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Chung K, Hughes MC, Koushkaki SR, Risberg MR, Alcantara M, Amico JM. Hospice Capacity to Provide General Inpatient Care: Emergency Department Utilization and Live Discharge Among Cancer Patients. Am J Hosp Palliat Care 2024; 41:63-72. [PMID: 37088870 DOI: 10.1177/10499091231170598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023] Open
Abstract
General inpatient (GIP) hospice care is used only minimally for hospice patients, and more than a quarter of Medicare hospice facilities do not provide GIP care. To determine the impact of hospices' capacity to provide on emergency department use during hospice enrollment and live discharge from hospice, we used Surveillance, Epidemiology, and End Results-Medicare linked data and CMS Provider of Services data from 2007 to 2013 from ten states and two metropolitan regions. Grouping hospices into three GIP care provision categories: 1) no-GIP; 2) GIP-contract; and 3) GIP-IHF where hospices directly provide GIP care in their own inpatient hospice facility (IHF), we built a multilevel logistic model that accounted for unobserved hospice characteristics. Nearly 9% of the study sample received GIP care, of which 82% received such care in the last week of discharge. GIP-IHF hospices had lower live discharge rates than no-GIP hospices (AOR: .61; 95% CI: .47-.79; P < .001) and GIP-contract hospices (AOR: .84; 95% CI: .70-1.00; P < .05). Similarly, GIP-contract hospices were also associated with a decreased risk of live discharge, compared to no-GIP hospices (AOR: .76; CI: .62-.92; P < .05). There was no difference in emergency department use between no-GIP hospices and hospices with such capacity. Our results suggest that hospices capable of providing GIP care have lower live discharge rates than their counterparts. However, the fact that GIP care tends to be provided too close to death limits its effectiveness in preventing avoidable emergency department use.
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Affiliation(s)
- Kyusuk Chung
- Department of Health Sciences, California State University Northridge, Northridge, CA, USA
| | - M Courtney Hughes
- Northern Illinois University, School of Health Studies, DeKalb, IL, USA
| | | | - Mia Richelle Risberg
- Department of Health Sciences, California State University Northridge, Northridge, CA, USA
| | - Michelle Alcantara
- Department of Health Sciences, California State University Northridge, Northridge, CA, USA
| | - Jennifer M Amico
- Kaiser Foundation Hospitals, Medical Group Administration, Woodland Hills, CA, USA
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Wallace CL, Wladkowski SP. Improving Policy and Practices of Hospice Live Discharge: A Historical Exploration of the Medicare Hospice Benefit. J Aging Soc Policy 2023:1-16. [PMID: 38037716 PMCID: PMC11143077 DOI: 10.1080/08959420.2023.2286164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 10/13/2023] [Indexed: 12/02/2023]
Abstract
Hospice care in the US is heavily regulated to ensure access to the Medicare Hospice Benefit (MHB) for individuals with serious illness. Policy changes to the MHB, many of which intended to minimize potential fraud (e.g. focused medical reviews; documentation requirements for certifications, recertifications, and discharges; requirements of physician narratives and face-to-face visits), directly impact current hospice discharge practices and experiences. When patients revoke hospice or are unable to be recertified due to a stabilized condition, they lose access to the holistic philosophy of care and experience additional stressors with increased potential for burdensome transitions. Patients with chronic conditions, such as Alzheimer's disease or related dementias, Chronic Obstructive Pulmonary Disease, or heart failure are more likely to have longer length of stays and are more often discharged alive from hospice. Few policy changes have been made to account for growing incidents of patients dying of chronic illness though the policy was originally created primarily for cancer patients, reflecting a time when most patients were dying of cancer. This manuscript describes the uniquely American phenomenon of a hospice live discharge, reviews relevant and historical policies, and provides recommendations for future research, policy, and practice to better support patients and families during this critical healthcare transition.
