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Response to the Letter to the Editor by Matthew Raider, “Hospice in the Nursing Home: Perspective of a Medical Director”
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Letters to the Editor / JAMDA 16 (2015) 433e437
Susan C. Miller, PhD Brown University School of Public Health Providence, RI http://dx.doi.org/10.1016/j.jamda.2015.02.008
Response to the Letter to the Editor by Matthew Raider, “Hospice in the Nursing Home: Perspective of a Medical Director” To the Editor: The old idiom “don’t throw the baby out with the bath water” applies to the use and misuse of hospice in the nursing home. Office of Inspector General reports and epidemiologic data suggest that hospice is often not properly used in long-term care (LTC) with increasing numbers of very long and very short hospice stays, high deficiency rates, nebulous diagnoses used for enrollment, and questionable effectiveness of LTC-hospice collaborations.1e4 However, as several authors have pointed out, hospice use in the LTC setting has been shown to improve several patient care outcomes and reduce cost at all time periods.1,5e7 I will argue that hospice has a very important, yet distinct, role in the LTC setting (compared with the home or hospital settings) and it is up to both hospice and nursing home medical directors to help better define and operationalize those roles. Since the emergence of the hospice benefit in the 1980s, LTC facilities have changed dramatically, with a greater focus on rehabilitation. LTC providers increasingly have more training in acute care practices and less in end-of-life care. Communication skills to discuss goals of care and education in the management of complex issues are often underdeveloped, which limits the ability for LTC staff to participate in end-of-life discussions and care planning, especially in the nursing and social work fields.8 It is now time to reassess and properly use additional resources, such as hospice, to fill the palliative care gaps left by the shift to the post-acute care model of LTC. The article by Unroe et al9 shows that although most surveyed nursing home personnel had a favorable view of hospice, there were many reported negative experiences, primarily from the nursing staff. I will argue that hospice agencies that plan to enroll LTC residents ought to focus on the needs of the nursing home, such as better medication assessment (as pointed out by Dr Raider), communication between families and providers, and education of nursing home staff on management of end-of-life issues. The provision of additional assistance for daily personal care by hospice staff can help facility staff to focus attention on other residents with high care needs and allocate limited resources for other important programs, such as exercise classes, meaningful social activities, and person-centered dementia care. Alternatively, funds allocated to the Medicare hospice benefit could be re-allocated to the nursing facilities themselves to develop internal palliative and end-of-life programs. This could help to eliminate the communication barriers of having an external party
involved in care and allow each facility to build a program to fit its unique resident population. Demonstration projects have been proposed to measure the effects of such programs on cost, access, quality of care, and survival. Huskamp et al10 describe a modified program for LTC, which drops the 6-month prognostic requirement and requirement to forgo curative treatments while providing a combination of palliative and psychosocial-spiritual support. In this model, supplemental payments are made directly to the nursing home and end-of-life services are “carved-in” and adjusted to need. The facilities may choose to train their own staff to provide care directly or contract with local hospice companies to provide this care. This model has not yet been tested, and although facilities would be held accountable for the quality of care provided, quality indicators and the threshold for patient eligibility have not yet been determined. In 2014, the Centers for Medicare and Medicaid Services (CMS) called for research protocols to test concurrent hospice and curative-intent demonstration projects for patients with advanced illness as outlined in the Affordable Care Act section 3140. Unfortunately, both nursing facility residents and patients with dementia were excluded from program eligibility. It is imperative that medical directors and other leaders in LTC request demonstration project funds from CMS to test new models that will enhance the care provided at the end of life for our vulnerable LTC population. In the meantime, let’s work together with our hospice providers to better define their roles, improve communication, and provide excellent palliative care, instead of throwing them out to the curb.
