Ed's Note: This article is reprinted from the inaugural issue of Integrated Healthcare Delivery. To subscribe, visit IHDelivery.com.
Hospice care is focused on the palliation of serious and terminally ill patients’ pain and symptoms. While the concepts of hospice care have been around for hundreds of years, many are still unsure about what hospice care actually entails.
The Medicare hospice benefit was established in 1982 to ensure patients in their last six months of life would have access to high-quality palliative care provided by a multidisciplinary team. Since then, the hospice industry has expanded. The National Hospice and Palliative Care Organization reported more than 1.5 million people received care from hospice in 2012. This care is focused on the patient and family, supported by a team of clinicians and other services primarily delivered in a patient’s home. Hospice care can also be delivered in any setting from hospitals to nursing homes.
Even with hospice’s focus on supportive care to terminally ill patients at the end of life, some enrollees leave hospice before death in search of therapies that may prolong survival. Approximately 15% of hospice enrollees leave hospice care alive. Certain types of patients may be more likely to withdraw to seek life-prolonging therapies, and it is important for hospice providers to adequately assess the revocation risks.
In order to understand some of the difficulties that face hospice programs in the United States, one must understand the Medicare Hospice Benefit. Patients must have a prognosis of six months or less to receive hospice care under the Medicare Hospice Benefit. Care is reimbursed on a per diem basis, and inpatient care is restricted to pain and symptom management that cannot be managed in another setting. The level of care provided also depends upon criteria that must be met. Care levels can range from scheduled home visits to around-the-clock nursing in the home or a healthcare setting.
The hospice provider becomes the recipient of the Medicare benefit and therefore is the payer if care outside of hospice is received. A single 9-1-1 call and transport to an emergency department by ambulance places a substantial financial strain on hospice providers. Charges from an ED visit and hospitalization for care can exceed $10,000, for which the hospice provider is responsible. Enrollees may revoke the hospice benefit at any time by simply signing a document, following which their traditional Medicare benefits are restored. The revocation process is similar for Medicaid and most private insurers. These rehospitalizations and revocations are often predictable but most hospice providers lack the external partnerships to break the cycle.
In addition to understanding how cultural preferences for end-of-life care may influence decisions to withdraw from hospice, another important consideration is what happens to those who leave hospice. Most patients are referred to hospice shortly before death, when life-prolonging therapies, even if used, may not be effective. Many patients are referred to hospice by clinical care providers who have not fully explained what hospice care is. Others remain in denial of what their clinical status truly is and are not ready to accept it.
MedStar Mobile Healthcare in Fort Worth, TX began initiatives in 2009 to reduce unnecessary ambulance transports and direct patients who call 9-1-1 with low-acuity complaints to a more appropriate location for care than an ED. At the same time, Vitas Hospice of North Texas was developing an assessment tool to help identify patients and families at high risk for rehospitalization or revocation. A meeting between MedStar and Vitas started a partnership that continues to grow.
Vitas was aware of the success MedStar was having with its Mobile Health Paramedic (MHP) program, and asked: if high-risk hospice patients or families called 9-1-1, could a partnership between EMS and hospice help prevent rehospitalizations and revocation of hospice?
Vitas’ assessment tool identifies patients and family at high risk for revocation. The first high-risk indicator is a patient receiving aggressive therapies that may result in a hospice discharge. The second indicator is patients having a high-risk diagnosis like COPD, end-stage AIDS or being a pediatric patient. Finally, if there is a history of calling 9-1-1, these patients are recognized as high-risk during the admission process and are referred to the MedStar program.
The criteria are often obvious. From an EMS perspective, families are the most common callers to 9-1-1 in the hospice setting. Reasons for calling are often related to conditions normally associated with the medical diagnosis or even end-of-life situations. If the family calls the hospice provider and they are immediately available, hospice responds and is able to provide the needed care and comfort to the family. However, when families are scared, or uncomfortable with the estimated time of arrival of the hospice provider, they may call 9-1-1. Most EMS providers lack the special training to intervene in these difficult situations. Most often, EMS simply fulfills the family’s request and transports the patient to the ED. With EMS reimbursement tied to transportation to a hospital, few systems are looking for alternatives.
Patients at medium risk for rehospitalizations and revocation of hospice include those with a newly diagnosed condition, those who have declined (or their family has declined) a DNR, those who lack appropriate family care or support at home, and those who have controversy or disunion in the family concerning hospice.
When patients and families at risk are identified, a referral is made from Vitas to MedStar. The MedStar MHP schedules a home visit to meet with the patient and their family. The MHP provides a non-emergency phone number that is answered in the MedStar call center by the emergency medical dispatcher. The patient’s address is also flagged in the computer aided dispatch system. In the event that a 9-1-1 call is received from that address, an alert is given to the 9-1-1 call taker notifying them that a program hospice patient is at that address.
If a call comes in on a non-emergency number and the call taker identifies no emergency, the MHP is dispatched to respond alone. If a medical emergency is identified or the caller is unable to verbalize the need, a traditional 9-1-1 response is dispatched, which includes ambulance, fire department first responders and the MHP. MedStar then notifies the Vitas call center of the situation so they can dispatch staff to the home and evaluate the situation.
The goal of the program is to keep the patient enrolled in hospice while helping to meet the patient’s and family’s needs. The MHP also has a protocol to utilize the hospice care pack, which includes pain medication and often a sedative, until the hospice nurse arrives.
Since the program started in early 2013, Vitas has referred 112 patients to the program. MedStar enrolled 97 of the 112. Some were excluded due to being outside the MedStar service area, and some died prior to the initial visit. Of those enrolled, 57 (58.8%) have completed the program and 24 (21.4%) are still active. One had a significant improvement in clinical status and was discharged from hospice. Eleven (11.3%) revoked hospice, which was an improvement from the number expected. There have been 11 9-1-1 calls from enrolled patients. Five of those were transported; three were taken to the ED and two were directly admitted to an inpatient hospice bed. Vitas is reimbursing MedStar for enrolling patients, on a fee-for-service basis.
The preliminary data show this program has decreased the expected rehospitalization and revocation of high-risk hospice patients. Families have been extremely satisfied with the program. Those who have needed to utilize the MHP have voiced their comfort in knowing there was someone there when the hospice provider was delayed.
Vitas is looking to expand this program into other areas. Current limitations are primarily focused around the 9-1-1 call. Newer, remote monitoring devices may help overcome the 9-1-1 call limitations. If patients or families have problems, activating the remote system will provide a direct connection to the communications center without the need to make a phone call. Partnerships between MedStar and other EMS providers will be the key in those expanded service areas.
With changes in healthcare upon us, we must look to new, innovative delivery models and partnerships. This Hospice Revocation Prevention Program is an example of how two healthcare delivery companies whose practices only cross in the worst of times can create a partnership that improves not only our practices, but the experience of patients and their families in one of the most difficult times.
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Sean Burton is the clinical programs manager of the Mobile Integrated Health and Critical Care Programs at MedStar Mobile Healthcare in Fort Worth, TX. Sean began his career in EMS 18 years ago, coming to MedStar in 2001. During this time he has functioned as a primary paramedic, field training officer, operations supervisor and as the clinical quality coordinator. Sean was the recipient of an EMS Top 10 Innovators award in 2012 for his work with the MedStar Mobile Healthcare team. He is a national speaker and published author on mobile integrated healthcare programs. Sean is a critical care certified paramedic with an Associate of Science degree from the United States Air Force.