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Earlier access to hospice care might improve end-of-life care for West Virginia's elders.

As the health care system shifts towards a value-based payment system, West Virginia hospices can provide value at end of life when involved at the right time. In 2013, West Virginia ranked second in emergency room use, hospital admission rate and cancer death rate and has a high incidence of chronic disease among elders when compared to other states. (1) However, West Virginia ranked 42nd in hospice utilization for Medicare beneficiaries and a third of hospice patients were admitted in the last week of life. There are opportunities to improve quality of care and reduce costs if hospice referrals are made at least a month before death. Earlier communication with patients facing a serious illness and more community education should remove barriers to access.

West Virginia hospices now care for more than 10,000 patients a year and access to hospice care has steadily improved in the past decade: more hospices are providing care in nursing facilities and seven free-standing hospice inpatient facilities have opened since 2001. Hospice care is coordinated by an interdisciplinary team. Services are physician-directed and include skilled nursing visits; psychosocial and spiritual support; assistance with personal care and support from volunteers. Telephone support and visits are available 24-7 to help patients remain at home. When inpatient care is required for symptom management or the family needs respite, hospice will coordinate this, but the majority of patients die at home or in the facility they call home (see Figure 1).

Hospice care is a choice, but if this option is never offered, patients are more likely to receive aggressive care near death and families may miss meaningful opportunities to be together. The question "Would you be surprised if this patient died within six months?" is often used by physicians to determine which patients should be referred. The newly proposed definition of serious illness is 'a condition that carries a high risk of mortality, negatively impacts quality of life and daily function, and/or is burdensome in symptoms, treatments, or caregiver stress. (2) When patients have a serious illness, clarifying individual preferences for care and treatment is essential and conversations about hospice should occur long before the final days. If the conversation is held at least a month before death, patients are twice as likely to choose hospice. (3) If the physician suggests hospice, this has been shown to be the single most important predictor of whether the patient will enroll. (4) The newly proposed physician reimbursement for end-of-life conversations may allow more time for communication about options. Myths about hospice need to be dispelled. Families are sometimes afraid that hospice care will hasten death, but research has shown that hospice care does not shorten survival and patients with heart failure and lung cancer actually live longer with hospice support. (5)

The Institute of Medicine (IOM)'s Dying in America Report recommends a hospice approach because it is patient-centered, family-oriented and evidence-based, but in the IOM report there are many testimonials from families who could not get hospice until very late. (6) Wang et al's recent study reported that 'older adults, females, adults with reported race of white, and adults residing in metropolitan areas, areas with higher income, and areas with higher education were more likely to use hospice. (7) Lower income and education in southern West Virginia may explain the lower hospice utilization, but more research would be needed to rule out other causes. The IOM suggests that the physician certification of terminal illness is a major barrier to the use of hospice and recommends policy changes. (6)

To qualify for the Medicare Hospice Benefit, patients must have a prognosis of less than six months if the illness runs its expected course. If the patient lives longer than 6 months, hospice benefits can continue when the physician continues to certify terminal illness, but if patients improve they will be discharged. Prognostication was easier in the 1980's when the majority of hospice patients had cancer. Cancer remains the most common diagnosis, but 65% of West Virginia hospice patients have non-malignant diseases, such as heart failure, COPD and dementia (see Figure 2). One of the fastest growing diagnoses is debility in the frail elder due to multiple comorbidities, but this can no longer be used as the primary terminal diagnosis. The hospice physician will document the diagnoses and eligibility in a narrative after careful review of the records. Criteria such as frequent hospitalizations, rapid decline, poor nutritional status and the presence of other co-morbid conditions are used to determine eligibility. The patient must agree to a palliative approach and to be cared for at home or in a home-like setting, such as a nursing facility.

The Center for Medicare Services has announced that 141 hospices will participate in a new Medicare Care Choices Model. Although none of the test sites are in West Virginia, this innovative model may help more patients transition to hospice while receiving curative treatments. If successfully implemented, this could help West Virginia in the future. Highmark Blue Cross Medicare Advantage Plan beneficiaries in West Virginia already have an option to receive 'Advanced Illness Services' from a contracted hospice to help with pain and symptom management and psychosocial support. This program also helps some transition to full hospice support when aggressive therapies have marginal benefit. Several West Virginia hospices provide palliative care services or transitional care to those who are not ready for hospice. Advance Practice Registered Nurses and physicians working in hospices can serve as consultants when patients do not qualify for the Medicare Hospice Benefit. This can help with pain and symptom management and goal clarification for those who want to continue curative treatment.

Prognostication can be more difficult in patients with nonmalignant diseases who may have periods of relative stability. Patients need to know that their condition may improve with hospice care and if that happens, they could be discharged and readmitted later if needed. Cancer patients may delay hospice due to the many life-prolonging treatments that are now available, but palliative care services can provide a transition. Hospice care is not all about death and dying unless accessed very late: it is about living fully for as long as that is possible before pursuing a peaceful death at home or in a home-like setting. Hospice care can also transform the loss of a loved one for family and friends and ease their bereavement.

Chris Zinn RN MSc CHPN

Executive Director of the Hospice Council of West Virginia

References

(1.) Kaiser Family Foundation. State Data: 2013. http://kff.org/statedata. Accessed August 19th, 2015.

(2.) Kelley AS: Defining "Serious Illness." J Palliat Med 2014; 17: 985

(3.) Mack JW, Cronin A, Keating NL, Taback N, Huskamp HA, Earle CC, Weeks JC: Associations between end of life discussion characteristics and care received near death: a prospective cohort study. J Clin Oncol. 2012; 30: 4387-4395

(4.) Obermeyer Z, Powers BW, Maker M, Keating NL, Cutler DM: Physician characteristics strongly predict patient enrollment in hospice. Health Aff (Millwood) 2015; 34:993-1000

(5.) Connor SR, Pyenson B, Fitch K, Spence C, Iwasaki K: Comparing hospice and nonhospice patient survival among patients who die within a three-year window. J Pain Symptom Manage 2007;33:238-246

(6.) Institute of Medicine. Dying in America Report. www.iom.edu/Reports/2014/ Dying-In-America-Improving-Quality-andHonoring-Individual-Preferences-Near-the- End-of-Life.aspx

(7.) Wang SY, Aldridge MD, Gross CP, Canavan M: Geographic variation of hospice use patterns at the end of life. J Palliat Med-not available-, ahead of print doi:10.1089/ jpm.2014.0425
Figure 1: Location of Death for WV Hospice Patients

Location of death for WV Hospice Patients

2013 WV Hospice Deaths

Place of residence           51.00%
Hospice Inpatient Facility   27.00%
Hospital                      5.00%
Nursing Facilities              17%

Note: Table made from pie chart.

Figure 2: 2013 WV Hospice Diagnoses

Cancer             35%
Heart Disease   12.50%
Dementia           12%
Lung Disease       13%
Kidney Disease      4%
Stroke/Coma         5%
Liver Disease    2.50%
Other              16%

Note: Table made from pie chart.
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Title Annotation:Special Article
Author:Zinn, Chris
Publication:West Virginia Medical Journal
Article Type:Report
Geographic Code:1U5WV
Date:Nov 1, 2015
Words:1323
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