the United States. The Centers for Disease Control publish morbidity- adjusted, or healthy life expectancy, statistics for each state. This is an estimate of healthy years left for an individual aged 65. It is interesting to note that a 65 year old resident of Utah may expect greater than 15 more healthy years, while a 65 year old resident of Nevada may expect less than 13 (CDC, 2013).

There is a significant movement to eliminate these tremendous health disparities within the public sector.

I would like to highlight a few of them, particularly the work being done to decrease health disparities for the aging community.

The Commission on Social Determinants of Health (The Commission) was established in 2005 by the World Health Organization (WHO).  This Commission calls for governments worldwide to eradicate health inequities within one generation. This appeal is made to all countries, regardless of economic status or developmental position. It is a collaboration of policy on a global level. The Commission calls for societies to address health inequalities through social, economic and health care policy. The executive summary of the Commission highlights three recommendations and action steps. The first of these is to improve daily living conditions. This includes promoting health throughout the lifespan, including the process of aging (WHO, 2008). The Commission asserts that governments should make health a top priority. This may be accomplished by assuring that policies across all disciplines (economic, education, transportation, trade etc.) complement, rather than contradict, the development of health care policy.

The National Institute on Aging (NIA) has created a strategic plan to eliminate health inequality among the elderly. The NIA is specifically addressing disparity among racial and ethnic minority populations. Current population trends anticipate that the number of Hispanic Americans over the age of 65 will increase eleven-fold by the year 2050 (NIA, n.d). This poses unique opportunities for the government to direct its efforts toward specific populations. The NIA contends that to eliminate health disparities among populations research must include not only the physiologic components of aging but the economic, social, genetic and environmental processes.

These health care inequalities persist through the availability of palliative care services. Research has demonstrated persistent barriers to access and utilization of palliative care services among minority groups (Smith & Brawley, 2014). The research further indicates that African Americans are more likely to exhaust their financial resources in end of life care than their Caucasian counterparts (Martin et al, 2011). Advocates of palliative services suggest a multilevel intervention to improve inequalities through policy development. This includes well-funded research, education for providers, an increase in public awareness and improved care delivery models (Smith & Brawley, 2014). A bill has been introduced in Congress to support this multidimensional approach to end of life care. H.R. 1666 was introduced in the House of Representatives in 2013. A similar bill was introduced in the Senate in 2014. It directs leaders of the Centers for Disease Control, the Department of Health and Human Services and the Administrator for the Health Resources and Service Administration to address palliative service needs through funding, education and strategic research collaboration (Congress.gov) Although this bill died in committee it represents great promise in the public approach to palliative care.

We can see that on a grand scale there are initiatives to eliminate health care inequality for the aged. The WHO and the NIA provide a framework for successful policy change.  Congressional leaders are building policy initiatives. Next week we will discuss how federal and state reforms are affecting the aging population, addressing health care disparities and influencing the delivery of palliative care.

References

Centers for Disease Control. (2013). State specific healthy life expectancy at age 65 years. Retrieved from http://www.cdc.gov/about/cdcdirector/life-expectancy.html

Congress.gov. (n.d.) H.R. 1666- Patient centered quality care for life act. Retrieved from https://www.congress.gov/bill/113th-congress/house-bill/1666

Martin, M.Y., Pisu, M., Oster, R. A., Urmie, J. M., Schrag, D., Huskamp, H.A… Fouad, M.N. (2011). Racial variation in willingness to trade financial resources for life-prolonging cancer treatment. Cancer, 117(15), 3476-3484.

National Institute on Aging (n.d.). Health disparities strategic plan: Fiscal years 2009-2013. Retrieved from http://www.nia.nih.gov/about/health-disparities-strategic-plan-fiscal-years-2009-2013/missionvision-statement

Smith, C. and Brawley, O. (2014).Disparities in access to palliative care. Health Affairs Blog. Retrieved from http://healthaffairs.org/blog/2014/07/30/disparities-in-access-to-palliative-care/

United Nations Department of Economic and Social Affairs (UN DESA). (2011). World population prospects: The 2010 Revision.

