by editor | Dec 8, 2024 | Hospice Research Articles
Abstract
The Medicare hospice program is intended to provide palliative care to terminal patients, but
patients with long stays in hospice are highly profitable, motivating concerns about overuse
among the Alzheimer’s and Dementia (ADRD) population in the rapidly growing for-profit
sector. We provide the first causal estimates of the effect of for-profit hospice on patient spending
using the entry of for-profit hospices over twenty years. We find hospice has saved money for
Medicare by offsetting other expensive care among ADRD patients. As a result, policies limiting
hospice use including revenue caps and anti-fraud lawsuits are distortionary and deter cost-saving
admissions.
Read the Full Article
Link to full Article: https://tinyurl.com/43ffsufm
by editor | Dec 8, 2024 | Hospice Research Articles
Abstract
The US hospice industry has shifted from not-for-profit to for-profit ownership models,1,2 producing concerns about care quality. For-profit hospices may have higher rates of live discharges3 and hospitalizations4 and worse caregiver-reported experiences.1 Recently, hospices have been acquired by private equity firms (PEFs) and publicly traded companies (PTCs).5 Although all for-profit ownership models are oriented toward profit maximization, PEF and PTC ownership structures are distinct in being incentivized to generate short-term and above-market returns for investors,5 raising questions about the potential influence of financial objectives on quality. We compared differences in caregiver-reported hospice quality across categories of ownership.
Link to Full Article
Link to article: https://tinyurl.com/bdda96ej
by editor | Dec 8, 2024 | Hospice Research Articles
Abstract
Objective: The project aimed to standardize advanced care planning (ACP) at an internal medicine clinic by initiating physician-patient communication regarding the patient’s knowledge, understanding, and openness to pursuing advanced medical directives.
Methods: Data collection was conducted from February 1 to April 1, 2024, with the study concluding on April 24, 2024. ACP was facilitated through an initial standardized six-question pre-intervention survey in both English and Spanish. This pre-survey included questions on prior survey exposure within the past three months, current age, existing or previous medical conditions, possession of an advance directive (e.g., living will or durable power of attorney for healthcare), and interest in learning more about advanced medical directives. For patients interested in learning more, standardized educational materials from the National Institute on Aging were provided, along with a Texas out-of-hospital do-not-resuscitate (OOH-DNR) order, a Medical Power of Attorney form, and instructions in both English and Spanish. Post-education, patients completed a post-intervention survey asking if they had previously discussed advanced medical directives with a physician. The survey also included Likert scale questions about the discussion’s usefulness, comfort with end-of-life discussions, perceived importance of advanced directives, and likelihood of completing an advance directive.
Results: During the three months, 52 patients completed the pre-intervention survey, with an average age of 59 years. Hypertension, dyslipidemia, and diabetes were the most common conditions among participants. Statistical tests indicated no significant difference between patients’ age or number of comorbidities and possession of an advance directive (p > 0.05), nor was there a significant association between these variables and interest in learning more about advanced directives (p > 0.05). However, post-intervention survey results showed a significant correlation between age and prior discussions about advanced directives (p = 0.013) and between the number of comorbidities and having had past discussions (p = 0.025). Only 1.2% of patients reported having advanced directives before this study, highlighting a substantial gap in documentation.
Conclusion: This project revealed a notable gap in ACP documentation among patients at the internal medicine clinic, with very few patients having advanced directives prior to the intervention. While age and comorbidity count were not significantly associated with interest in advanced directives, older patients and those with more comorbidities were more likely to have had previous discussions. This underscores the need for targeted efforts to encourage ACP, particularly among younger patients and those with fewer medical conditions. Standardized educational resources effectively facilitated discussions, raising awareness and promoting engagement in ACP.
Discussion
This article describes a quality-improvement project in an academic internal medicine clinic that set out to standardize advance care planning (ACP) conversations with adult patients. Resident physicians used a brief, bilingual pre-visit survey (English/Spanish) to ask about prior exposure to ACP, whether patients already had documents (living will, medical power of attorney, out-of-hospital DNR), and whether they wanted more information.
Patients who were interested received standardized education from the National Institute on Aging plus printed Texas OOH-DNR and medical power of attorney forms with bilingual instructions; afterward they completed a short post-visit survey about the usefulness of the conversation, their comfort with end-of-life discussions, and their likelihood of completing directives.
Over three months, 52 patients (average age 59) completed the pre-survey; hypertension, dyslipidemia, and diabetes were the most common comorbidities. Baseline ACP documentation was extremely low. Only a handful of patients reported having any advance directive, and many were unsure. Age and number of comorbidities were not linked to who had completed directives or who was interested in learning more.
