Updated: Apr 3, 2019
November is National Hospice and Palliative Care Month, and the 2018 theme of “My Hospice” offers an important opportunity to examine the state of hospice in the U.S., and the challenges and opportunities that hospices face amid a national movement to expand palliative care.
The emergence of community-based palliative care models that nobly strive to make palliative care accessible further upstream has had an impact on hospice in several ways, experts say. Many hospices are evolving or expanding to add palliative care services that allow them to effectively support patients early in the course of serious illness, and through the end of life.
Still, some hospice leaders fear the rapid growth may lead to uneven quality in the services being delivered. In addition, some clinicians opt to refer only to palliative care, rather than hospice, to delay or avoid having to tell a patient that his or her condition is terminal. That can shift resources away from hospice, and leave patients without the full level of support they need as end of life approaches.
Physician Training is Key
Nonprofit, community-based hospices may be especially vulnerable in the changing marketplace when referrals drop, says Samira Beckwith, CEO of Hope Healthcare in Fort Myers, Fla.
“I’ve had several doctors tell me recently, ‘Now I don’t have to refer my patients to hospice. They get just enough services from these other providers and I never have to have the conversation (about a terminal prognosis),” says Beckwith. “Patients and families don’t know what they’re not getting. (They’re) happy to just get something.” She says Hope has already seen a decline in referrals and length of stay that she attributes to this type of poor communication and a lack of understanding about what palliative care and hospice provide.
Better education is the answer, other experts say, including training that helps clinicians appreciate the specialized skills and approaches required by palliative care, understand the differences between palliative care and hospice and when to refer to each, and how to communicate difficult news to patients and families.
“Palliative care and hospice each provide vital services that work hand-in-hand to support patients through every stage of serious illness, from diagnosis until death,” said Jennifer Moore Ballentine, Executive Director of the CSU Institute for Palliative Care, which offers continuing education for healthcare professionals seeking high-quality training in palliative care. “The really important thing is meeting patients and families where they are and delivering the level of care that most effectively addresses their physical, psychosocial, and spiritual suffering. That may be palliative care, or it may be hospice. At best, it’s palliative care now, with a timely transition to hospice when curative care is no longer effective or desired.”
Problems with Medicare
Another barrier facing hospices today centers around Medicare rules and regulations that some hospice professionals say unfairly penalize or withhold payment at a time when more and more Americans need end-of-life support and services.
According to the National Hospice and Palliative Care Organization’s most recent “Facts and Figures on Hospice,” a total of 4,382 Medicare-certified hospices cared for 1.43 million Medicare beneficiaries in 2016—representing nearly half of all Medicare decedents that year. That’s a level of penetration that the founders of the hospice movement in the 1970s could only have dreamt about.
Meanwhile, average length of stay on the hospice benefit has declined slightly in recent years, from 73 days in 2013 to 71 days in 2016. And nearly three in 10 hospice patients receive services for one week or less—the final seven days leading up to their deaths.
Even so, Medicare Administrative Contractors and an alphab