World Health Organization (WHO). (2008). Closing the gap in a generation. Commission on Social Determinants of Health, Final Report. Retrieved from http://www.who.int/social_determinants/thecommission/finalreport/en/

Week 5- The Process of Health Care Policy Making

As I researched information on the process of policy-making I was intrigued by the cute cartoons and graphical representations of how bills become law. It seemed that perhaps this was incongruent with what we see in public… it takes a long time to pass a law. I decided to follow the path of California Senate Bill 1004 (SB 1004). This bill provides palliative care benefits for California residents receiving Medicaid insurance services. California’s Medicaid program operates under the name Medical. With the expansion of the Medical program, after the passage of the Affordable Care Act, approximately 30% of Californians are expected to participate in this insurance coverage (Gorn, 2014). Thus, although SB 1004 was created to reach a certain group of individuals a large number of residents will be affected by this legislation.

John Kingdon (2011) writes that “the critical factor that explains the prominence of an item on the agenda is not its source, but instead the climate in government or the receptivity to ideas of a given type, regardless of the source” (p. 72).  SB 1004 was introduced by Senator Ed Hernandez. Senator Hernandez is an optometrist and serves as the Chair for the Senate Committee on Health.  While Senator Hernandez is certainly a well-respected and trusted authority in the political arena, palliative care legislation had moved to the forefront of the discussion because of its proven ability to provide quality, cost-effective healthcare interventions. This bill was initiated based on the success of its predecessor AB 1745, a pediatric palliative care waiver program.

SB 1004 was introduced by Senator Hernandez for the first time on February 13, 2014, it was signed into law by Governor Brown on September 25, 2014. Let me show you what happened in between:

Date Action
2/13/2014 Introduced. Read first time. To Com. on RLS. for assignment. To print.
2/14/2014 From printer. May be acted upon on or after March 16.
2/27/2014 Referred to Com. on HEALTH.
4/2/2014 Set for hearing April 30.
4/22/2014 Set, first hearing. Hearing canceled at the request of author.
4/23/2014 Set for hearing May 7.
5/5/2014 From committee with author’s amendments. Read second time and amended. Re-referred to Com. on HEALTH.
5/7/2014 From committee: Do pass and re-refer to Com. on APPR. (Ayes 9. Noes 0. Page 3402.) (May 7). Re-referred to Com. on APPR.
5/9/2014 Set for hearing May 19.
5/19/2014 Placed on APPR. suspense file.
5/20/2014 Set for hearing May 23.
5/23/2014 Read second time. Ordered to third reading.
5/23/2014 From committee: Do pass. (Ayes 7. Noes 0. Page 3707.) (May 23).
5/27/2014 Read third time. Passed. (Ayes 34. Noes 0. Page 3599.) Ordered to the Assembly.
5/28/2014 In Assembly. Read first time. Held at Desk.
6/2/2014 Referred to Com. on HEALTH.
6/18/2014 From committee: Do pass and re-refer to Com. on APPR. (Ayes 18. Noes 0.) (June 17). Re-referred to Com. on APPR.
7/2/2014 Set, first hearing. Referred to APPR. suspense file.
8/14/2014 From committee: Do pass as amended. (Ayes 12. Noes 0.) (August 14).
8/18/2014 Read second time and amended. Ordered to second reading.
8/19/2014 Read second time. Ordered to third reading.
8/22/2014 Ordered to third reading.
8/22/2014 Read third time and amended. (Page 6343.)
8/26/2014 In Senate. Concurrence in Assembly amendments pending.
8/26/2014 Read third time. Passed. (Ayes 77. Noes 0. Page 6496.) Ordered to the Senate.
8/27/2014 Assembly amendments concurred in. (Ayes 36. Noes 0. Page 4908.) Ordered to engrossing and enrolling.
9/4/2014 Enrolled and presented to the Governor at 11 a.m.
9/25/2014 Chaptered by Secretary of State. Chapter 574, Statutes of 2014.
9/25/2014 Approved by the Governor.

(From SB-1004 Health care: Palliative Care, California Legislative Information)

**Note that each vote on this bill was unanimously in favor. There were no listed opponents to the bill. It would be interesting to follow the process on more highly contested legislation.

I learned several things while following the path of SB 1004:

-As Kingdon referenced, the timing must be right for a successful policy implementation.

Healthcare is looking for high value, low cost interventions.

-New policy does need trusted and committed supporters.

Senator Hernandez and palliative care advocates.

-A large majority of the work on policy takes place in committees.

Committee on Rules, Committee on Appropriations, Committee on Health

– Even without significant opposition, policy implementation is a lengthy process.

February 13- September 25 just in the senate and assembly.