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Affiliation(s)
- Cara L Wallace
- Trudy Busch Valentine School of Nursing, Saint Louis University, Saint Louis, MO, USA
| | - Stephanie P Wladkowski
- Social Work, Health & Human Services, Bowling Green State University, Bowling Green, Ohio, USA
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Wladkowski SP, Enguídanos S. Alzheimer's Disease and Related Dementias: Caregiver Perspectives on Hospice Re-Enrollment Following a Hospice Live Discharge. J Palliat Med 2023; 26:1374-1379. [PMID: 37155702 DOI: 10.1089/jpm.2023.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Background: The number of individuals dying of Alzheimer's disease and related dementias (ADRDs) is steadily increasing and they represent the largest group of hospice enrollees. In 2020, 15.4% of hospice patients across the United States were discharged alive from hospice care, with 5.6% decertified due to being "no longer terminally ill." A live discharge from hospice care can disrupt care continuity, increase hospitalizations and emergency room visits, and reduce the quality of life for patients and families. Furthermore, this discontinuity may impede re-enrollment into hospice services and receipt of community bereavement services. Objectives: The aim of this study is to explore the perspectives of caregivers of adults with ADRDs around hospice re-enrollment following a live discharge from hospice. Design: We conducted semistructured interviews of caregivers of adults with ADRDs who experienced a live discharge from hospice (n = 24). Thematic analysis was used to analyze data. Results: Three-quarters of participants (n = 16) would consider re-enrolling their loved one in hospice. However, some believed they would have to wait for a medical crisis (n = 6) to re-enroll, while others (n = 10) questioned the appropriateness of hospice for patients with ADRDs if they cannot remain in hospice care until death. Conclusions: A live discharge for ADRD patients impacts caregivers' decisions on whether they will choose to re-enroll a patient who has been discharged alive from hospice. Further research and support of caregivers through the discharge process are necessary to ensure that patients and their caregivers remain connected to hospice agencies postdischarge.
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Affiliation(s)
| | - Susan Enguídanos
- USC Leonard Davis School of Gerontology, Los Angeles, California, USA
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Hunt LJ, Gan S, Smith AK, Aldridge MD, Boscardin WJ, Harrison KL, James JE, Lee AK, Yaffe K. Hospice Quality, Race, and Disenrollment in Hospice Enrollees With Dementia. J Palliat Med 2023; 26:1100-1108. [PMID: 37010377 PMCID: PMC10440673 DOI: 10.1089/jpm.2023.0011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 04/04/2023] Open
Abstract
Background: Racial and ethnic minoritized people with dementia (PWD) are at high risk of disenrollment from hospice, yet little is known about the relationship between hospice quality and racial disparities in disenrollment among PWD. Objective: To assess the association between race and disenrollment between and within hospice quality categories in PWD. Design/Setting/Subjects: Retrospective cohort study of 100% Medicare beneficiaries 65+ enrolled in hospice with a principal diagnosis of dementia, July 2012-December 2017. Race and ethnicity (White/Black/Hispanic/Asian and Pacific Islander [AAPI]) was assessed with the Research Triangle Institute (RTI) algorithm. Hospice quality was assessed with the publicly-available Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey item on overall hospice rating, including a category for hospices exempt from public reporting (unrated). Results: The sample included 673,102 PWD (mean age 86, 66% female, 85% White, 7.3% Black, 6.3% Hispanic, 1.6% AAPI) enrolled in 4371 hospices nationwide. Likelihood of disenrollment was higher in hospices in the lowest quartile of quality ratings (vs. highest quartile) for both White (adjusted odds ratio [AOR] 1.12 [95% confidence interval 1.06-1.19]) and minoritized PWD (AOR range 1.2-1.3) and was substantially higher in unrated hospices (AOR range 1.8-2.0). Within both low- and high-quality hospices, minoritized PWD were more likely to be disenrolled compared with White PWD (AOR range 1.18-1.45). Conclusions: Hospice quality predicts disenrollment, but does not fully explain disparities in disenrollment for minoritized PWD. Efforts to improve racial equity in hospice should focus both on increasing equity in access to high-quality hospices and improving care for racial minoritized PWD in all hospices.