However, in the subgroup who completed post-surveys (n=23), older patients and those with more comorbidities were more likely to have had prior ACP conversations with a clinician. After the intervention, most patients said the discussion was helpful, strongly agreed that directives are important, and the vast majority reported that they now plan to complete advance directives in the future.
Takeaways for hospice agencies?
For hospice agencies, the message is clear: by the time people arrive on hospice, most still may not have had structured ACP or created documents, even if they live with serious chronic illness.
This study shows that short, scripted, bilingual conversations plus simple, printed forms can meaningfully move patients toward planning. This is something hospice agencies could adapt in their own admissions, routine visits, and community outreach.
Practical questions for hospice agencies to consider include: Do we assume referring clinics have “already done” ACP, or do we build it into our own workflows and track completion rates? Are we offering culturally and linguistically appropriate ACP materials like this clinic did? Could we partner with local primary-care practices to co-host ACP days, share standardized scripts, or co-branded NIA-based education? In our marketing, are we explicitly presenting hospice as part of a continuum that starts with good ACP in clinic, reassuring families that our role is to honor the choices they put in writing and to support them in having those hard conversations earlier, not only at the very end?
Link to Read Article
Link to article: Improving Advanced Care Planning Discussions
by editor | Dec 7, 2024 | Hospice 101 - Aides, Hospice 101 - Chaplain, Hospice 101 - Nurses, Hospice 101 - Social Workers
The world of hospice care is deeply personal and profoundly compassionate. As a hospice clinician, your primary focus is providing compassionate care to your patients and their families during their most vulnerable moments. But the intimate nature of home-based care can sometimes expose you to unexpected risks of workplace violence.
The Growing Concern of Workplace Violence
In recent years, workplace violence has emerged as a critical issue in healthcare, particularly for homecare professionals. A survey conducted by Transcend Strategy Group (https://transcend-strategy.com/insights-workforce-safety/) revealed that over 50% of healthcare workers have witnessed or experienced a violent event.
Workplace violence extends far beyond physical assault. It encompasses a broad spectrum of threatening behaviors including verbal abuse, psychological harassment, and intimidation. These experiences can have devastating consequences — not just physically — but emotionally and professionally.
There are some steps that you can take to help reduce your risk of experiencing workplace violence including pre-visit preparation, situational awareness, and setting boundaries. Let’s explore these further.
Pre-Visit Preparation is Key
Effective safety starts with thorough preparation. Before entering a home, confirm who will be present during your visit. Don’t hesitate to ask about potential safety concerns, ask to have pets restrained, and ensure no weapons are visible. Clear communication with patients and their families can prevent many potential incidents.
Proactive Safety Strategies: Situational Awareness
On visiting a patient’s home, situational awareness is a key preventative action. Situational awareness begins before you even step into a patient’s home. As you approach, take a moment to observe your surroundings. Notice changes in the in the environment – are things different from the previous times you visited the patient’s home? Are there more or fewer cars? Did something change in appearance? This isn’t about paranoia – it’s about being prepared and alert.
When you enter the patient’s home and say hello to the patient and family members, ask the patient or caregiver to introduce you to anyone else in the room if there are new people there. As you look around the room, note potential exit routes in case you need to quickly exit.
Setting Boundaries and Maintaining Professionalism
Your personal safety is paramount. While providing compassionate care is your mission, it should never come at the expense of your well-being. If a situation feels uncomfortable or threatening, you have the absolute right to remove yourself. Engage with management immediately if you feel that your safety is compromised.
Reporting and Documentation: A Critical Process
If you experience workplace violence, it is important that you report the event and that the event is documented. Unfortunately, clinicians are often hesitant to report the experience, citing reasons such as:
- Workplace violence is “part of the job” (acceptance)
- It wasn’t really a big deal… (acceptance)
- Nothing can be done about it anyway (acceptance)
- What will management think if I say something (fear of job loss)
- I want to avoid conflict with the patient/patient’s family (fear of job loss)
- I don’t want to be labeled as incompetent (fear of job loss)
- I was in the wrong place at the wrong time” (blame)
Although you may hesitate to report an incident, it is important that every incident of workplace violence is documented.
Documenting incidents is not just a procedural requirement – it’s a crucial step in preventing future occurrences and in protecting fellow clinical staff. Detailed, confidential reports help agencies identify patterns, implement preventive measures, and create safer working environments. It is important that fellow staff members are aware of potentially problematic situations that may arise when they visit the patient.
