Top Ten Tips Palliative Care Clinicians Should Know About Hospice Live Discharge.

Hospice care is designed to support the medical and psychosocial needs of individuals with serious illness and their caregivers through the dying process. Some individuals, though, leave hospice prior to death, generally referred to as disenrollment or a "live discharge." Live discharge from hospice is a common and often distressing issue for hospice patients, their caregivers, and also for hospice professionals and agencies. This paper discusses common issues surrounding live discharge that clinicians and other healthcare professionals should consider when dealing with live discharge in their own clinical practices. Where applicable, we provide practical steps for hospice and palliative care clinicians to better support patients and families through this critical care transition. Further, we offer strategic directions interprofessional clinicians can take to affect systemic change to improve live discharge experiences.

Live Discharge of Hospice Patients with Alzheimer's Disease and Related Dementias: A Systematic Review.

Background: Hospice is intended to promote the comfort and quality of life of dying patients and their families. When patients are discharged from hospice prior to death (ie, experience a "live discharge"), care continuity is disrupted. This systematic review summarizes the growing body of evidence on live discharge among hospice patients with Alzheimer's Disease and related dementias (ADRD), a clinical subpopulation that disproportionately experiences this often burdensome care transition. Methods: Researchers conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Reviewers searched AgeLine, APA PsycINFO (Ovid), CINAHL Plus with Full Text, ProQuest Dissertations & Theses Global, PubMed, Scopus, and Web of Science (Core Collection). Reviewers extracted data and synthesized findings from 9 records, which reported findings from 10 individual studies. Results: The reviewed studies, which were generally of high quality, consistently identified diagnosis of ADRD as a risk factor for live discharge from hospice. The relationship between race and live hospice discharge was less clear and likely dependent upon the type of discharge under investigation and other (eg, systemic-level) factors. Research on patient and family experiences underscored the extent to which live hospice discharge can be distressing, confusing, and associated with numerous losses. Conclusion: Research specific to live discharge among ADRD patients and their families is limited. Synthesis across included studies points to the importance for future research to differentiate between types of live discharge-revocation vsversus decertification-as these are vastly different experiences in choice and circumstances.

Hospice Capacity to Provide General Inpatient Care: Emergency Department Utilization and Live Discharge Among Cancer Patients.

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.

Improving Policy and Practices of Hospice Live Discharge: A Historical Exploration of the Medicare Hospice Benefit.

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.

Hospice serves 1.72 million people a year, of which 15.4% are discharged alive, a process impacted by policy.Live discharges are disruptive for patients, families, clinicians, and agencies, but little guidance exists in policy.Policy changes focus on minimizing fraud related to long-lengths of stay, which disproportionately occur for chronic illnesses where six-month prognostication is a challenge.Changes to hospice policy do not account for growing incidents of chronic illness, even though the policy was originally created for cancer patients, the primary cause of death at that time.Understanding policy connections to hospice live discharge is pertinent to identifying solutions for improvement.

Identifying Key Domains and Implementation Challenges for a Live Discharge From Hospice Protocol.

Background: Hospice agencies lack an explicit live discharge process to guide practitioners in transitioning these patients and their primary caregivers (PCGs) out of hospice care. Based on previous research and input from an advisory committee, a live discharge protocol (LDP) was drafted with .three general areas of assessment: 1) concrete services; 2) psychosocial assessment; and 3) 30-day post discharge follow-up phone call. This study sought to gather perspectives from hospice social workers on the proposed assessment components and other needs in implementing a LDP. Methods: Purposive, convenience sampling occurred over 4 months. Participants were hospice social workers (n = 14) recruited through personal and professional contacts and social media. Four focus groups were conducted via Zoom. Data was analyzed using thematic analysis. Results: Three major themes appeared: 1) benefits and challenges of having a structured discharge protocol (n = 14); 2) need for specific LDP roles across team members (n = 11); and 3) education and clear boundaries for both patients/PCGs and professionals (n = 9). Conclusions: All three assessment components of the preliminary LDP were deemed necessary by participants; however, implementation challenges were both unique for each agency and reflective of the broader hospice culture. Further research is needed to measure the impact of the LDP.

Hospice for the Primary Care Physician.