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Affiliation(s)
- Lauren J. Hunt
- Department of Physiological Nursing, University of California, San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
| | - Siqi Gan
- Northern California Institute for Research and Education, San Francisco, California, USA
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Alexander K. Smith
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Melissa D. Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - W. John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Krista L. Harrison
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer E. James
- Institute for Health and Aging, University of California, San Francisco, San Francisco, California, USA
| | - Alexandra K. Lee
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Kristine Yaffe
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
- Department of Psychiatry, University of California, San Francisco, San Francisco, California, USA
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Zhang Y, Shao H, Zhang M, Li J. Healthcare Utilization and Mortality After Hospice Live Discharge Among Medicare Patients With and Without Alzheimer's Disease and Related Dementias. J Gen Intern Med 2023; 38:2272-2278. [PMID: 36650330 PMCID: PMC10406979 DOI: 10.1007/s11606-023-08031-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/30/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Little is known about post-discharge outcomes among patients who were discharged alive from hospice. OBJECTIVE To compare healthcare utilization and mortality after hospice live discharge among Medicare patients with and without Alzheimer's disease and related dementias (ADRD). DESIGN Retrospective cohort study using Medicare claims data of a 20% random sample of Medicare fee-for-service (FFS) patients. PARTICIPANTS A total of 153,696 Medicare FFS patients experienced live discharge from hospice between 2014 and 2019. MEASURES Two types of burdensome transition (type 1: live discharge from hospice followed by hospitalization and subsequent hospice readmission; type 2: live discharge from hospice followed by hospitalization with the patient deceased in the hospital), acute care utilization, hospice readmission, and mortality in the 30 and 180 days after live discharge and between live discharge and death. RESULTS Compared with non-ADRD patients, ADRD patients were less likely to experience burdensome transitions (type 1: adjusted odds ratio [aOR], 0.94; 95% confidence interval [CI], 0.90-0.98; type 2: aOR, 0.70; 95% CI, 0.65-0.75), more likely to have ED visits (aOR, 1.05; 95% CI, 1.01-1.09), less likely to die (aOR, 0.71; 95% CI, 0.69-0.73), and less likely to be readmitted to hospice (aOR, 0.86; 95% CI, 0.84-0.89) 30 days after live discharge. Results of 180-day post-discharge outcomes were largely consistent with results of 30-day outcomes. Among patients who died as of December 31, 2019, ADRD patients were less likely to be hospitalized (aOR, 0.88; 95% CI, 0.85-0.92) and more likely to be readmitted to hospice (aOR, 1.12; 95% CI, 1.08-1.16) between live discharge and death. Significant racial/ethnicity disparities in acute care utilization and mortality after live discharge existed in both ADRD and non-ADRD groups. CONCLUSION ADRD patients had lower mortality, a longer survival time, a lower rate of hospitalization, and an initially lower but gradually increasing rate of hospice readmission than non-ADRD patients after hospice live discharge. These different trajectories warrant further investigation of the eligibility of their initial hospice enrollment. Black patients had significantly worse outcomes after hospice live discharge compared with White patients.
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Affiliation(s)
- Yongkang Zhang
- Department of Population Health Sciences, Weill Medical College of Cornell University, 402 East 67th Street, New York, NY, 10065, USA.