Contact Information / Buddy System
Make sure that you have provided your management with emergency contact information for so that someone can be contacted in the case of an emergency. Avoid after dark visits. If after dark visits cannot be avoided, use the “buddy system.” Make sure that someone knows where you are going and is anticipating your return or is anticipating contact from you and will either go out to look for you or call 911 if they do not hear from you.
Wrapping it Up
In summary, workplace violence is a real concern for home healthcare workers but here are steps that you can take to protect yourself:
- Conduct a home assessment to identify potential risks in the home. Be sure to act on those potential risks.
- Establish boundaries: Set your personal safety boundaries. Your personal safety is most important.
- Emergency contact: Ensure your management knows whom you would like to have contacted in case of emergency
- Avoid after dark visits: Try not to visit patient homes after dark.
- Buddy system: Make sure someone knows where you are going, knows when to expect to hear from you, and will go look for you or will call 911 if they do not hear from you by the predesignated time.
- Early termination of visit: If you feel that a situation has escalated or that you are feeling threatened, terminate the visit and engage with management to notify them of the situation.
Want to Learn More?
by editor | Oct 13, 2024 | Compliance and Regulatory - Directors, Hospice 101 - Aides, Hospice 101 - Chaplain, Hospice 101 - Nurses, Hospice 101 - Office Team, Hospice 101 - Social Workers, Interdisciplinary Team, Regulatory Compliance, Rules and Regulations - Chaplains, Rules and Regulations - Nurses, Rules and Regulations - Social Workers
The hospice interdisciplinary group (IDG) creates a patient’s plan of care and provides holistic care to the patient, caregiver, and family. Hospice Conditions of Participation require the IDG to “review, revise, and document the individualized plan as frequent as the patient’s condition requires, but no less frequently than every 15 calendar days.”
As such, the IDG meet at a minimum every 15 days. In many hospice organizations, the interdisciplinary group meets weekly to review patient status and to determine if changes are required to a patient’s plan of care. It is important that during the IDG meeting patients’ care plans are reviewed and updated based upon patients’ assessments. Timely and accurate documentation is critical; this documentation may be reviewed by surveyors and by CMS to ensure compliance with regulations.
Who is required to attend an IDG Meeting
Required members of the IDG meeting include:
- A doctor who is an employee or under contract with the hospice agency
- Registered nurse
- Social worker
- Pastoral or other counselor
These four individuals are minimum participants in the IDG meeting. If one of these members i missing from the IDG meeting, the meeting does not meet Medicare regulations and it is considered as if the meeting did not take place. . Care must be taken to ensure that the minimum requirement – IDG meeting with the participation of at least these four individuals at a minimum of once every 15 days – is met.
Additionally, a staff member is typically identified to serve as the scribe for the IDG meeting. The scribe captures any changes to a patient’s plan of care that are agreed upon during the meeting.
What activities occur during the IDG meeting?
When the meeting begins, all participants sign the meeting sign-in sheet. These sheets serve as documented proof that the hospice has met the Medicare Conditions of Participation – that the required members of IDG participated in the meeting. Sign in sheets are stored in a place that is accessible for review upon the request of auditors or surveyors.
Prior to the IDG meeting, a list is drawn up of the patients who will be reviewed during the meeting. For each of these patient’s members of the care team provide an update on the patient’s current condition, highlighting any concerns. The team then discusses the plan for the upcoming two weeks.
Patients may be ordered for discussion as follows:
- Deaths
- Admissions
- Recertifications
- Evaluation
Let’s review each of these in detail.
Deaths
Each death since the prior IDG meeting is reviewed. The team discusses whether bereavement has been requested or declined. In the case where bereavement has been requested, the individuals who will be receiving bereavement services are identified. Any further details or concerns on the services that will be provided are discussed.
Admissions
The RN Case manager discusses any new admissions since the prior IDG meeting, including patient diagnosis and hospice eligibility criteria. Visit frequency is discussed, hospice aide services, and patient psychosocial needs. Typically, all team members partake in this discussion including a discussion about patient medications and prognostic indicators.
Recertifications
At this stage in the IDG the team discusses all patients who are the end of their benefit period and need to be recertified. Any face-to-face visits that were conducted will be discussed and any that are still pending will need to be scheduled. For patients who were evaluated and are found not to meet criteria, the team discusses how to notify the family and details on how to transition the patient off of hospice care.
Evaluations
All remaining patients on the list are reviewed by the members of the IDG. The team discusses whether any changes to the plan of care are needed, whether any medications need to be changed or if any additional support is required (e.g., chaplain, volunteer). The plan of care may be updated if the team agrees that a change in visit frequency is required.
Updating patients’ plan of care
While each patient is discussed, any changes to the patient’s plan of care are entered into the patient’s chart, which is signed by the medical director.