Finally, successful policy development is not complete just by obtaining the right signatures. This is merely another step in the process. On February 23 the Department of Health Care Services will be holding a stakeholder meeting to discuss the implementation of SB 1004. The meeting is open to providers, health plans and community advocates, among others. I am looking forward to attending this meeting and sharing the discussion with you in the coming weeks.

References

California State Senator Dr. Ed Hernandez, O.D. (2015) Retrieved from http://sd22.senate.ca.gov/

Gorn, D. (2014) Medical enrollment jumps to 11.3 million. California healthline.Retrieved from http://www.californiahealthline.org/capitol-desk/2014/11/medical-jumps-  to-11-3-million

Kingdon, J. (2010). Agendas, Alternatives, and Public Policies, Update Edition (2nd ed.). London: Longman Publishing Group.

Week 4- The Players in Healthcare Policy Making: Traditional and Contemporary roles.

Within the United States, the development of healthcare policy continues to travel a long and winding road. Although the American public might assume that the president and his advisors are the primary players in public policy, the system is far more complex. John Kingdon (2011) writes that the key roles in policy development may be evaluated by their ability to set the agenda, propose alternative solutions and promote implementation.  Individuals are often not able to drive all three of these components. Kingdon (2011) continues that the president and his appointees are often the ‘agenda setters’ within policy development. These executive level roles are able to move issues up and down a continuum of importance. However, alternatives to each proposed policy may come from other areas. Elected officials might bring solutions from their constituents. Special interest groups may propose new ideas. The success and implementation of a particular policy is more often built outside of the traditional governmental agencies. In healthcare we must consider the American Medical Association, the American Nurses Association and the American Hospital Association, among others, as formidable forces in policy development.

All of the players in policy development referenced above may be considered ‘historic’ or traditional roles. And while governmental agencies generally have the final say when enacting policy, our healthcare landscape is changing. Now more than ever the individual consumer may be involved in which policy is implemented successfully in their environment. With the breadth of influence found through social media, the individual has the power to shape policy. People may now be involved in policy development from the comfort of their living room. A well-timed ‘tweet’ or Facebook post could soon flood the country with new ideas regarding health policy development. Consumer Reports is a well- respected advocate for fair and equitable solutions. They are trusted by many Americans. This organization is just one of many that have branched into the world of healthcare policy. Their affiliate Consumers Union seeks to derive policy from the research conducted for Consumer Reports. They have developed the Safe Patient Project. This work has arisen from the large amount of publicity directed at hospital acquired infections. Consider the following video:

This video has over 120,000 ‘likes’ at the time of this post- in just two months. This is just one example of many organizations outside the traditional political arena that seek to drive healthcare policy. It appears that this is the wave of the future. The healthcare industry giants have recognized that social media is a force in policy making. From local elected officials to organizations like the Centers for Disease Control, the consumer’s use of social media is having an impact on the creation and development of policy.

One organization that is a key player in the development of policy relating to palliative care is the Coalition for Compassionate Care of California (CCCC). Founded in 1998, this group seeks to advocate for patients and families suffering with serious illness. The group targets healthcare providers and state policy makers. They are currently addressing legislation related a state-wide database for POLST forms.

Although it would be easy to concede that insurance and pharmaceutical giants have the resources to set healthcare policy, the trend is toward the individual consumer. This is where policy happens. These are the people who will vote in the coming years. According to Its All Politics (Seipel, 2014), a site sponsored by National Public Radio, the upcoming generations are engaged in issues at a local level. The younger generations are particularly disheartened by ‘politics’ and choose to tackle issues from ground level rather than wait for a governmental decree. Whether we like it or not the faces of politics are changing. The nationwide Rock the Vote campaign employs Madonna and Lil Jon to lure individuals to the issues. This is the new foundation of policy making.  The healthcare industry should fully engage in creating policy that reflects the values of the consumers.

Getting the public involved in policy…

Early 1900’s                   VS                      Early 2014

Early 1900's Rock the Voteimg_3146-2886cd4839923e8ef8801bcc57bd31a92c2f85ec-s800-c85

References

Consumers Union. (2015). Health Care. Retrieved from https://consumersunion.org/topic/health-care/

Coalition for Compassionate Care of California. (2015). Mission. Retrieved from   http://coalitionccc.org/who-we-are/mission/

Kingdon, J. (2010). Agendas, Alternatives, and Public Policies, Update Edition (2nd ed.). London: Longman Publishing Group.