| | - Hui Shao
- Center for Drug Evaluation and Safety, Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Manyao Zhang
- Department of Population Health Sciences, Weill Medical College of Cornell University, 402 East 67th Street, New York, NY, 10065, USA
| | - Jing Li
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, WA, USA
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Gianattasio KZ, Power MC, Lupu D, Prather C, Moghtaderi A. Medicare Hospice Policy Changes and Beneficiaries' Rate of Live Discharge and Length-of-Stay. J Pain Symptom Manage 2023; 65:162-172. [PMID: 36526252 PMCID: PMC9928899 DOI: 10.1016/j.jpainsymman.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/18/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022]
Abstract
CONTEXT The 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act systemized audits of long hospice stays, and the 2016 two-tier payment system decreased daily reimbursement rates after 60 days of enrollment. Both aimed to reduce long stays. OBJECTIVES Examine how live discharge rates and length of stay changed in relation to the policies. METHODS We computed monthly hospice-level percent live discharges and length of stay using 2008-2019 Medicare hospice claims. We compared prepolicies trends and postpolicies trends overall, within Alzheimer's disease and related dementias (ADRD) patients, within lung cancer patients, and stratified by hospice ownership (for-profit vs. nonprofit/government-owned). RESULTS We included 10,539,912 and 10,453,025 episodes of care in the analytical samples for live discharge and length of stay analyses, respectively. Overall percent live discharges declined during the prepolicies period (-0.13 percentage-points per month, 95% CI: -0.14, -0.12), but exhibited no significant change during the postpolicies period. Trends were driven primarily by for-profits, with similar patterns within ADRD and lung cancer patients. Overall, mean length of stay increased over time, with greater rate of increase during the postpolicies period (0.41 days per month, 95% CI: 0.39, 0.42) compared to the prepolicies period (0.12 days per month, 95% CI: 0.10, 0.14). Length-of-stay increased faster among ADRD patients, but changed minimally for lung cancer patients. CONCLUSION Live discharge rates declined significantly during the prepolicies period, but plateaued after implementation of the policies, driven by changes in for-profits. However, the policies did not reduce length of stay, which increased at faster rates, suggesting that postpolicies excess live discharges were not restricted to long-stay patients.
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Affiliation(s)
- Kan Z Gianattasio
- Department of Health Policy and Management (K.Z.G., A.M.), George Washington University Milken Institute School of Public Health, Washington, DC; Department of Health Care Evaluation (K.Z.G.), NORC at the University of Chicago, Bethesda, Maryland.
| | - Melinda C Power
- Department of Epidemiology (M.C.P.), George Washington University Milken Institute School of Public Health, Washington, DC
| | - Dale Lupu
- George Washington University School of Nursing (D.L.), Washington, DC
| | - Christina Prather
- Division of Geriatrics and Palliative Medicine (C.P.), George Washington School of Medicine and Health Sciences, Washington, DC
| | - Ali Moghtaderi
- Department of Health Policy and Management (K.Z.G., A.M.), George Washington University Milken Institute School of Public Health, Washington, DC
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Hunt LJ, Gan S, Boscardin WJ, Yaffe K, Ritchie CS, Aldridge MD, Smith AK. A national study of disenrollment from hospice among people with dementia. J Am Geriatr Soc 2022; 70:2858-2870. [PMID: 35670444 PMCID: PMC9588572 DOI: 10.1111/jgs.17912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND People with dementia (PWD) are at high risk for hospice disenrollment, yet little is known about patterns of disenrollment among the growing number of hospice enrollees with dementia. DESIGN Retrospective, observational cohort study of 100% Medicare beneficiaries with dementia aged 65 and older enrolled in the Medicare Hospice Benefit between July 2012 and December 2017. Outcome measures included hospice-initiated disenrollment for patients whose rate of decline ceased to meet the Medicare hospice eligibility guideline of "expected death within 6 months" (extended prognosis) and patient-initiated disenrollment (revocation). Hospice, regional, and patient risk factors and variation were assessed with multilevel mixed-effects logistic regression models. RESULTS Among 867,695 hospice enrollees with dementia, 70,945 (8.2%) were disenrolled due to extended prognosis and 43,133 (5.0%) revoked within 1-year of their index admission. There was substantial variation in hospice provider disenrollment due to extended prognosis (10th-90th percentile 4.5%-14.6%, adjusted median odds ratio (MOR) 1.86, 95% confidence interval (CI) 1.82, 1.91) and revocation (10th-90th percentile 2.5%-10.1%, MOR 2.09, 95% CI 2.03, 2.14). Among hospital referral regions (HRR), there was more variation in revocation (10th-90th percentile 3.5%-7.6%, MOR 1.4, 95% CI 1.34, 1.47) than extended prognosis (10th-90th percentile 7.0%-9.5%, MOR 1.23, 95% CI 1.18, 1.27), with much higher revocation rates noted in HRRs located in the Southeast and Southern California. A number of patient and hospice characteristics were associated with higher odds of both types of disenrollment (younger age, female sex, minoritized race and ethnicity, Medicaid dual eligibility, Medicare Part C enrollment), while some were associated with revocation only (more comorbidities, newer, smaller, and for-profit hospices). CONCLUSIONS In this nationally representative study of hospice enrollees with dementia, hospice disenrollment varied by type of hospice, geographic region, and patient characteristics including age, sex, race, and ethnicity. These findings raise important questions about whether and how the Medicare Hospice Benefit could be adapted to reduce disparities and better support PWD.
