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Hospice Care Linked to Higher Family Satisfaction

Hospice care linked to higher family satisfaction

By Lisa Rapaport SOURCE: Journal of Clinical Oncology, online December 19, 2016.

(Reuters Health) - Families of terminally ill cancer patients may be more satisfied with the end-of-life treatment their loved ones receive when it involves hospice care, a recent study suggests.

Researchers examined interview data from 1,970 family members of deceased cancer patients. The patients all had advanced lung or colorectal cancer, and roughly half had received hospice care.

Hospice was associated with better symptom relief, attainment of pain-management goals, and quality of end-of-life care, the study found. Families of patients who received at least 30 days of hospice care reported the highest quality of life outcomes.

Many people think of hospice as something that should be saved for the very end of life, said study co-author Dr. Alexi Wright of Harvard Medical School and Dana-Farber Cancer Institute in Boston.

“However, our findings suggest that earlier hospice enrollment is associated with better symptom management, less pain, better quality of care, and a higher likelihood that patients will receive the care that they want in their own environment,” Wright added by email.

Patients with advanced cancer often experience pain, difficulty breathing and distress at the end of life and use intensive, hospital-based care during their final days, researchers note in the Journal of Clinical Oncology.

Hospice offers an alternative approach focused on comfort and often delivers care within a home environment that many families may prefer. 

About 80 percent of families in the hospice group reported the amount of pain medicine was just right, compared with 73 percent of the families that didn’t use hospice services.

With hospice, 78 percent of families said the patient got the right amount of relief from breathing difficulties, compared with 70 percent for the non-hospice group.

In addition, 80 percent of hospice families said patients’ end of life wishes were followed, compared with 74 percent in the other group.

Patients received excellent end-of-life care according to 57 percent of the hospice families and just 42 percent of the other families.

The results add to a growing body of evidence linking hospice to better quality of life for patients, a greater likelihood of dying in the location of choice, and less bereavement-related distress for caregivers, said Dr. Camilla Zimmermann, a palliative care researcher at the University of Toronto who wasn’t involved in the study.

Patients and families should know that enrollment in hospice for more than 30 days is associated with better quality of care at the end of life, Zimmermann said by email.

When people have little or no hospice care, it’s often at least in part because patients and families didn’t know about their end-of-life care options soon enough, said Dr. Preeti Malani of the University of Michigan in Ann Arbor.

“Candid discussions about end of life care with family and with the medical team caring for a patient need to happen sooner and in an ongoing manner,” Malani, who wasn’t involved in the study, said by email. “There also needs to be greater recognition of palliative care (not hospice care) as complementary to curative therapies.”

Palliative treatments are used to relieve symptoms. Unlike hospice, palliative care doesn’t require patients to forego active cancer treatments or have six months or less to live, said Dio Kavalieratos of the University of Pittsburgh. “Palliative care can be provided from the day of diagnosis, and can help ease a transition to hospice care if appropriate,” Kavalieratos, who wasn’t involved in the study, added by email.

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Analysis dissects business of dying

The Washington Post

Analysis dissects business of dying

Monday , December 29, 2014 - 10:05 AM

"Dr. Geoff Coleman takes a peek at a photo held by hospice patient Olivia Thebolt as he makes his...

The Washington Post

WASHINGTON — The influx of for-profit companies into the hospice field has benefited patients, advocates say, because the commercial companies made big investments in technology, focused on efficiency and made care more accessible.

But a Washington Post analysis of hundreds of thousands of U.S. hospice records indicates that, as those companies transformed a movement once dominated by community and religious organizations into a $17 billion industry, patient care suffered along the way.

On several key measures, for-profit hospices as a group fall short of those run by nonprofit organizations.

The typical for-profit hospice:

• Spends less on nursing per patient.

• Is less likely to have sent a nurse to a patient’s home in the last days of life.

• Is less likely to provide more intense levels of care for patients undergoing a crisis in their symptoms.

• Has a higher percentage of patients who drop out of hospice care before dying. High rates of dropout are often viewed as a sign that patients were pushed out of hospice when their care grew expensive, left dissatisfied or were enrolled for hospice even though they were not close to death.

The quality of individual hospices varies widely. In some cases, for-profit hospices provide service at levels comparable to nonprofits, according to the review. But the data analysis, based on hundreds of thousands of Medicare patient and hospice records from 2013, shows that the gap between the for-profits as a whole and nonprofits is striking and consistent, regardless of hospice size.

“Unfortunately, a lot of people have come into the business for the wrong reasons,” said Michael Girard, who with his wife Deb owns the Circle of Life for-profit hospice in Reno, Nevada. “A lot of the problems we have in hospice today have happened with the entry of what I call the ‘vulture capitalists.‘ “

About half of Americans of retirement age will employ a hospice service before death, but public information about the agencies is meager, and many consumers are unaware whether a hospice operates as a nonprofit or for-profit.

