Hospices can enhance access for urban populations by creating teams that are more inclusive and reflective of the communities that they serve. Useful strategies include outreach programs, linkages with other programs in community facilities, and trained volunteers and staff who can work with patients in nontraditional settings.29,30
The Hospice of Florida Sun coast, for example, is a nonprofit group that was established by volunteers and serves more than 1,200 patients per day in Pinellas County in Florida. About three quarters of its AIDS patients and about half of its nursing-home residents are Medicaid beneficiaries. It is able to offer $8 million a year in uncompensated care through the fund-raising efforts of a dedicated foundation and well-developed volunteer programs. Its intergenerational teen volunteer programs includes a ‘Life Time Legacies’ life-review program by trained teens with terminally ill patients. It has also created a coalition of 22 faith-based communities with more than 130 volunteers who provide care for terminally ill or older members. Its 67-bed residential program has offered more than 1,300 patients the ability to live in a 24-h home-like setting who would not be able to live in other living arrangements. It also offers service to 88 of the 91 skilled nursing facilities in Pinellas County. It has also pioneered a patient-information system ‘Sun coast solutions’ that is currently used in the care of over 20,000 patients each day across the country. This allows teams to exchange information electronically, access clinical data 24 h/day, and to access optimal symptom-management protocols and increases the proportion of clinicians’ time spent with patients each week by 20%.
African Americans and Latinos have been highly receptive to end-of-life care services that emphasize family consensus and spirituality and provide relief for patients and families. Surveys indicate a need for improving awareness of hospice in these communities.24
One New York hospice, Continuum Jacob Perlow, has enhanced access to palliative care for economically disenfranchised patients through initiatives such as a hospice residence in the Bronx which was established in 2005. Of 136 sequential admissions, 38 have been for patients who were homeless and would not otherwise have had access to hospice services. Its staff’s diversity reflects that of the borough. Thirty eight percent are white, 34% African American and Afro-Caribbean, 25% Hispanic, and 3% are Asian. The staff provides care to an average daily census of 135–150 Bronx residents and their families. In 2005, they cared for 730 patients and their families. Ninety percent of this care is provided in the patients’ homes. The diversity of its staff coupled with outreach programs are allowing inroads to be made in access to hospice care for a predominantly low-income and minority population. A hospice-supported palliative care and case-management team in collaboration with the palliative-care service in the Emergency Department at Montefiore Medical Center (MMC) allowed close to one third of patients who died over the course of the pilot project’s activities access to hospice services; this compares favorably with an estimate of 7.7% of patients who were admitted to acute care at the medical center between 2000 and 2003 who died with the hospice benefit in place. Of patients served, 65% were African American or Hispanic. Of significance, approximately 78% of patients who died who were served by this project died outside of the medical center. The enhanced availability of home hospice and palliative homecare services may account for these patients ability to die in their place of residence.28,31
The development of hospice contracts with many local long-term-care facilities has permitted terminally ill older adults who require more care than can be provided in the home-care setting with access to an additional tier of services in nursing homes that may also account for some reduced utilization of the acute-care setting by such patients.
Community hospitals nationally and in the Bronx have increased access to hospice by the development of contracts with multiple hospice providers and designation of hospital beds as being available for hospice ensuring access to acute care for patients who have acute worsening of progressive illnesses warranting hospitalizations. Hospices provide services on available community resources and participate in interdisciplinary rounds for patients who are hospitalized to identify patients who would benefit from hospice.
This integration of hospice into the operations of acute-care hospitals has occurred in parallel with the development of full-time multidisciplinary palliative-care consultation services in most of the acute-care hospitals in the Bronx. The palliative-care service at MMC, for example, is now able to provide consultative and primary in-patient care to approximately 40% of the adult patients who die at the Medical Center each year. In one advance-practice-nurse-staffed intensive-care-unit-based project, 75 critically ill patients were able to be placed on hospice between 2005 and 2007. Formalized training on hospice and palliative medicine has been incorporated into the curricula of family-medicine and internal-medicine residencies, medical students, geriatric, psychiatry, and oncology fellowships at MMC. Hospice is supporting the development of hospice and palliative-care physicians and social-work fellowships at MMC and in other community medical centers for health-care professionals who will subsequently develop similar programs for low-income patients and families in other community urban settings.
Other recent developments in hospice care include a shift from the traditional dichotomous cure or palliation paradigms with the advent of Open Access policies for hospice eligibility which remove the stipulation that patients discontinue disease-modifying therapy to enroll on hospice. For urban economically disenfranchised patients, the ability to continue certain therapies, such as palliative chemotherapy or radiation at the same time as which they can receive multidisciplinary home hospice care, may facilitate the transition to end-of-life care that is more supportive in its focus and less likely to be associated with death associated with the use of life-prolonging treatments.
Financial Implications of Greater Access to Hospice
While many acute-care hospitals can support home-care agencies, most hospices are not divisions of acute-care hospitals. To maintain a census sufficiently high to support the cost of a multidisciplinary team, most hospices partner with multiple acute-care and long-term facilities. The provision of palliative home care is time-intensive and requires specific expertise and training. Hospices can partner with home-care agencies through the provision of one-time consultations by advance-practice nurses or physicians which can be reimbursed through Medicare part B without an increment in cost to the home-care organization.32
In long-term-care settings, the hospice can add another tier of services for patients that are also reimbursed through Medicare. Such services can enhance quality of care such as additional nurses’ aide hours for patients with advanced dementia, increased focus on pain as a result of weekly visits by nurses and focus on psychosocial and spiritual well-being by hospice social workers and chaplains. However, for many older long-term residents at the end of life who are not yet dual eligible for Medicare and Medicaid, hospice may not be an option as the room and board charges for the nursing home would be out of pocket.
Hospice may enhance the impact of hospital palliative-care teams on rates of use of acute care. Home visits by hospital-based teams are sporadic, time-intensive, and not sustained by the reimbursement for such services by payers. Enrollment on hospice can permit a moderate revenue stream for acute-care hospitals for patients who are critically ill at the end of life who require on-going hospitalization and for whom discharge is not practical due to the level of medical support that they require. Such patients are likely to have protracted hospitalizations which exceed the Diagnosis-Related Group limits of payment by many payers. Hospice can also subsidize the cost of implementation of hospital palliative-care programs which cannot sustain themselves financially through reimbursement by payers. For many financially strained urban community hospitals, this could permit the implementation of palliative-care programs.