Why Hospice Care Belongs in Nursing Homes, Part 1.

There could be more reasons for collaboration than meet the eye

In 1999, the National Hospice Foundation conducted a national survey ("Baby Boomers Fear Talking to Parents About Death," June 1999) of 4,500 Americans 45 years of age and older. Respondents expressed 10 wishes for a loved one if he or she had only six months to live:

1. Someone to be sure my wishes are enforced

2. Choice among the types of services I could receive

3. Pain control tailored to my wishes

4. Emotional support for my family and me

5. An opportunity to put my life in order

6. Spiritual support for my family and me

7. Hospice care provided no matter where I am living

8. A team of professionals, such as physicians, nurses and counselors, to care for me

9. The ability to be cared for and to die in my own home or a family member's home

10. Continuity with the same caregivers, no matter where I am staying

Having these wishes fulfilled is just as important for a nursing facility resident as it is for a patient who resides at home. Based upon our experience with the largest hospice provider serving the greater Washington, D.C., area, we believe that nursing facilities and hospice care providers can team up to create a positive impact on end-of-life care for residents. Most recently, a major federally funded study of hospice services in nursing homes validated this point. This article will explore the key findings of this comprehensive study to clarify the benefits of this relationship. A future article will outline ways to develop a nursing home/hospice collaboration.

Hospice is a concept of care in which the physical, psychological, spiritual and social needs of the terminally ill patient and his or her family are met (see "Hospice Terminology"). Hospices offer palliative care to the terminally ill, focusing on managing pain and other symptoms related to terminal illness, rather than on providing curative treatments.

The vast majority of hospice care is provided under Medicare's hospice benefit. Congress created this benefit in 1982 as a cost-effective approach to providing palliative care services to Medicare beneficiaries who are expected to live for six months or less. The process for using the hospice benefit is different, however, from that of other Medicare benefits, such as home healthcare. Each beneficiary must specifically elect the hospice benefit, in the process waiving any right to Medicare-reimbursed curative care for a terminal condition. (The beneficiary may still be treated for other medical problems under the Medicare program, such as a broken hip unrelated to the terminal condition.) Once under Medicare's hospice benefit, the Medicare beneficiary and his/her family have access to a full range of palliative care services (see "Medicare Palliative Care Services").

Use of hospice care is growing, with Medicare as the predominant payer, paying for 77% of all hospice care in the United States. Specifically:

* Of the 2.4 million Americans who died in 1999 (25% of whom died in a nursing facility), hospice care was provided to approximately 700,000 persons.

* One in five Medicare beneficiaries who died in 1998 used hospice, up dramatically from the 1 in 12 in 1992.

* Hospices do care for patients with non-cancer diagnoses. Patients with CHF, COPD, stroke and Alzheimer's disease account for 18% of Medicare hospice recipients.

Most hospices serve patients in their own homes, which might be an assisted living facility or other residential setting. Medicare beneficiaries residing in nursing facilities can only receive hospice benefits if the facility chooses to contract with a hospice provider. The actual use of Medicare's hospice benefit in nursing facilities is far less than the expected need for such care. Presently, approximately 12% of Medicare hospice beneficiaries are residents of nursing facilities--and this translates to only 1% of the entire nursing facility population. Many more nursing facility residents could benefit from Medicare's hospice benefit if it were made available to them.

While there are numerous barriers to providing hospice care in nursing faculties, two are cited frequently:

1. Nursing home staff often question the "value-added" of contracted hospice services. Some nursing home staff feel that they alone should meet the needs of dying residents, without the additional services (and costs to the Medicare program) of hospice providers.

Our view is that hospice providers specialize in providing palliative care and can be viewed as consultants to nursing facility staff in the care of dying persons. Hospice brings specialized expertise in pain management and the most appropriate interventions to support the dying resident.

2. Some nursing facilities are further discouraged from contracting with hospices because of what is generally viewed as inadequate reimbursement for the "room and board" level of care. As a result of scrutiny by the Department of Health and Human Services (HHS) Office of Inspector General (OIG), the general rule is that hospices can pay nursing facilities no more than 95% of the Medicaid rate to provide room and board for a dually eligible beneficiary, plus a small amount for supplies.

While the available reimbursement is constrained by regulations, a successful collaboration will benefit the clinical staff throughout the entire facility. For example, training in pain management techniques is made available staff-wide and bereavement support is offered to families and staff.