The federal government has been trying — for years — to develop a way to measure and report hospice quality, but the effort has lagged behind other health-care industries. The Washington Post has published an online hospice guide that provides detailed information on more than 3,000 hospices.

The findings on for-profit hospices come amid repeated complaints within the industry that pressure to cut costs, combined with sparse government oversight, has led some companies to focus on the bottom line to the detriment of patients.

Hospice operators have an economic incentive to provide less care because they get paid a flat daily fee from Medicare for each of their patients. That means that the fewer services they provide, the wider their profit margin.

Industry advocates warned against using the findings to rule out care from a for-profit hospice.

“There are many, many factors in making a decision about what hospice to choose,” said Theresa Forster, vice president of the National Association for Home Care & Hospice, which represents for-profit and nonprofit hospices. “National trends may not apply at the local level. The key issues are the hospice’s ability to provide good end-of-life care.”

Through a spokesman, the National Hospice and Palliative Care Organization, another industry group, declined to comment on the findings.

Dave Williams, the chief financial officer of Chemed, which owns the largest U.S. hospice chain, said that for-profits offer several advantages for patients: They can more easily raise money for investments in equipment and expansion; they can achieve a size that offers them economies of scale; and, pushed by investors, they are encouraged to be more efficient.

He emphasized that size and scale matter because a large hospice can afford to lose money on some patients who may need extraordinary care.

“For large hospices that have been around a long time, the quality of care is going to be the same, whether they are for-profit or nonprofit,” Williams said. “The only way you can compete for patients and referrals over a long period of time is to provide the best possible care.”

The rise in hospice usage — today roughly half of older Americans who die have received some hospice care — has created a boom in the industry. In 2012, Medicare spent more than $15 billion on hospice care, which offers terminally ill patients treatment that focuses on providing comfort rather than aggressive methods aimed at a cure.

The number of hospice firms has risen rapidly, and over the past decade the growth has come almost entirely from new for-profit operations. Between 2000 and 2012, the number of for-profit hospices tripled to 2,196, according to federal figures, compared with about 1,500 nonprofit hospices, including those run by local governments.

The industry growth has been accompanied by remarkable turbulence, too. Between 1999 and 2009, more than 40 percent of hospices experienced one or more changes in ownership, according to researchers.

The expansion has been driven in large part by investors, including private equity firms, hedge funds and entrepreneurs. More than a dozen private equity firms have invested in businesses that provide hospice care, including giants such as The Carlyle Group, Kohlberg & Company, Summit Partners and GTCR.

“Hospice [mergers and acquisitions] market is red hot (peak valuation levels),” according to a presentation by financial analysts at Cain Brothers last year, which cited, among other things, the favorable U.S. demographics — more old people.

“Hospice continues to be of robust interest to Wall Street,” said Carsten Beith, a managing director at Cain Brothers.

He said that the influx of private equity money has allowed the industry to expand and to fund investments in technology. The demands of investors have also pushed hospices to provide good care at lower costs and a hospice that spends less on nursing is not necessarily providing less care, he said.

“An operating model that is more efficient doesn’t translate into patient care deficiencies,” Beith said.

But some in the industry — often those in the traditional nonprofit hospices — have questioned whether the goals of a for-profit company and a dying patient are easily aligned.

“If you think as a businessman and you want to make money, you will cut and cut and cut,” said Helen Zebarth, who cofounded the nonprofit Blue Ridge Hospice in Winchester, Virginia, in 1979. A former cardiac nurse, Zebarth decided to create a hospice after visiting the famed St. Christopher’s hospice in London in the mid-‘70s.

Back in Winchester, she and colleagues operated the fledgling operation on a shoestring budget out of a hospital basement. At the time, hospice services had to be paid for by donations because insurance and Medicare didn’t cover it.

“It was free for everyone,” she said. “And the community supported it.”

She credits the beginning of Medicare and insurance coverage with allowing far more people in the United States to receive hospice services.

But it also turned hospice into a big business, which operates side-by-side with the visionaries remaining from the movement’s early days.

Today, the amount the Blue Ridge Hospice spends on nursing per patient is more than 50 percent higher than the state average. It offers an array of extra services, including music therapy. It accepts patients with no insurance coverage. It also built its own inpatient unit.

It pays for the extras with donations from the community and a string of thrift shops it operates.

“We really want to take care of people — that’s our goal,” Zebarth said. “That’s where we are focused.”

The debate over the role of for-profit companies has come up before in health care, most often with hospitals. Within that field, some researchers have found generally negligible differences between the care provided by for-profits and nonprofits.

“When simple measures of quality are used — such as mortality — we have not seen differences between the quality of for-profit and nonprofit hospitals,” said Frank Sloan, a Duke University health and economics professor.

