Transforming Palliative Care in Nursing Homes: The Social Work Role (End of Life Care: A Series)

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These specialists will also help patients and their families better understand the palliative process. Ho and family. By increasing palliative care planning we can keep people living at home longer, surrounded by their loves ones. The trouble is, sometimes that discussion never happens. This program helps to meet the health and spiritual needs of patients and families, and that is very important to our family.

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Nursing and the Future of Palliative Care

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“Whole Person Care” is Not Just Goals of Care

More specifically, the lower payments for days 61 and thereafter aimed to make longer stays less profitable, while the SIA payments aimed to incentivize providers to offer the skilled care patients often need at the very end of life. Since for-profit agencies disproportionately enroll longer stay patients, these providers will likely lose most under the new policy. Based on our analysis of hospice claims, for instance, 68 percent of for-profit agencies' total hospice days would be reimbursed at the lower rate compared to 61 percent the of total days of not-for-profit hospice agencies; tiered payments would result in payments that were 0.

Suiting the Needs: A Palliative Approach in Residential Aged Care

The impact of the SIA payments is harder to estimate, because information from hospice claims has not previously distinguished between registered nurse RN and licensed practical nurse LPN hours. Only the former are covered. Using these data as an upper bound, the financial impact of these added payments would be quite modest overall a 0.

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Of course, providers might alter their behavior in response to the payment changes. Agencies might seek to de-emphasize longer hospice stays, depending on the adequacy of the lower rate relative to the marginal costs of caring for longer-stay patients. More than a quarter of hospice users currently enroll for three days or less before death arguably too short a duration for hospice to provide substantial benefit , and 40 percent of these late referrals are preceded by hospitalizations or intensive care unit ICU stays; thus, the greater reimbursement of short-stay hospice days warrants particular attention going forward.

The recent reforms could begin to align Medicare hospice payments more closely with agency costs to some extent, but they do not address three payment-related issues that we would argue are more important to the future of the Medicare hospice benefit:. As a result, the six-month prognosis requirement and the requirement to forgo life-sustaining treatment for the terminal condition have arguably become more problematic.

Hospice Payment Reforms Are A Modest Step Forward, But More Changes Are Needed | Health Affairs

In fact, with hospice eligibility linked to prognosis and not specifically to clinical need , the predominant focus of policymakers has been on ensuring its appropriate use rather than on integrating hospice and palliative services into a broader continuum of services… whenever patients need them. This three-year, budget-neutral demonstration offers hospice-eligible Medicare beneficiaries who have not yet elected hospice the option to receive palliative care services from participating hospice agencies while still receiving therapeutic services from other providers.

Beginning January , the demonstration will roll out in hospice agencies nationwide. Although the demonstration does not alter the six-month prognosis standard, it does offer targeted groups of beneficiaries concurrent access to hospice and therapeutic services for the same underlying condition. The impact of these changes remains to be seen.

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The demonstration by definition leaves out important hospice user groups, such as those with dementia and end-stage renal disease, and it is unclear whether the monthly payments to hospice agencies will be sufficient to spur substantial innovation. Nonetheless, the demonstration reflects a growing consensus that the Medicare hospice benefit needs to evolve in response to changing patient populations and preferences.

In a quest for greater value and improved care coordination, the Medicare program has increasingly moved toward integrated financing and delivery models. One could imagine such models as being potentially beneficial for patients with advanced illness at the end of life. We have written elsewhere about the potential strengths and limitations of removing the carve out, as well as safeguards that could be put into place under such an approach.

Relative to the current benefit, for instance, managed care plans could offer hospice to patients with longer or more uncertain prognoses, while also offering concurrent access to a broader range of palliative and therapeutic services. Insurers such as Aetna have reported success with similar approaches for their under commercial populations but have been unable to expand them to their Medicare Advantage enrollees. Of the carve out, Dr.


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  • The expansion of nursing-home hospice use has since been substantial, with almost one-in-three hospice enrollees now living in nursing homes.

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