In order to learn more about the use of the hospice benefit in nursing facilities and outcomes of care, HHS undertook a major study of the issue. The study, entitled, Synthesis and Analysis of Medicare's Hospice Benefit, is available at http://aspe.hhs.gov/daltcp/home.htm. This study documented for the first time important benefits to the resident and the nursing facility resulting from successful collaboration between hospice providers and nursing facility providers. Specifically, the study found that residents in nursing facilities receiving hospice care, as compared to residents in nursing facilities not receiving it:

* received superior pain assessments, and when daily pain was assessed, were far more likely to be treated;

* were significantly less likely to be hospitalized;

* were less likely to experience a persistent mood disorder;

* received fewer invasive procedures, such as physical restraints, nasogastric or intravenous feedings, and intravenous and intramuscular medications; and

* experienced less dyspnea or shortness of breath.

The findings regarding reduced acute care admissions prior to death are impressive because of the quality of care and cost savings implications. The table shows the percent of patients with acute hospital stay immediately prior to death.

These findings support our view that residents in nursing facilities receiving hospice care experience a higher quality of life at the end of life.

There are many ways in which nursing facilities can provide high-quality end-of-life care that is consistent with residents' wishes. Successful approaches can include developing a facility statement regarding end-of-life philosophy; using palliative care protocols that define appropriate pain management; and documenting the goals and wishes of a resident at the end of life. Offering hospice care, when appropriate, is also a strategy that reflects a facility's commitment to these goals.

When a nursing facility enters into a contract with a hospice provider, many different types of benefits will accrue. The hospice interdisciplinary staff is available as a resource to facility staff, at the same time they are providing care to the resident. On a day-to-day basis, the hospice will:

* assist staff in managing physical symptoms that are not under control;

* provide additional staffing to help resolve complex issues requiring palliative care expertise;

* assist staff in managing the psychosocial issues of both the resident and family;

* provide specific expertise in addressing dehydration and fecal impaction--both common occurrences in the dying resident; and

* provide supporting documentation of high-quality and appropriate care for the dying resident.

Before entering into a collaboration, the nursing facility should have a clear understanding of the relevant nursing facility and hospice "conditions of participation," respective levels of care, issues surrounding the coordinated plan of care and reimbursement issues. Part 2 of this article will provide this "how to" information.

David English is the president and CEO of Hospice and Palliative Care of Metropolitan Washington, one of the nation's Largest nonprofit Medicare-certified hospice providers and the umbrella organization for Hospice of Northern Virginia, Hospice Care of D.C. and Hospice of Suburban Maryland. Jade Gong, a consultant in long-term care, serves on the board of directors of the Hospice of Northern Virginia.

                          Percent of Patients
                        with Acute Hospital Stay
                            Prior to Death.
Days before death      Hospice enrolled  Not hospice enrolled
Last 30 days of Life         12%                 41%
Last 90 days of Life         24%                 53%
Last 180 days of Life        40%                 62%

Hospice Terminology

Hospice Care: A concept of care in which the physical, psychological, spiritual and social needs of a terminally ill resident and his/her family are met.

Palliative Care: Interdisciplinary care that aims to relieve suffering and improve quality of life. Palliative care affirms life and death as normal and is available to any resident and/or family member living with or anticipating a life-threatening illness.

Medicare's Hospice Benefit: A benefit that covers medical and palliative care services for terminally ill Medicare beneficiaries who elect it. It covers all treatments for which the goal is to relieve symptoms related to the terminal illness. The criteria for Medicare's hospice benefit are Medicare Part A eligibility; a progressive, life-limiting disease; certification by referring physician and hospice medical director that the patient has less than six-months' prognosis if disease runs its normal course; and the beneficiary has elected Medicare's hospice benefit.

Advance Care Planning: The process of identifying the resident's personal perspectives and values which, in conjunction with the resident's current and anticipated medical condition, provide the basis for making end-of-life decisions.

Medicare Palliative Care Services

* Pain and symptom management

* Bereavement care

* RN, social worker, clergy member, CNA and volunteer visits

* Physical, occupational and speech therapy

* Drugs, DME and supplies related to the terminal condition

* Wound care and consulting services

* Chemotherapy and radiation therapy for palliation

* Assisting the resident and family to make such end-of-life decisions as the use of CPR and of artificial hydration and nutrition