References 1. Miller SC, Lima J, Gozalo PL, Mor V. The growth of hospice care in US nursing homes. J Am Geriatr Soc 2010;58:1482e1488. 2. National Hospice and Palliative Care Organization. Hospice Care in America. NHPCO Facts and Figures, 2013 edition. Available at: http://nhpco.org/sites/ default/files/public/Statistics_Research/2013_Facts_Figures.pdf. Accessed February 17 2015. 3. Office of the Inspector General. Medicare Hospices: Certification and Centers for Medicare & Medicaid Services Oversight, OEI-06e05e00260, Apr 2007. Available at: http://oig.hhs.gov/oei/reports/oei-06-05-00260.pdf. Accessed February 17 2015. 4. Office of the Inspector General. Medicare Hospice Care for Beneficiaries in Nursing Facilities: Compliance with Medicare Coverage Requirements, OEI02e06e00221, Sept 2009. Available at: http://oig.hhs.gov/oei/reports/oei-0206-00221.pdf. Accessed February 17 2015. 5. Kelley AS, Deb P, Du Q, et al. Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths of stay. Health Aff (Millwood) 2013;32:552e561. 6. Zheng NT, Mukamel DB, Friedman B, et al. The effect of hospice on hospitalizations of nursing home residents. J Am Med Dir Assoc 2015;16: 155e159. 7. Swagerty D. Integrating palliative care in the nursing home: An interprofessional opportunity. J Am Med Dir Assoc 2014;15:863e865. 8. Bern-Klug M, Kramer KW, Chan G, et al. Characteristics of nursing home social services directors: How common is a degree in social work? J Am Med Dir Assoc 2009;10:36e44. 9. Unroe KT, Cagle JG, Dennis ME, et al. Hospice in the nursing home: Perspectives of front line nursing home staff. J Am Med Dir Assoc 2014;15:881e884. 10. Huskamp HA, Stevenson DG, Chernew ME, Newhouse JP. A new Medicare endof-life benefit for nursing home residents. Health Aff (Millwood) 2010;29: 130e135.
Milta O. Little, DO, CMD Division of Geriatric Medicine Saint Louis University School of Medicine St. Louis, Missouri http://dx.doi.org/10.1016/j.jamda.2015.02.009
Letters to the Editor / JAMDA 16 (2015) 433e437
Susan C. Miller, PhD Brown University School of Public Health Providence, RI http://dx.doi.org/10.1016/j.jamda.2015.02.008
Response to the Letter to the Editor by Matthew Raider, “Hospice in the Nursing Home: Perspective of a Medical Director” To the Editor: The old idiom “don’t throw the baby out with the bath water” applies to the use and misuse of hospice in the nursing home. Office of Inspector General reports and epidemiologic data suggest that hospice is often not properly used in long-term care (LTC) with increasing numbers of very long and very short hospice stays, high deficiency rates, nebulous diagnoses used for enrollment, and questionable effectiveness of LTC-hospice collaborations.1e4 However, as several authors have pointed out, hospice use in the LTC setting has been shown to improve several patient care outcomes and reduce cost at all time periods.1,5e7 I will argue that hospice has a very important, yet distinct, role in the LTC setting (compared with the home or hospital settings) and it is up to both hospice and nursing home medical directors to help better define and operationalize those roles. Since the emergence of the hospice benefit in the 1980s, LTC facilities have changed dramatically, with a greater focus on rehabilitation. LTC providers increasingly have more training in acute care practices and less in end-of-life care. Communication skills to discuss goals of care and education in the management of complex issues are often underdeveloped, which limits the ability for LTC staff to participate in end-of-life discussions and care planning, especially in the nursing and social work fields.8 It is now time to reassess and properly use additional resources, such as hospice, to fill the palliative care gaps left by the shift to the post-acute care model of LTC. The article by Unroe et al9 shows that although most surveyed nursing home personnel had a favorable view of hospice, there were many reported negative experiences, primarily from the nursing staff. I will argue that hospice agencies that plan to enroll LTC residents ought to focus on the needs of the nursing home, such as better medication assessment (as pointed out by Dr Raider), communication between families and providers, and education of nursing home staff on management of end-of-life issues. The provision of additional assistance for daily personal care by hospice staff can help facility staff to focus attention on other residents with high care needs and allocate limited resources for other important programs, such as exercise classes, meaningful social activities, and person-centered dementia care. Alternatively, funds allocated to the Medicare hospice benefit could be re-allocated to the nursing facilities themselves to develop internal palliative and end-of-life programs. This could help to eliminate the communication barriers of having an external party