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Affiliation(s)
- Lauren J. Hunt
- Department of Physiological Nursing, University of California, San Francisco
- Global Brain Health Institute, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Siqi Gan
- Northern California Institute for Research and Education, San Francisco, CA
| | - W. John Boscardin
- Division of Geriatrics, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Kristine Yaffe
- Department of Psychiatry, University of California, San Francisco
- Department of Neurology, University of California, San Francisco
| | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, MA
- Mongan Institute for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA
| | - Melissa D. Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, NY, NY
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Ankuda CK, Moreno J, Teno JM, Aldridge MD. Transitions from Home Health to Hospice: The Role of Agency Affiliation. J Palliat Med 2022; 25:873-879. [PMID: 34964665 PMCID: PMC9360178 DOI: 10.1089/jpm.2021.0390] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 01/31/2023] Open
Abstract
Background: Home health agencies (HHAs) are often affiliated with hospice agencies and commonly care for patients with serious illness within the Medicare program. HHAs may therefore provide a potential opportunity to facilitate timely referral to hospice when appropriate. Objectives: To determine if patients cared for by HHAs affiliated with hospice agencies experience differential hospice use and care patterns. Design: Nationally representative cohort study. Setting/Subjects: 1431 decedents in the 2002 to 2017 Medicare Current Beneficiary Survey who received home health in the last year of life in the United States. Measurements: Primary independent variable was HHA hospice affiliation. Primary dependent variable was hospice enrollment; secondary dependent variables were hospice live discharge and length of stay. Results: The 27.3% of decedents cared for by a HHA affiliated with a hospice had greater education levels and wealth and were more likely to live in the Midwest and Northeast. In adjusted models, HHA-hospice affiliated decedents had greater odds of enrolling in hospice compared to those cared for by HHAs not affiliated with a hospice, corresponding to a hospice enrollment rate of 51.0% for those cared for by HHAs affiliated with hospices versus 39.7% for HHAs not affiliated (p = 0.004). There were no differences in hospice length of stay or live discharge rate by hospice affiliation. Conclusion: Medicare beneficiaries cared for by HHAs affiliated with hospices are more likely to enroll in hospice at the end of life. This has implications for improving hospice access through home health incentives and models of care.
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Affiliation(s)
- Claire K. Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jaison Moreno
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joan M. Teno
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Melissa D. Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatric Research Education and Clinical Center (GRECC), James J Peters Bronx Veterans Affairs Medical Center, Bronx, New York, USA
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Cross SH, Ramkalawan JR, Ring JF, Boucher NA. “That little bit of time”: Transition-to-Hospice Perspectives from Hospice Staff and Bereaved Family. Innov Aging 2022; 6:igab057. [PMID: 35155835 PMCID: PMC8827325 DOI: 10.1093/geroni/igab057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Objectives Many patients lack understanding of hospice services and their preparation for the transition to hospice at home may be insufficient. This study explored how hospice admissions staff and caregivers of hospice patients perceive the hospice admission process and the transition to hospice at home. Research Design and Methods We conducted in-depth, semistructured interviews with 2 subgroups: hospice admissions staff (n = 15) and bereaved caregivers of former hospice patients (n = 20). We performed a 3-coder descriptive content analysis. Results There were 4 overall themes: (a) issues relating to the referring/prehospice provider, (b) issues relating to hospital discharge/care transition home, (c) issues relating to the first touch of hospice, and (d) the impact of coronavirus disease 2019 (COVID-19) on hospice admissions. Patients are often referred to hospice without clear prognostic understanding, at times placing staff in the uncomfortable position of breaking difficult news. Stigma may make patients and families fearful of enrolling in hospice, and misconceptions about hospice are common. Caregivers emphasize the need for increased attention to their emotional needs. Staff revealed the emotional challenges they experience conducting admissions. Both staff and caregivers indicate that the transition to hospice is often emotionally and logistically burdensome, especially when discharging home from the hospital. Both subgroups report insufficient caregiver preparation for taking care of a dying patient at home, particularly regarding medication management. COVID-19 created challenges yet prompted innovative changes to hospice admission processes. Discussion and Implications Findings demonstrate a need to improve the hospice admissions process, better supporting terminally ill patients and their families.
