How can hospices address length-of-stay picture?
Better data, new benefit structures discussed
Although hospices across the country agree that the shrinking length of stay in hospice is a challenge, financially, administratively, and clinically, answers for how to address the issue are harder to come by.
More education of physicians and the public, so they understand what hospice is, what it offers, and how it can best be utilized, has been needed since the movement’s early days. But some providers suggest that all the education in the world isn’t enough to change deeply ingrained patterns of behavior for physicians, insurers, and potential clients. They have started looking elsewhere for answers.
First of all, hospice managers need to understand, as well as they can, the true nature of the problem. Who are the short-stay patients, and how do they compare with longer stay patients? Who are their physicians, and how do their referral patterns compare with agency norms? What are the most common diagnoses for these patients? Where were they served in the 30 days before coming to hospice? What is the hospice’s cost per day for shorter and longer stay patients, and how does this relate to payers’ cost data for the time dying patients are not enrolled in hospice during their final months of life? "We all have a vague notion of these patients, but none of us have really torn the issue apart," says Porter Storey, MD, medical director of the Hospice at the Texas Medical Center in Houston.
"We ended up doing a lot of different things trying to figure out why and how to better provide services to these short-stay patients," says John Ceynar, RN, CRNH, admissions coordinator for HealthSpan Hospice in Roseville, MN. "One thing we identified. Patients were refusing hospice services until very late. We determined that’s not going to change. So we asked the next question, Can we identify short-stay patients, in order to serve them better?’"
Experienced hospice professionals may believe they can pick out the short-stay patients in advance, but that may not necessarily be true. "I asked our assessment nurse to make a prediction of length of stay for 75 patients admitted over a three-month period," Ceynar says. "Our thinking was that would be easy to do, but the reality is it’s very hard. She was only able to pick out the patients who would live less than seven days 21% of the time."
Adds Gretchen Brown, MSW, president and CEO of Hospice of the Bluegrass in Lexington, KY, "The data such as SUPPORT [Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment] point out that nobody really knows how to do this very well, yet we in hospice are being judged on it."
Another question for hospices is how to streamline key services and processes to reduce time lags and increase efficiency in managing crisis patients. Can they use continuous quality improvement techniques to redesign processes such as intake, admissions, charting, and billing, in order to maximize the time they can spend with late referrals?
Ceynar’s hospice experimented with a three-pronged admission process:
• speedy admissions on crisis referrals, with the goal of getting out and starting the paperwork and problem-solving as quickly as possible;
• needy admissions, with complex needs and problems requiring intensive involvement of the full team;
• regular admissions.
"We tried it for a couple of weeks, and it didn’t work. It was impossible to make the determination over the phone. So we decided to have one admission team do all admissions and make sure these admission people have the skill, expertise, and time to do the job. In a sense, we’re now treating everybody as a short-stay patient," Ceynar says.
In a presentation at the National Hospice Organization’s annual meeting in Atlanta in October, Robin L. McMahon, MSW, LCSW, and Eileen Dohmann, RNC, MBA, of Inova VNA Hospice in Fairfax, VA, described how their agency developed an action plan for short-stay patients, focusing on issues of time management, efficiency, team communication, and identification of any available resources within the agency and in the family’s support system. In some cases, medications are ordered even before the first home visit, and team members are informed immediately by phone if it looks like a short-stay case. Certain information, such as a funeral planning guide, is included in the information packet given to the family at the time of admission. The admission nurse also tries to do some physical care on the first visit, to demonstrate to the family what hospice is all about.
What else can hospices do about service delivery for these patients? "We have created a committee charged with looking at how to deal with short-stay patients," Brown says. It may be that chaplains need to visit each patient within the first few days, since waiting until the second week could be too late, she explains. "These patients may need different things. They’re more anxious, for starters. Maybe the nurse can’t go back to the office and call the family’s priest tomorrow because that would be too late."
Although families of short-stay patients may be just as satisfied with their care, in subsequent bereavement surveys they have indicated that they wished the hospice referral would have come earlier, Ceynar says. "Given this data, even though patients up front are saying, I’m not ready,’ we know that once they experience our services, they sometimes do an about-face and acknowledge that they wish they had signed up sooner. I think we may need to do some work around that," he explains. "How do we talk about our services and the connotation of the word hospice?"
"Ultimately, I think we’ll come up with plans for effective short-term work smaller supplies of medications, more intensive social work," says Jo Cunningham, MA, vice president of Lifespan Home Health and Hospice in Battle Creek, MI. "Even those patients on service for three days are so grateful. It takes more planning, but I think we can do it and do it really well."
Some hospices have found that they can change perceptions in the community by emphasizing other aspects of their services, such as grief counseling for families of patients who didn’t die in hospice, or programs in the schools, even a capital campaign for a new office building. "One of the things that helped us the most is our new 36-bed hospice residential center," which opened in June 1996, says Pamela Melbourne, director of Hospice Atlanta. "It makes hospice more visible, and it has helped some of our physicians to use it as transitional care for patients going home from the hospital. It makes people more prone to consider hospice referrals and creates a higher understanding of what hospice means," she says.
Hospice of Petaluma has been working with several ethics-related resources in its hospital system to tackle the short-stay dilemma, says CQI coordinator Marilee Blonski, RN, MSN. A joint ethics consultation by David Blake with the Center for Health Care Ethics in Orange, CA, was held with the system’s home health agency in October, to explore the ethics of transferring patients to hospice. The hospice’s parent hospital has offered its bioethics committee as a forum for discussing the issues with physicians, while a joint continuum committee has also been meeting to explore the issues, Blonski says.
Other hospices talk about increasing the use of continuous care for imminently dying patients who are truly in crisis, or promoting more cordial relationships with referral sources and physicians, so that patients discharged when their condition stabilizes can be brought back on board quickly and smoothly when they take a turn for the worse. Solid data on actual cost and utilization experience with short-stay patients may help to persuade some managed care payers to consider other approaches, while the hospice medical director can play a key role in working one-on-one with referring physicians.
Ultimately, however, the problem may require a remedy in the public policy arena. "The biggest issue is whether the Medicare benefit is still appropriate," Melbourne says. "Should we have a higher reimbursement rate for patients on such a short stay? The reality is that health care has changed since the Medicare benefit was enacted."
"I think some tiered Medicare alternatives [for short-stay patients] may be valid, although I’m not sure it would fly in Congress," says Rodney S. Taylor, executive director of Hernando Pasco Hospice in Hudson, FL.
Designing a tiered system or different levels of care for short-stay patients could be an administrative and bookkeeping nightmare for hospices, especially since it’s so hard to identify short-stay patients in advance, adds Jacob Blass, MA, president and CEO of Hospice of Metro Denver. "Ultimately the reimbursement mechanism for hospice must change. I believe before very much longer the Medicare carve-out will be more of a detriment than an advantage to our industry."
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