Improving Coordination between LTC Facilities and Hospice Providers

The Centers for Medicare & Medicaid Services have issued a proposed rule to change the guidelines in how long-term care facilities arrange for hospice services with Medicare-certified providers. From McKnight’s:

The rule would help long-term care facilities working with hospice facilities have definitive guidelines detailing the roles and responsibilities each organization must execute. Current regulations allow a long-term care facility to choose to have a written agreement with one or more hospice providers for a Medicare-eligible resident who chooses to have hospice. But if the facility chooses not to contract with a Medicare-certified hospice to provide hospice services for the resident who wants it, the facility is responsible for assisting the resident in transferring to a facility that will arrange for the provision of such services.

Comments to the proposed rule may be submitted online at http://www.regulations.gov using code CMS-3140-P by December 21, 2010.

Hospice in Rural America

Hospice services in rural areas are a critical part of the health care delivery system. Over 25% of Americans live in what is considered a rural or frontier area. Almost one in three adults living in rural America is in poor to fair health, and nearly half have at least one major chronic illness.

Rural hospices have a rich history; many of them have been operating for decades, chiefly as nonprofit organizations. While rural hospices often rely on volunteers and philanthropy to deliver their services, they are often led by talented clinicians dedicated to assuring the very best of end-of-life care in their communities.

A report by the National Rural Health Association, entitled Providing Hospice and Palliative Care in Rural and Frontier Areas, showed that 39% of America's hospices define themselves as rural and 40% serve both rural and urban areas. The number of palliative care programs serving rural areas is increasing. However, reliable hospice and palliative care access for all rural and frontier areas have yet to be achieved. Accessing health care services in rural areas presents special challenges and opportunities.

A new Fact Sheet, "Hospice in Rural America," is now available in HFA's Hospice Information Center. Download this resource today.

Costs of Disenrolling from Hospice Examined

The October edition of the Journal of Clinical Oncology included a study that looked at cancer patients who disenrolled from hospice programs before death. Data from over 90,000 patients served by over 1,300 hospices from 1998 to 2002 were examined. Researchers from Mount Sinai School of Medicine found that patients who left hospice care had medical costs that were five times higher than patients who remained. In addition, they were far more likely to be admitted to a hospital, spend longer in the hospital when admitted, and more likely to visit an emergency department. From the press release:

The study did not investigate why patients disenrolled from hospice care and does not include individuals who were enrolled in a Medicare managed care organization before hospice enrollment. The researchers recommend that future studies include patient and caregiver interviews to help understand the hospice disenrollment process.

"Currently, 39 percent of decedents in this country were under the care of a hospice," continued Dr. Carlson. "Rather than focusing on how to decrease Medicare expenditures by restricting access to the Medicare Hospice Benefit, policy makers should focus on how to decrease the potential barriers to remaining enrolled with hospice until death, with an eye to both decreasing Medicare costs and potentially improving patient and family outcomes."

Atul Gawande Discusses How to Have an End-Of-Life Conversation

The video excerpt below shows Atul Gawande speaking at a program titled "How to Live When You Have to Die," and recorded at the New Yorker Festival on October 2, 2010. He discusses what things a doctor needs to discuss with a patient who has a terminal illness; the list was given to him by Dr. Susan Block, a palliative care physician at the Dana-Farber Cancer Institute. Gawande's talk expanded upon his well-received August 2010 feature in the New Yorker, "Letting Go," that urged a re-thinking of how we provide end-of-life care.

Three Studies Examine End-of-Life Care in U.S. and Canada

The Archives of Internal Medicine published three articles online October 11, 2010 that investigate end-of-life care. Two studies look at older patients with heart failure at the end of life in the United States and Canada, respectively. Another looks at the utilization of hospice services among prostate cancer patients in the United States.

The U.S. study of nearly 230,000 heart failure patients on Medicare between 2000 and 2007 looked at their use of resources in the last 6 months of life. The study authors concluded, "Among Medicare beneficiaries with heart failure, health care resource use at the end of life increased over time with higher rates of intensive care and higher costs. However, the use of hospice services also increased markedly, representing a shift in patterns of care at the end of life." Despite the increase in hospice use, nearly one-third of patients were only enrolled within seven days of death.

The study based in Canada looked at 33,144 patients from 2000 to 2006 and concluded, "Resource use in the last 6 months of life among patients with HF in Alberta is changing, with a reduction in hospitalizations, in-hospital deaths, and an increase in the use of outpatient services. However, EOL costs are substantial and continue to increase."

The third study looked at over 14,000 men dying of prostate cancer and their use of hospice. The median enrollment in a hospice program was 14 days before death. The authors concluded, "The proportion of individuals using hospice is increasing, but the timing of hospice referral remains poor. Those who enroll in hospice are less likely to receive high-intensity end-of-life care."

Special Challenges for Aging LGBT Seniors

Paula Span recently wrote on the New York Times’ New Old Age blog that aging and end-of-life challenges are greater for LGBT (lesbian, gay, bisexual, transgender) seniors than the rest of the population. LGBT older adults may run into barriers getting their basic needs met because of lack of recognition by society, service providers, and families of origin.

Hospice Foundation of America, through its grant-supported Hospice Information Center, is producing a one-hour webinar on “Aging and End-of-Life Care Challenges in the LGBT Community” that will be available in a few days. Read the Fact Sheet being produced with the webinar here. With an estimated 2 to 7 million older LGBT Americans across the country right now, this timely webinar is designed to help eldercare, hospice, and other end-of-life professionals learn more about creating a welcoming and inclusive organization for LGBT elders.