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Affiliation(s)
- Sarah H Cross
- Sanford School of Public Policy, Duke University, Durham, NC, USA
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
| | - Janel R Ramkalawan
- Sanford School of Public Policy, Duke University, Durham, NC, USA
- School of Medicine, Duke University, Durham, NC, USA
| | | | - Nathan A Boucher
- Sanford School of Public Policy, Duke University, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health System HSR&D, Durham, NC, USA
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Clayton MF, Utz R, Iacob E, Towsley GL, Eaton J, Fuhrmann HJ, Dassel K, Caserta M, Supiano K. Live hospice discharge: Experiences of families, and hospice staff. PATIENT EDUCATION AND COUNSELING 2021; 104:2054-2059. [PMID: 33454147 PMCID: PMC8726000 DOI: 10.1016/j.pec.2021.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 12/29/2020] [Accepted: 01/02/2021] [Indexed: 05/14/2023]
Abstract
OBJECTIVE To examine live hospice discharge prevalence and experiences of families and hospice staff. Hospice eligibility is based on a cancer model where decline and death are predicable. Decline is less predictable for diagnoses such as dementia, frequently resulting in involuntary live hospice discharge. METHODS A mixed-method integration of hospice 2013-17 admission/discharge data, 5 family interviews, hospice discipline-specific focus groups (3 aides, 2 nurses, 1 administrator interview) and a discipline-combined focus group (all 6 staff; each staff participant engaged in two data collection experiences). RESULTS 5648 hospice admissions occurred between 2013-17; 795 patients experienced live discharge. The most prevalent admitting diagnosis was cancer, the most prevalent live discharge diagnosis was dementia. Family caregiver themes were Attitude and experience with hospice, Discharge experience, and Continued need/desire for hospice following discharge. Staff themes were Discharge circumstances, Regulatory guidelines, and Changing practice to meet regulatory guidelines. CONCLUSION Involuntary live hospice discharge precludes patient-centered care due to policy constraints, especially for those with noncancer diagnoses. Families and staff noted the paradox of beneficial hospice care, yet this care resulted in ineligibility for continued hospice services. PRACTICE IMPLICATIONS Transparent, patient-family-staff communication (including CNAs) facilitates hospice live discharge planning. Hospice service eligibility policy changes are needed.
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Affiliation(s)
- Margaret F Clayton
- College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT, 84112, USA.
| | - Rebecca Utz
- Department of Sociology, University of Utah, 390 1530 E #301 Salt Lake City, UT, 84112, USA
| | - Eli Iacob
- College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT, 84112, USA
| | - Gail L Towsley
- College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT, 84112, USA
| | - Jacqueline Eaton
- College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT, 84112, USA
| | - Hollie J Fuhrmann
- College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT, 84112, USA
| | - Kara Dassel
- College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT, 84112, USA
| | - Michael Caserta
- College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT, 84112, USA
| | - Katherine Supiano
- College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT, 84112, USA
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Abstract
Live discharges from hospice may occur because of patient choice or provider choice. However, when discharges occur before death, patients and families may feel abandoned and left to manage care needs previously provided by hospice. The purpose of this systematic review was to better understand the nature of live discharges, including frequency, patient characteristics, and hospice characteristics. Of 44 studies identified for review, 13 met inclusion criteria and were published between 2008 and 2018. Live discharge rates varied from 5% to 23%. Patients' prehospice characteristics varied widely based on diagnosis, comorbidities, gender, race, and ethnicity. Hospice characteristics indicated that the likelihood of a live discharge was increased for patients enrolled in for-profit hospices and in rural areas. Only 2 studies captured the patient/family perspective of the live discharge experience, finding that the loss of hospice support was fraught with difficulties. A need for further study of the live discharge experience and the practices of hospices with high live discharge rates was identified.
