Today’s hospice: challenging, but still rewarding

More competition, changes in the patient population, new reporting requirements and reimbursement issues are just some of the challenges facing hospice providers today.

A competitive environment

Aberdeen Place Hospice, based in Roswell, is a new provider going through the licensure process. It’s initially serving 10 metro counties. “Atlanta has more than 100 non-profit and for-profit hospice agencies, but there is room for new ones, especially in the more rural counties,” said Jo Sturm, director of operations. “There are lots of patients who aren’t being served who would benefit from hospice care.”

With Atlanta’s population growing and aging, the base of potential hospice patients is expanding. That means that large, established providers, like Visiting Nurse Health System, are continuing to add capacity and resources to meet the needs, said Mark Oshnock, president.

Competition not only gives patients choice, but it keeps the industry focused on giving the best care, said Lisa Pritchett, RN, BSN, CHPN, manager for the Cumming inpatient facility and patient care coordinator, Embracing Hospice Care. “There is no sense of complacency in this market. We can’t afford to rest on our laurels. Quality care and clinician training are our focus.”

Changes in patient population

Cancer brought most patients to hospice in the 1970s. Today, only 36.9 percent of hospice patients have cancer. Today’s hospice patients may have dementia, heart disease, lung disease and multiple medical complications.

“There’s been a big shift in the acuity level of our patients and a trend to shorter lengths of stay. The median stay for our patients now is nine days,” said Henderson. Shorter stays makes it difficult for all of the multidisciplinary caregivers (doctors, nurses, aids, social workers, chaplains, volunteers) of hospice to get to the bedside or be as fully effective in meeting the physical, social, emotional and spiritual needs of patients as they would like. With a 3-6 month window, they could do more, but doctors are often reluctant to stop treatment that could cure, and families aren’t always ready to accept that it’s time for hospice.

Patients and their families don’t always understand that hospice isn’t about hurrying death, but about giving a patient the best quality of life possible in their final days. Some even improve and are discharged. “Because we’re visiting once a week; and monitoring all medications, we see what is going on and can catch things quickly. We can reduce hospital and emergency room visits,” said Denise Lukow, RN, IBCLC, nurse manager for Aberdeen Place Hospice. “If a patient with dementia suddenly becomes combative, a family would likely take him to the hospital. If that patient was in hospice, we would check for a urinary infection or other causes. A simple antibiotic might be the answer.”

More complex cases require nurses with more skills, said Ginna McFarling, CNP, RN, a nurse practitioner with Visiting Nurse Health System. “The image of a hospice nurse as someone who just gives morphine and holds hands is very outdated. Our patients may have ventricular assist devices, pace makers or defibrillators and IV lines. We need nurses with ER, ICU, med-surge or oncology experience and we provide our nurses with continuous training.” Hospice nurses don’t have to worry about losing their skills. They’ll be using them and sharing their knowledge with the families they serve.

“A big part of hospice is educating and empowering family members, so that they can care for their loved ones and move through the grief process themselves,” said Megan Stidman, FNPC, RN, with Visiting Nurse Health System.

New reporting requirements

With Medicare and Medicaid paying for the vast majority of hospice services, any change to that system affects the entire industry. “It’s safe to say that Medicare scrutiny is at an all- time high, and that’s not necessarily a bad thing, as we search for ways to make health care more cost-effective,” said Henderson. The regulations for Medicare certified hospice providers were significantly revised in 2008.

Hospice stays are no longer open-ended. Medicare now requires a face-to-face evaluation after 180 days by a nurse practitioner or a doctor employed by the hospice agency to assess the validity of continued care.

“Hospice has always been a nursing-oriented care model, but this changes it to a more physician-oriented model. There’s much greater physician involvement, but no greater reimbursement,” said Leena Dutta, MD, medical director, Visiting Nurse Health System. With sicker patients requiring more care, and tighter regulations, “we have to allocate our resources wisely,” she said.

The Centers for Medicare and Medicaid (CMS) are no longer accepting debility or failure to thrive as primary hospice diagnoses, so hospice physicians must identify more specific diagnoses, as well as discern which medications are necessary and which should be eliminated. “Those conversations with families and sometimes hard decisions require more time and involvement and put a greater strain on budgets,” said Dutta.

A positive outcome is that physicians are at team meetings and more involved in day-to-day care, said Pritchett. “That makes the care model more collaborative and that can only benefit our patients,” she said.

As with other segments in health care, CMS is now requiring hospice agencies to track and send quality measurements electronically in order to receive full reimbursement. “Regulations have been tightened over the past five years. Keeping track of quality measures is good. We did that anyway, but it makes sure that patients are being monitored for pain and benefitting from best practices,” said Lukow. Formal reporting, however adds to hospice’s administrative costs.

Reimbursement issues

As part of the 2013 Sequestration, hospice payment rates took a 2 percent cut. At the same time CMS issued new clarification on what drugs it will cover under Medicare Part D for hospice patients. It will no longer pay separately for medications that are considered related to a patient’s hospice diagnosis.

“Unlike hospitals which are reimbursed according to the level of service provided, hospice only gets a flat per diem payment,” said Dutta. “With the level of care going up and the cost of care rising, we all need to be good stewards of our funds.”

Traditionally, chemotherapy and radiation were automatically eliminated with hospice, but if radiation will reduce a tumor and give a patient a better quality of life in his last days, then it may be deemed a necessary part of hospice care, said Pritchett. There’s often a fine line between cure and comfort and those decisions require more one-on-one assessments, more communication with payers and more education of families. As hospice care grows more complex, agencies are incurring greater medication costs.

Rewarding work despite challenges

Despite the challenges, hospice providers believe that this segment of health care will continue to grow. Research has shown it to be beneficial and cost-effective. “It’s a better alternative. It saves health care dollars overall and reduces family stress,” said Lukow. To be invited in to help patients and families write the final chapters of their lives and make it a better experience is rewarding work, she said.

“My expectation of hospice nursing was injecting morphine into a patient lying in a coma. But when I started at Visiting Nurse, I met families who turned to me for answers and support,” said McFarling. “It felt like a calling to help them move from fear, anxiety and grief into peace and acceptance. Before, I delivered babies and that was exciting, but now I feel like I’m there to honor the journey of people’s entire lives. I know I make a difference.”