Where the two vary, he said, is in business practices, with for-profit hospital chains more aggressively marketing other services to patients.

By contrast, significant differences appear to distinguish for-profit and nonprofit hospices.

The Post analysis is based on the 2013 cost reports and other billing data that hospices are obliged to file if they accept Medicare patients. Medicare pays for the vast majority of hospice care in the United States.

While they are not audited, the reports are supposed to reflect what the hospice spends each year in caring for patients.

The key findings:

• Nonprofit hospices typically spent about $36 a day per patient on nursing visits; for-profit hospices spent $30 per day, or 17 percent less. The gap between for-profits and nonprofits remain whether the hospices are old or new.

• Nonprofit hospices are much more likely to provide the more intense services — continuous nursing and inpatient care — required by patients whose symptoms are difficult to control. Nonprofits offered about 10 times as much of this per patient-day as did for-profits.

• While hospices of both kinds usually dispatch a nurse to see a patient at some point during the last two days of life, for-profit hospices are more likely to fail in this regard, according to the analysis. A typical patient at a for-profit hospice is 22 percent less likely to have been visited by a nurse during this window than a patient at a nonprofit hospice, the numbers show, a sign that for-profit hospices may be less responsive during this critical time.

• Patients at for-profit hospices are much more likely to drop out of hospice care than patients at nonprofit hospices.

The proportion of patients leaving a for-profit hospice is typically 22 percent, while it is only 14 percent at nonprofits.

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NHPCO Applauds Passage of the IMPACT Act

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The legislation recently passed by the U.S. House and Senate regarding hospice care is summarized below. Much of it relates to the fact that many hospices are not being surveyed frequently enough.  Old Colony Hospice supports this legislation and has consistently demonstrated its commitment to excellence in the provision of hospice and palliative care services through its voluntary accreditation through Community Health Accreditation Program (CHAP).  CHAP,  founded in 1968, is the oldest community-based accreditation program with the most experience of any other accrediting program and the oldest national community-based accrediting body.

Every three years, Old Colony Hospice voluntarily undergoes the CHAP accreditation process.  This non-biased third party review ensures that we have policies and procedures compliant with current state and federal regulations and industry standards of practice and care.  This adherence to the CHAP standards demonstrates that Old Colony Hospice voluntarily earned recognition from a nationally-recognized body for EXCEEDING the minimum standards required.  We are constantly evaluating our organization in order to continue to provide the highest quality of care to our patients and their loved ones.  You can count on us!

Learn more about CHAP here!!!


For Immediate Release:
September 19, 2014

NHPCO Applauds Passage of the IMPACT Act

Hospice provisions added to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) will create increased transparency within the hospice community

(Alexandria, Va) –  This week, the U.S. House of Representatives and Senate passed the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). This legislation includes several hospice integrity provisions that are backed by the hospice community. The National Hospice and Palliative Care Organization supports this legislation and applauds the additional oversight it will bring to end-of-life care providers.

The IMPACT Act (H.R. 4994), requires more frequent surveys of hospice providers – a measure the hospice community and NHPCO has championed for more than a decade. The bill mandates that all Medicare-certified hospices be surveyed at least as frequently as every three years for at least the next ten years.

A 2007 HHS Office of the Inspector General report found that current survey measures for Medicare-certified hospices was not providing sufficient oversight. 

“Currently, hospices can go eight years or more without ever being surveyed, which is far too long,” said J. Donald Schumacher, NHPCO president and CEO. “More consistent surveys, and the process providers go through to prepare for them, will help hospices and ultimately benefit the patients and families in their care.”

Additionally, the new legislation will facilitate medical reviews for hospice programs with a soon to be determined percentage/number of patients receiving care for more than 180 days. The specific patient load that would trigger this medical review is yet to be set by CMS.

Such a medical review of what are known as “long stay” patients will help ensure that hospices are caring for individuals with life-limiting illnesses that are often harder to prognosticate than in the earlier days of hospice care when most patients had a cancer diagnoses.

NHPCO has supported this provision since it was originally recommended by MedPAC in 2009. 

The legislation also includes a provision that would align hospice reimbursement and the hospice aggregate financial cap to a common inflationary index. NHPCO has continually supported the existence of the cap as a cost containment mechanism that works to prevent inappropriate financial incentives for hospice programs.

“Under NHPCO’s leadership, the hospice community has been on the frontlines of advocating for increased transparency, program integrity, and accountability. We believe that the hospice provisions included in the IMPACT Act are critically important steps in this direction,” stressed Schumacher.

NHPCO reports that more than 1.5 million dying Americans receive care for the nation’s hospice providers every year and hospice provides the kind of care people want at the end of life.

To learn more about hospice and how it helps patients and families or to find a hospice in your community, visit the website Moments of Life: Made Possible by Hospice.