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12
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Prater LC, Wickizer T, Bower JK, Bose-Brill S. The Impact of Advance Care Planning on End-of-Life Care: Do the Type and Timing Make a Difference for Patients With Advanced Cancer Referred to Hospice? Am J Hosp Palliat Care 2019; 36:1089-1095. [DOI: 10.1177/1049909119848987] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: This study aimed to determine the impact of advanced care planning (ACP) on potentially avoidable hospital admissions at the end of life (EOL) among a sample of hospice-referred patients with cancer, in order to present actionable considerations for the practicing clinician. Methods: This study was designed as a retrospective cohort using electronic health record data that assessed likelihood of hospital admissions in the last 30 days of life for 1185 patients with a primary diagnosis of cancer, referred to hospice between January 1, 2014, and December 31, 2015, at a large academic medical center. Inverse probability treatment weighting based on calculated propensity scores balanced measured covariates between those with and without ACP at baseline. Odds ratios (ORs) were calculated from estimated potential outcome means for the impact of ACP on admissions in the last 30 days of life. Results: A verified do-not-resuscitate (DNR) order prior to the last 30 days of life was associated with reduced odds of admission compared to those without a DNR (OR = 0.30; P < .001). An ACP note in the problem list prior to the last 30 days of life was associated with reduced odds of admission compared to those without an ACP note (OR = 0.71, P = .042), and further reduced odds if done 6 months prior to death (OR = 0.35, P < .001). Conclusions: This study shows that dedicated ACP documentation is associated with fewer admissions in the last 30 days of life for patients with advanced cancer referred to hospice. Improving ACP processes prior to hospice referral holds promise for reducing EOL admissions.
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Affiliation(s)
- Laura C. Prater
- Department of General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Thomas Wickizer
- The Ohio State University College of Public Health, Columbus, OH, USA
| | - Julie K. Bower
- The Ohio State University College of Public Health, Columbus, OH, USA
| | - Seuli Bose-Brill
- Department of General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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13
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Wladkowski SP, Wallace CL. Current Practices of Live Discharge from Hospice: Social Work Perspectives. HEALTH & SOCIAL WORK 2019; 44:30-38. [PMID: 30561640 DOI: 10.1093/hsw/hly040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 03/13/2018] [Indexed: 06/09/2023]
Abstract
Hospice provides holistic support for individuals living with terminal illness and to their caregivers during the bereavement period. However, some individuals who enroll in hospice services are decertified as they do not experience a decline in health as quickly as required by current regulations, a practice referred to as a live discharge. The interruption in care can affect the physical and psychosocial care needs for individuals and caregivers and leave hospice clinicians with questions about how to best support them. However, there are no formal guidelines to support this process. This qualitative study (N = 24) explored the current practices of hospice social workers across the United States engaged in the live discharge process. Results from this study emphasize the need to bridge the gaps between policy and practice. Specifically, results highlight the challenges hospice social workers face to replicate or supplement the holistic support and unique services hospice provides for individuals discharged alive, and suggest further research to develop live discharge guidelines to identify appropriate support for patients and their caregivers who no longer meet hospice eligibility requirements.
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Affiliation(s)
- Stephanie P Wladkowski
- Stephanie P. Wladkowski, PhD, LMSW, is assistant professor, School of Social Work, Eastern Michigan University, 317 Marshall Hall, Ypsilanti, MI 48197; e-mail: . Cara L. Wallace, PhD, LMSW, is assistant professor, School of Social Work, Saint Louis University
| | - Cara L Wallace
- Stephanie P. Wladkowski, PhD, LMSW, is assistant professor, School of Social Work, Eastern Michigan University, 317 Marshall Hall, Ypsilanti, MI 48197; e-mail: . Cara L. Wallace, PhD, LMSW, is assistant professor, School of Social Work, Saint Louis University
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14
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Dolin R, Holmes GM, Stearns SC, Kirk DA, Hanson LC, Taylor DH, Silberman P. A Positive Association Between Hospice Profit Margin And The Rate At Which Patients Are Discharged Before Death. Health Aff (Millwood) 2018; 36:1291-1298. [PMID: 28679817 DOI: 10.1377/hlthaff.2017.0113] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hospice care is designed to support patients and families through the final phase of illness and death. Yet for more than a decade, hospices have steadily increased the rate at which they discharge patients before death-a practice known as "live discharge." Although certain live discharges are consistent with high-quality care, regulators have expressed concern that some hospices' desire to maximize profits drives them to inappropriately discharge patients. We used Medicare claims data for 2012-13 and cost reports for 2011-13 to explore relationships between hospice-level financial margins and live discharge rates among freestanding hospices. Adjusted analyses showed positive and significant associations between both operating and total margins and hospice-level rates of live discharge: One-unit increases in operating and total margin were associated with increases of 3 percent and 4 percent in expected hospice-level live discharge rates, respectively. These findings suggest that additional research is needed to explore links between profitability and patient-centeredness in the Medicare hospice program.