Hospice is a model of care that offers significant benefits to patients at the end of their lives, their families, and also to the primary care physicians who have diligently cared for their patients. As comprehensive care physicians, primary care physicians can benefit from a strong understanding of hospice and the Medicare Hospice Benefit. This article describes the history of hospice, palliative care versus hospice care, clinical appropriateness of the hospice patient, the regulatory guidelines of the Medicare Hospice Benefit, hospice reimbursement, primary care reimbursement, and employment opportunities in hospice.

Hospice Underutilization in the U.S.: The Misalignment of Regulatory Policy and Clinical Reality.

After three and a half decades of experience with the Medicare hospice benefit in the U.S., despite excellent quality outcomes in symptom management, patient and family satisfaction, and reduction in health care costs, only 12%-15% of beneficiaries' days during the last year of life are spent being cared for within the highly cost-effective interdisciplinary coordinated advanced illness care model known as hospice. Although there are many reasons for this, including difficulties in acknowledging mortality among patients, their families, and physicians, a significant cause of low overall hospice utilization and intractably low median lengths of stay, reflective of late admissions, can be attributed to increasingly difficult and highly variable prognostic determinations for most of the leading causes of death among Medicare beneficiaries. Medicare is the payer for most hospice care in the U.S. and requires certification of a prognosis of six months or less for a beneficiary to access hospice support. At the time of admission to hospice, two physicians must predict that a patient is more likely to die in the next six months than survive, based on clinical status. In addition to prognostic uncertainty constituting a barrier to timely hospice referral, the Centers for Medicare and Medicaid Services and its payer contractors have developed a robust and expensive retrospective review process that penalizes hospices when patients outlive their expected prognosis. The administratively burdensome and financially punitive review practices further delay or limit access to care for eligible patients as certifying physicians and agencies, fearful of the financial and legal repercussions of reviews and audits, are hesitant to take patients under care unless they are clearly in the dying process. This article will review pertinent history and address the core problem of access to a health care benefit built on a policy that requires far greater prognostic certainty than any clinician can reasonably ascertain and fails to take into consideration the favorable impact hospice care has on terminally ill patients in improving prognosis. This clinical conundrum that limits access of seriously ill people to high-value quality care is of profound importance to the U.S. Medicare population and also one with potential relevance to all complex and regulated health systems and to other models of care whose eligibility criteria are based on prognostication.

Hospice Visit Patterns in the Last Seven Days of Life and the Service Intensity Add-On Payment.

BACKGROUND: Hospice in-person visits in the last week of life are critical to ensure quality of care. In 2016, The Centers for Medicare & Medicaid Services (CMS) introduced a Service Intensity Add-on (SIA) payment for in-person routine home care (RHC) visits by a registered nurse or social worker in the last 7 days of life. OBJECTIVES: The aim of the study was to examine visit patterns in the last week of life and provide SIA payment impact estimates. DESIGN/MEASUREMENTS: Hospice data from 42 volunteer hospice programs for the 6-year period of 2005-2010 were examined. The data included information on the type and duration of visits/other care, the staff discipline, and patient demographics, diagnoses, date of death, and care setting (home, assisted living, nursing home). RESULTS: In their last week of life, 251,407 decedents received 2,818,695 visits during 1,352,638 RHC days. Forty-four percent of the decedents had at least one SIA-eligible visit (in-person direct care visit by a registered nurse (RN) or social worker (SW)); 6.6% had only phone contact, and 30.4% had no hospice contact. Rates of RHC days with SIA-eligible days varied considerably across hospices (31% to 60.9%). For the 86.3% decedents with any SIA-eligible visits, average SIA payment would have been $202.5 (Median = $177.2, inter quartile range [IQR] = $108.3-$275.6), which represents a 21.6% increase over the average regular RHC payments received during the last week of life. CONCLUSIONS: The relative size of the new SIA payment introduced by CMS has the potential to increase RN/SW visits and reduce disparities in visit patterns in the last week of life.

Palliative Care Scorecard.

