Length of Stay The median length of stay (LOS) for Medicare patients receiving hospice care was 18 days, and more than 25% of decedents enrolled in hospice during the last week of life (MedPAC, 2020; NHPCO, 2020). Despite having six months eligibility on the Medicare Hospice Benefit, most patients receive care for a few days to a few weeks. Research has shown that a longer LOS has an increased patient care benefit; therefore, these short LOS deprive patients and families support and education that are needed at the end of life (EOL; MedPAC, 2020). Research Physician/Provider Reluctance Barriers affecting timely referrals to hospice care by physicians or other providers include uncertainty of prognosis, education regarding the criteria for admission to hospice services, and discomfort in discussing the prognosis with the patient and family (Tran, 2020). More specifically, these practitioners have difficulty in decision making when the patient has met the terminal or six months or less measurement criteria (Tran, 2020). In addition, many healthcare providers have difficulty speaking Patients’ or Families’ Lack of Acceptance Many hospice clinical teams point out that families are misinformed about what hospice care is and that it makes them feel as if they are giving up on their loved one (Cicolello & Anandarajah, 2019). The most common misconception is that one can only go to hospice when they are imminently dying (Cicolello & Anandarajah, 2019). In one study that looked at financial incentives towards specific tasks, procedures, or services which aim the focus more towards volume than the quality of care and has been more focused on the acute care and institutional care, rather than community-based care (C-TAC, 2017). Unfortunately, this type of payment structure and emphasis has caused practitioners to delay advanced care planning, palliative care, and hospice referrals by continuing unnecessary and arguably futile clinical interventions for financial gain (MedPAC, 2020). This practice has resulted in an underutilization of hospice services as indicated by the Levels of Hospice Care and Services There are four levels of hospice care, defined by Medicare, which correspond to both acuity level and payment structure: Routine home care, continuous (aka crisis) home care, respite care, and general inpatient care (Centers for Medicare & Medicaid Services [CMS], 2020). 1. Routine home care: The level of care that most patients receive at home. This consists of interdisciplinary care delivered on an intermittent basis at the patient’s home. This includes skilled nursing facilities (SNFS), group homes, and assisted living facilities (ALF; CMS, 2021a). 2. Continuous home care: Used when patients have symptom management needs that require temporary 24-hour support (CMS, 2021). This level of care, also known as crisis care, assists patients who may require a higher level of nursing care but desire to stay at home (CMS, 2021). 3. Respite care: Caregivers are allowed a period of rest while patients are cared for by an IDT in a facility. In respite care, patients are allowed five days of care while on hospice services. Respites are preplanned stays in facilities (e.g., Volunteer Services Hospice volunteers are used in day-to-day administrative and/ or direct patient care roles. More specifically, volunteers must provide this type of support “in an amount that, at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff” (CMS, 2020, p. 102). Volunteers are an essential part of the IDT and endure rigorous training
indicates there are multiple factors that most likely contribute to these short stays; these factors include (MedPAC, 2020): ● Physician/provider reluctancy or discomfort with EOL conversations until death is imminent ● Patients’ or families’ lack of acceptance of a terminal prognosis ● Continuation of aggressive clinical interventions because of financial incentives in the fee for service (FFS) plans about EOL. According to Cicolello and Anandarajah (2019), there is an aspect of avoidance and emotional stress among physicians: “One physician stated, ‘Sometimes I can get very close to people, and I don’t want to do it too, so sometimes it’s my own personal barrier’” (Cicolello & Anandarajah, 2019, p. 873). Because of this delay, the patient is often imminently or actively dying when the decision is made to approach the family.
barriers to hospice care, participants commented on both the beneficial and the potentially detrimental beliefs, including how families can find comfort at EOL; however, sometimes the hope of a miracle “could lead to prolonged suffering because of nonmedically indicated life-sustaining measures” (Cicolello & Anandarajah, 2019, p. 875). CONTINUATION OF AGGRESSIVE CLINICAL INTERVENTIONS BECAUSE OF FINANCIAL INCENTIVES The FFS payment system has historically paid for and provided percentage of palliative care deaths and discharges that were higher in larger hospitals (C-TAC, 2019).
All these barriers further emphasize the need for clinicians to educate themselves on the benefits of early palliative care and hospice referrals, as these services have been proven to improve quality of life, improve patient outcomes and goals, and reduce costs (C-TAC, 2019). As the population ages, life expectancy increases, and the prevalence of advanced illness rises, clinicians must be ready to introduce hospice and palliative care services early in a patient’s serious illness trajectory and not in the last days of a patient’s life. inpatient units or SNFS) which can occur under the following circumstances. ○ Caregivers who may be suffering from physical or emotional exhaustion from taking care of a patient around the clock ○ Caregivers who would like to attend a family event such as a graduation, wedding, or funeral ○ Caregivers who become ill and cannot take care of the patient (NHPCO, 2019b) 4. General inpatient care: When the patient develops uncontrolled acute symptoms or a medical issue which cannot be resolved in the home or with continuous care, general inpatient care must be provided by the hospice. This includes issues such as (NHPCO, 2019a): ○ Uncontrolled pain and/or agitation ○ Uncontrolled seizures ○ Uncontrolled nausea and vomiting ○ Unmanageable dyspnea ○ Complex wound care ○ Minor comfort care procedures (e.g., paracentesis) to participate in hospice programs. Their role in the IDT is to assist in various tasks, including caregiver support, patient companionship, legacy writing, and administrative duties.
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