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Affiliation(s)
- Rachel Dolin
- Rachel Dolin is a fellow at the David A. Winston Health Policy Fellowship, in Washington, D.C. Previously, she was a National Science Foundation Graduate Research Fellow in the Department of Health Policy and Management, Gillings School of Global Public Health, at the University of North Carolina at Chapel Hill (UNC)
| | - G Mark Holmes
- G. Mark Holmes is an associate professor in the Department of Health Policy and Management, Gillings School of Global Public Health, and director of the Cecil G. Sheps Center for Health Services Research, both at UNC
| | - Sally C Stearns
- Sally C. Stearns is a professor in the Department of Health Policy and Management, Gillings School of Global Public Health, UNC
| | - Denise A Kirk
- Denise A. Kirk is an applications analyst in the North Carolina Rural Health Research Program at the Cecil G. Sheps Center for Health Services Research, UNC
| | - Laura C Hanson
- Laura C. Hanson is a professor of medicine in the Division of Geriatric Medicine, associate director of the Geriatric Fellowship Program, and director of the Palliative Care Program, all at UNC
| | - Donald H Taylor
- Donald H. Taylor Jr. is a professor in the Sanford School of Public Policy, Duke University, in Durham, North Carolina
| | - Pam Silberman
- Pam Silberman is a professor of the practice and director of the Executive Doctoral Program in Health Leadership, Department of Health Policy and Management, Gillings School of Global Public Health, and associate director for policy analysis at the Cecil G. Sheps Center for Health Services Research, all at UNC
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15
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Dolin R, Silberman P, Kirk DA, Stearns SC, Hanson LC, Taylor DH, Holmes GM. Do Live Discharge Rates Increase as Hospices Approach Their Medicare Aggregate Payment Caps? J Pain Symptom Manage 2018; 55:775-784. [PMID: 29180057 DOI: 10.1016/j.jpainsymman.2017.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 11/15/2017] [Accepted: 11/17/2017] [Indexed: 10/18/2022]
Abstract
CONTEXT The rate of live discharge from hospice and the proportion of hospices exceeding their aggregate caps have both increased for the last 15 years, becoming a source of federal scrutiny. The cap restricts aggregate payments hospices receive from Medicare during a 12-month period. The risk of repayment and the manner in which the cap is calculated may incentivize hospices coming close to their cap ceilings to discharge existing patients before the end of the cap year. OBJECTIVE The objective of this work was to explore annual cap-risk trends and live discharge patterns. We hypothesized that as a hospice comes closer to exceeding its cap, a patient's likelihood of being discharged alive increases. METHODS We analyzed monthly hospice outcomes using 2012-2013 Medicare claims. RESULTS Adjusted analyses showed a positive and statistically significant relationship between cap risk and live discharges. CONCLUSION Policymakers ought to consider the unintended consequences the aggregate cap may be having on patient outcomes of care.
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Affiliation(s)
| | - Pam Silberman
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Denise A Kirk
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sally C Stearns
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Laura C Hanson
- Palliative Care Program, Division of Geriatric Medicine, Center for Aging and Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Donald H Taylor
- Sanford School of Public Policy, Duke University, Durham, North Carolina, USA
| | - G Mark Holmes
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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