Seipel, A. (2014). Millennial voters are paying attention- so why don’t more vote? It’s All Politics. Retrieved from             http://www.npr.org/blogs/itsallpolitics/2014/10/08/354187589/millennial-voters-are-paying-attention-so-why-don-t-more-actually-vote

Week Three- Definitions and the Premise of Policy Making

Jacqueline Switzer (Switzer, 1994) writes that at its foundation government is called to protect and extend civil rights. It is assumed that this should be the foundation of policy development.  This calls into question some basic terminology: what are ‘civil rights’ and what is ‘policy’?

The terms ‘human rights’ and ‘civil rights’ are often used interchangeably; particular to health care, the phrase ‘human rights’ is more broadly applied. Within the United Nations framework is a Committee on Economic, Social and Cultural Rights that translates these innate human rights into more specific obligations for each country. Both the World Health Organization and the United States committee agree that these rights are universal and each state has a responsibility to uphold these rights for its citizens. The Universal Declaration of Human Rights (1948) included thirty articles detailing what ‘human rights’ consists of. These included freedom from torture, freedom from slavery, the right to live safely and without fear among many others. This is often the foundation of policy making. The World Health Organization has recently included palliative care services within its consideration of human rights (Callaway & Krueger, 2014).

In its most naïve and basic form, policy is a fulfillment of each state’s obligation to uphold human rights. Switzer (1994) asserts that policies are generally a reflection of the current cultural values and attitudes. She continues that policy making is often a predictable, logical and sequential process. We might liken this to the nursing process. Consider the following example:

Assessment– – – A review of the current situation: Our population is aging rapidly. Healthcare spending in the final years of life is tremendous and yet people still do not receive the care they are seeking. The evidence demonstrates that palliative care provides high quality and cost-effective services for those with serious illness.

Diagnosis– – – Not everyone who desires palliative care has services available: Despite the known value of palliative care services, access to this intervention is limited in small and rural communities.

Planning– – – Palliative care services should be equally available in rural communities as it is in more metropolitan areas. Local, state and federal policy should protect the right to these services for its citizens. Consider development of a policy to subsidize development of palliative care programs in rural areas. A bill is placed on the ballot and the voters chose whether this would be a valuable allocation of their tax money.

Implementation– – – State governments allot funding for development of palliative care programs in hospitals with less than 100 beds. These services are extended to the rural community.

Evaluation– – – Were the funds used appropriately? Did this program increase the value and quality of care provided? Where patients and communities satisfied with the outcome? Further recommendations and modifications to the program… Begin to assess the situation again.

This is very rudimentary example of how policy making may follow a logical sequence, similar to the nursing process. Successful policy development and implementation requires that the problem, the policy and the politics of the times align (Kingdon, 2010).

Kingdon (2010) writes that in policy development there is a ‘window’ in which policy making can be successful. It is possible that for palliative care that ‘window’ or timeframe of opportunity is now.

References

The American Nurses Association (2015). The nursing process. Retrieved from http://www.nursingworld.org/EspeciallyForYou/What-is-Nursing/Tools-You-Need/Thenursingprocess.html

Callaway, M. and Krueger, S. (2014). A global victory for palliative care. Open Society Foundations. Retrieved from http://www.opensocietyfoundations.org/voices/global-victory-palliative-care

Switzer, J. V. (1994). Disabled policymaking/disabled policy. In Disabled rights: American disability policy and the fight for equality (pp.12-29). Washington DC: Georgetown University Press.

United Nations (1948). The universal declaration of human rights. Retrieved from http://www.ohchr.org/Documents/Publications/ABCannexesen.pdf

Week Two- How do policy and ethics influence health?

How do policy and ethics influence health?

The Center to Advance Palliative Care (CAPC) (Morrison & Meier, 2011) has cited three overarching themes for public consideration with respect to advancing palliative care practice in the United States. These include:

  • Development of a specialized workforce.
  • Funding to create a strong research base.
  • Improved access to services.

Let’s look at access to services in California. CAPC has published the data related to availability of providers and services in a state by state report-card format. While many large (greater than 300 bed) hospital facilities report active participation in palliative care programs, small hospitals have not had the same success. Thus access to these services in a more rural community is poor.