involved in care and allow each facility to build a program to fit its unique resident population. Demonstration projects have been proposed to measure the effects of such programs on cost, access, quality of care, and survival. Huskamp et al10 describe a modified program for LTC, which drops the 6-month prognostic requirement and requirement to forgo curative treatments while providing a combination of palliative and psychosocial-spiritual support. In this model, supplemental payments are made directly to the nursing home and end-of-life services are “carved-in” and adjusted to need. The facilities may choose to train their own staff to provide care directly or contract with local hospice companies to provide this care. This model has not yet been tested, and although facilities would be held accountable for the quality of care provided, quality indicators and the threshold for patient eligibility have not yet been determined. In 2014, the Centers for Medicare and Medicaid Services (CMS) called for research protocols to test concurrent hospice and curative-intent demonstration projects for patients with advanced illness as outlined in the Affordable Care Act section 3140. Unfortunately, both nursing facility residents and patients with dementia were excluded from program eligibility. It is imperative that medical directors and other leaders in LTC request demonstration project funds from CMS to test new models that will enhance the care provided at the end of life for our vulnerable LTC population. In the meantime, let’s work together with our hospice providers to better define their roles, improve communication, and provide excellent palliative care, instead of throwing them out to the curb.
References 1. Miller SC, Lima J, Gozalo PL, Mor V. The growth of hospice care in US nursing homes. J Am Geriatr Soc 2010;58:1482e1488. 2. National Hospice and Palliative Care Organization. Hospice Care in America. NHPCO Facts and Figures, 2013 edition. Available at: http://nhpco.org/sites/ default/files/public/Statistics_Research/2013_Facts_Figures.pdf. Accessed February 17 2015. 3. Office of the Inspector General. Medicare Hospices: Certification and Centers for Medicare & Medicaid Services Oversight, OEI-06e05e00260, Apr 2007. Available at: http://oig.hhs.gov/oei/reports/oei-06-05-00260.pdf. Accessed February 17 2015. 4. Office of the Inspector General. Medicare Hospice Care for Beneficiaries in Nursing Facilities: Compliance with Medicare Coverage Requirements, OEI02e06e00221, Sept 2009. Available at: http://oig.hhs.gov/oei/reports/oei-0206-00221.pdf. Accessed February 17 2015. 5. Kelley AS, Deb P, Du Q, et al. Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths of stay. Health Aff (Millwood) 2013;32:552e561. 6. Zheng NT, Mukamel DB, Friedman B, et al. The effect of hospice on hospitalizations of nursing home residents. J Am Med Dir Assoc 2015;16: 155e159. 7. Swagerty D. Integrating palliative care in the nursing home: An interprofessional opportunity. J Am Med Dir Assoc 2014;15:863e865. 8. Bern-Klug M, Kramer KW, Chan G, et al. Characteristics of nursing home social services directors: How common is a degree in social work? J Am Med Dir Assoc 2009;10:36e44. 9. Unroe KT, Cagle JG, Dennis ME, et al. Hospice in the nursing home: Perspectives of front line nursing home staff. J Am Med Dir Assoc 2014;15:881e884. 10. Huskamp HA, Stevenson DG, Chernew ME, Newhouse JP. A new Medicare endof-life benefit for nursing home residents. Health Aff (Millwood) 2010;29: 130e135.
Milta O. Little, DO, CMD Division of Geriatric Medicine Saint Louis University School of Medicine St. Louis, Missouri http://dx.doi.org/10.1016/j.jamda.2015.02.009