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Increasing Appropriate Hospice Use

Is Your Patient’s Serious Illness the Elephant in the Examining Room?

elephantOver the past year, the Minnesota communities of Alexandria, Mora, and Waconia increased hospice admissions by 8.7% and increased length of stay in hospice for patients, after participating in a Stratis Health hospice utilization project.

These three communities were selected for the project because they had lower hospice utilization rates and greater potential to optimize hospice use than many other Minnesota communities, based on readmission rates for chronic and life threatening conditions, as well as their aging populations.

Why increase hospice utilization?

Coverage for hospice services is available through Medicare, yet is underutilized by beneficiaries across the country, including in Minnesota. Hospice is a win-win benefit because it:

  • Provides patients who face a serious illness with relief from pain and symptoms
  • Offers patients and their families specialized services for emotional and psychosocial issues associated with dying
  • Saves money as hospice patients have lower rates of hospital and intensive care use, and fewer hospital readmissions

“Three or four months is about the perfect length of stay (LOS) for someone on hospice,” said Patrick Collins, director, Knute Nelson Hospice in Alexandria. “Patients get to know their provider and nurses—and they feel comfortable. We can get to know the family well to truly help them.”

When patients are referred to hospice, too many beneficiaries receive fewer days of care than afforded by Medicare. The national average LOS is 70 days per patient, compared to only 56 days for Minnesota Medicare patients in 2011. The national median LOS in 2013 was only 18.5 days and almost half of all hospice patients in the nation died or were discharged within 14 days of admission—well below the ideal LOS of 90 to 120 days.

Elephant in the examining room

Working with hospice programs and organizations that refer to hospice—physician clinics, assisted living facilities, hospitals, home care agencies, parish nursing, and long term care facilities, Stratis Health guided communities to identify barriers to hospice referral and optimization, assess end-of-life resources and patterns of care and service, and begin to build community action plans.

Using assessment tools, the three communities gathered feedback from lay persons and hospice patients and their families, which revealed a desire to obtain information about hospice in the event of a serious or life-limiting illness.

In discussions with health care professionals, patient denial and lack of acceptance of a serious illness/end of life emerged as the largest barrier to the use of hospice. This gap in perception between patients and health professionals was identified as the elephant in the room.

“Nearly all participants in the patient-provider relationship wanted to discuss hospice but wanted the other to broach the topic,” said Janelle Shearer, project lead for Stratis Health.

Removing the elephant

Based on the insights from the three communities, Stratis Health developed a toolkit for communities to help eligible patients receive hospice care sooner. A survey can be used to assess community readiness for hospice. Resources materials cover how to communicate with patients and families, and with providers.

The communities found that patients often don’t really understand their prognosis. “Sometimes patients, families, and physicians get caught up in the medical treatment without really taking the time to step back to understand their medical goals, whether curative or palliative,” said Lisa Hurt, home health/hospice services director, Ridgeview Medical Center, Waconia.

To address this, patient tools use an “Ask Your Doctor” theme. The word “hospice” is used sparingly because of perceived stigma. Brochures and wallet cards list the following questions for patients to bring to their doctors about their serious illness.

  • Do I have a serious or life-limiting illness?
  • Can my illness be cured?
  • If my illness can’t be cured, are there treatments that can slow down my illness?
  • What kind of care is available that focuses on making me comfortable?
  • If my illness keeps getting worse, when is it a good time to think about getting supportive and comfort-focused care?
  • Will you be the one to tell me when to contact hospice?
  • Will you stay involved with my care even when I am no longer looking for treatment for my disease?

Provider tools encourage physicians to be more proactive in initiating conversations about serious illnesses. For example, after an initial conversation about expectations and prognosis with a patient, oncologists and other specialty care physicians should return to that discussion when the patient isn’t improving with treatment.

The three communities have started implementing strategies on both the patient- and provider-side to start conversations about hospice. Ridgeview Medical Center includes “Ask Your Doctor” materials in its advanced care planning presentations to the community. “The questions and information included in the material provide an opportunity for patients and families to reflect on ‘what does quality of life mean for me?’” noted Hurt.

Collins credits the project with helping to build awareness among providers in Alexandria. “Providers are more willing to make referrals when death is not imminent but therapies are not improving patient conditions. Also, now when we contact primary care physicians based on family referrals, they are more willing to sign standing orders.”

Stratis Health conducted this Centers for Medicare & Medicaid (CMS) special innovation project as the Medicare Quality Improvement Organization for Minnesota. View the hospice toolkit.