State of California Report Card for Palliative Care Services

Retrieved from http://reportcard.capc.org/home/CA/RC/California/227 (24 January 2015)

The Standford School of Medicine (2015) reports that approximately 13% of the population in California reside in rural areas. The accounts for over 5 million individuals.  The assumption can be made that the majority of these individuals do not have access to palliative care services at their time of need.

Longest (2010) asserts that policy is the force behind many health determinants, this includes access to services. Public policy makes allowance for changes in the physical environment, reimbursement practices for hospitals and providers and funding for state and federal healthcare agencies. Access to services might also be limited in rural communities by the high cost of the care itself.

The American Medical Association (Levine et al., 2007) uses the term “equality of opportunity”. Do residents of rural areas have an equal opportunity to access quality care?

It is known that palliative care services provide a high quality- low cost service to individuals suffering from serious illness. Those individuals living in rural communities appear to be disadvantaged purely because of their place of residence. The question becomes ‘why is this valuable service unavailable in rural communities?’ Should these individuals have to leave their homes and families in a time of critical illness to seek better care? Is it ethical for individuals to ‘miss out’ on a valuable service because of where there home is located? Palliative care teams have successfully been implemented in approximately 80% of large hospitals in California (Morrison & Meier, 2011). These hospitals often have larger budgets for program implementation simply because of the volume of patients they service. Are additional funds needed to assist in the implementation of palliative services in the rural community? Should public policy be developed to ensure “equality of opportunity”?

Perhaps local, state and federal government could consider subsidizing the development of palliative care programs in rural areas. Considering the financial savings that might be afforded through long-term use of these services, the cost-to-benefit ratio is quite good.

References

Levine, M. A., Wynia,M. K., Schyve, P. M., Teagarden, J. R., Fleming, D. A., Donohue, S.K. … Emanuel, E. J. (2007) Improving access to health care: A consensus ethical framework to guide proposals for reform. Hastings Center Report, 37(5), 14-19.

Longest, B.B. Jr. (2010).  Health policymaking in the United States (5th ed.). Chicago, IL:  Health Administration Press.

Morrison, R. S. and Meier, D. E. (2011). America’s care of serious illness: A state by state report card on      access to palliative care in our nation’s hospitals. Center to Advance Palliative Care. Retrieved    from http://reportcard.capc.org/

Standford School of Medicine, eCampus Rural Health. (2015). Rural California: Demographics. Retrieved    from http://ruralhealth.stanford.edu/health-pros/factsheets/index.html

An Introduction

The rapid growth of the American elderly population necessitates that special attention is paid to the needs of these individuals. It is estimated that by the year 2030, 20% of our population will be over the age of 65 (AoA, 2013). Many of these individuals suffer from multiple chronic illnesses and thus utilize healthcare resources frequently. According to the Dartmouth Atlas of Health Care (2015), 90 million Americans suffer from at least one chronic illness. Although this imposes a tremendous financial burden on our system across the board, the brunt of the cost to treat these illnesses comes in the last two years of life (Dartmouth Atlas, 2015).

Despite the outpouring of dollars on these conditions many patients and their families have reported that their care was fragmented, confusing and expensive. Palliative care provides a solution to many of these frustrations. Palliative care offers a team-based approach to treating serious illness. Although closely aligned with hospice services, palliative care is not ‘prognosis-based’. The service is appropriate at any age or stage of disease. It is principally designed to treat symptoms, alleviate pain and the stress of chronic illness.

Fortunately, palliative care is a hot trend in the public arena (Center to Advance Palliative Care, 2014). Specifically, these services are becoming more widely available in large hospitals.

The concern is that these services might not be readily available or widely recognized in smaller community hospitals or outpatient settings. Recommendations have been made that public policy should emphasize increasing the capacity to provide palliative care services, reinforcing the scientific basis for this care and increasing the number of palliative care providers (Center to Advance Palliative Care, 2014).

My personal experience has been encountering a knowledge deficit with respect to palliative care services as well as a deficiency in available resources. This blog will examine current policy and advocacy initiatives directed at improving access to palliative care services on both a federal level and in the state of California.

References

Administration on Aging (AoA). (2013). Aging statistics. Retrieved from      http://www.aoa.gov/Aging_Statistics/

Center to Advance Palliative Care. (2014). Overview for policy makers. Retrieved from           https://www.capc.org/policymakers/overview/

Dartmouth Atlas of Health Care. (2015). Care of chronic illness in the last two years of life.         Retrieved from http://www.dartmouthatlas.org/data/topic/topic.aspx?cat=1