BACKGROUND: In response to poor healthcare quality outcomes and rising costs, healthcare reform triple aim has increased requirements for providers to demonstrate value to payers, partners, and the public. OBJECTIVE: Electronically automating measurement of the meaningful impact of palliative care (PC) programs on clinical, operational, and financial systems over time is imperative to the success of the field and the goal of development of this automated PC scorecard. DESIGN: The scorecard was organized into a format of quality measures identified by the Measuring What Matters (MWM) project that are defined as important to the team, automatically extracted from the electronic health record, valid, and can be impacted over time. SETTING: The scorecard was initially created using University of Florida Health (UF) data, a new PC program, and successfully applied and implemented at University of Colorado Anschutz Medical Campus (CU), a second institution with a mature PC program. MEASUREMENTS: Clinical metrics are organized in the scorecard based on MWM and described in terms of the metric definition, rationale for selection, measure type (structure, process, or outcome), and whether this represents a direct or proxy measure. RESULTS/CONCLUSIONS: The process of constructing the scorecard helped identify areas within both systems for potential improvement in team structure, clinical processes, and outcomes. In addition, by automating data extraction, the scorecard decreases costs associated with manual data entry and extraction, freeing clinical staff to care for patients and increasing the value of PC delivered to patients.

A Trial of Concurrent Care: Shedding Light on the Gray Zone.

BACKGROUND: Patients are hospice eligible when they have an estimated prognosis of 6 months and the readiness to forgo attempts at disease-modifying treatments related to their terminal illness. The decision to enroll in hospice is relatively clear when the prognosis is based on an incurable illness for which there are no further life-prolonging therapies. However, when the prognosis is based on a serious chronic illness for which possible interventions remain but must be forgone to access hospice support, the decision process is more complex. Such patients may benefit from a trial of concurrent care, receiving both disease-modifying and comfort-focused hospice care, while determining whether or not to pursue further treatment. OBJECTIVE: This article illuminates the need for concurrent care for hospice patients with serious illness. We present a case to exemplify this gap and offer a framework for managing patients in transition between disease-modifying therapies and hospice care. DISCUSSION: The case describes an 86-year-old woman with dry gangrene of her foot who was admitted to hospice for end-of-life care and, after a trial period on hospice, chose to pursue further treatment. CONCLUSION: Integrating concurrent care into the Medicare Hospice Benefit allows patients to receive care that aligns with their values, even as they experience and collect new information about their condition. We propose the TRIAL framework to assess evolving goals of care for hospice patients with serious chronic illness.

Knowledge About Hospice: Exploring Misconceptions, Attitudes, and Preferences for Care.

CONTEXT: Poor knowledge and misperceptions about hospice are believed to be common, but there is scant evidence about the public's understanding of hospice. OBJECTIVES: To examine hospice knowledge among geographically diverse adults; and describe linkages between knowledge, attitudes and beliefs about hospice care, and demographics. METHODS: A small cross-sectional telephone survey of adults living in the contiguous US was conducted using randomly selected numbers (cell phone and landline) and over-sampling of minorities. Measures assessed knowledge (23-item test), attitudes (8-item scale), experiences and preferences related to hospice. RESULTS: 123 participants completed surveys (response rate 46%). 106 (86%) had heard about hospice, 65 (54%) of whom had a personal experience with hospice. Participants had an average hospice knowledge test score of 18 (SD = 3.4) indicating moderate knowledge of hospice. A majority of respondents (62%) did not know that hospice cannot provide concurrent cure-oriented care. Misperceptions about eligibility, coverage of hospice, the provision of hospice in nursing homes or to persons who live alone were not uncommon (missed by >20%). Greater knowledge of hospice was associated with more favorable attitudes about the hospice philosophy of care (r = .22, p = .023) and a greater preference for hospice (p = .049). Respondents who were more educated, worked in the medical field, were non-Hispanic White, and had direct experience with hospice were also more likely to be more knowledgeable about hospice. CONCLUSION: Despite relatively high hospice awareness and favorability, myths and misperceptions about hospice still abound--and may drive ethnic disparities in end-of-life care. Educational interventions and future study are needed.

Trends in the Use of Volunteers in US Hospices: 2000 to 2010.

PURPOSE: Using a longitudinal sample of freestanding Medicare-certified hospices in the 50 US states and the District of Columbia, this study sought to explore the factors associated with volunteer demand and describe how volunteer use has changed from 2000 to 2010. RESULTS: A temporal decline in the extent of use of volunteers in freestanding hospices was observed over the study period. Findings indicated that both organizational and environmental factors influence the use of volunteers in US freestanding hospices. CONCLUSION: Given the importance of volunteers, both in the preservation of hospices' philanthropic traditions and in reducing health care expenditure at the end of life, research is needed to further evaluate the factors associated with this decline. Emphasis should be placed on improving the retention of the existing hospice volunteer workforce.