Updated Fact and Figures Show More People Received Hospice Care Last Year

A record 1.56 million people received hospice care in 2009, according to data collected by the National Hospice and Palliative Care Organization (NHPCO). Of the 2.45 million deaths in the United States last year, 41.6 percent were under the care of a hospice program, an increase from 38.8 percent the previous year. From the press release:

Findings include:

• A record 1.56 million people with a life-limiting illness received care from the nation's hospice providers.
• The average length of service remained steady at 69 days. Median length of service was also steady at 21.1 days (that means half of hospice patients received care for less than three weeks and half received care for more than three weeks).
• Routine home care accounted for 95.9 percent of patient care days.
• At 68.8 percent, the majority of hospice care was provided in the home, whether the patient's home is a private residence, nursing home, or residential facility.

Findings from the report are based on data from NHPCO's annual survey, the National Data Set, and NHPCO membership data. Secondary sources include Medicare Provider of Services certification data, Medicare hospice cost report data, state-mandated data submissions and state association membership surveys.

Celebrate World Hospice and Palliative Care Day

World Hospice and Palliative Care Day is Saturday, October 9th. The theme for World Day 2010 is "Sharing the Care".

World Hospice and Palliative Care Day is a unified day of action to celebrate and support hospice and palliative care around the world.

For more information, go to www.worldday.org

Support your local hospice and raise awareness of hospice services in your area.

Register Now for HFA's 2011 Program - Spirituality and End-of-Life Care

Spirituality and End-of-Life Care will discuss the differences and relationship between spirituality and religion, while also addressing spirituality during illness, death and grief; spiritual assessment and empowerment, and life review.

Many of the benefits of hosting this program are not new; they continue with the high standard of excellence that HFA programs are known for.

• HFA Brings the Experts to You! There's no need for expensive travel and many hours, or even days, away from the office.
• Low-cost CE Credits! Most boards have approved this program for awarding 3 credits to nurses, social workers, case managers, counselors, and more!
• Excellent for Community Outreach! Many host sites use the program as another opportunity to connect with their community. HFA will provide materials to help you promote this educational event.
  

For the first time, HFA's Living with Grief® educational program will be available only on DVD. The program can be shown beginning April 13, 2011. Continuing education credits are available for a year following the release date, but learners will enjoy discounted CEs during the first two weeks after the official release date of April 13.

All registered Site Coordinators will receive the 2011 DVD before the official release date and will be asked to not schedule a showing prior to April 13, but will have the DVD with ample time to test their equipment.

This programming change also allows you to take advantage of these additional educational opportunities, included in the low cost of registering:

• An option for your audience to speak with one of several panel members who will be available by telephone on April 13, as long as you show the program on that day.
• A bonus package that will include three webinars in late Spring/early Summer of 2011, allowing audiences to explore specific topics in more detail, including: Leaving Legacies-- Spiritual Meaning Making at the End-of-Life, including Reminiscence and Life Review; Dignity Enhancement Therapies, Living Eulogies and Other Meaning-Making Approaches; and The Dark Night of the Soul: Assisting Clients Coping with Spiritual Distress at the End-of-Life.
  

Continuing Education Credits will be available at no cost for these webinars.

Learn more about program and Register today! (Register by December 31, 2010 and save 15% off the $100 registration fee.)

October 2010 Palliative Care Grand Rounds

The October edition of Palliative Care Grand Rounds for 2010, highlighting blog posts related to hospice and palliative care, is up at the Palliative-SW blog.

Palliative-SW, started this past summer by SWHPN, the Social Work Hospice & Palliative Care Network, is hosting PCGR for the first time this month.

Check out PCGR, and we thank the folks at SWHPN for highlighting the Hospice and Caregiving blog this month.

Language Matters: The Misnomer of Full Treatment

Over at the GeriPal blog, Eric Widera writes about one thing he would change on current POLST (Physician Orders for Life-Sustaining Treatment) forms. The use of the words "full treatment."

POLST forms have been heralded by the end-of-life care community for allowing a patient's wishes for end-of-life treatment to be communicated across care settings (and have been often discussed here on the Hospice and Caregiving blog). The forms are being used with some variations by a number of states (see a map here.)

Widera writes that simply leaving off "full treatment" from the POLST form would be a better representation of what the patient is requesting, without the value-laden jargon. He gives these examples of other phrases that that do a poor job of expressing what they actually mean.

• Failure to Thrive: an expression of linguistic laziness in which the provider is too busy to express the underlying issues such as depression, weight loss, or mobility issues. In adult medicine, it is only used in describing a constellation of symptoms in the very old in the hopes that no further investigation is needed, often with stunningly great success in its implementation. Antonym: acromegaly.
• Withdrawal of Care: an expression of extreme self-doubt as a healer in which the provider of care conveys a feeling that only treatments that are focused on cure can truly be considered care. The effect: family members feel abandoned if they choose anything but invasive life prolonging interventions. Antonym: "Full Treatment”.
• Full Treatment: a phrase communicates that anything less than intubation, defibrillation, a-lines, peg tubes, and rectal tubes would constitute less than full treatment. A phrase that assumes that aggressive symptom management in home hospice from an interdisciplinary team of nurses, social workers, case managers, chaplains, and volunteers would be less rather than more treatment than in a hospital setting. A phrase that is fragment of a concept - waiting desperately for someone to add its relation to a goal (full treatment to ensure that he/she is without pain or suffering? Full treatment to ensure that he/she makes it to the birth of his granddaughter?). Antonym: Comfort care (which I won’t define as I’m not sure exactly what it is). Usage: see POLST section B

Language does matter. Hospice can be mistakenly thought of as the thing you do when there is "nothing else to be done." It's not. Hospice is the "something more" that can be done. It is the something more for the patient to be treated as a whole person, rather than the disease alone; it is the something more for the family members and loved ones who can be supported; it is the something more that allows a patient to live, each day, while they are dying.