Walla Walla Community Hospice (WWCH) is expanding its service area after a local hospital ended its hospice care program.

The Walla Walla, Wash.-based hospice, which currently serves its home county as well as Columbia County in Washington and parts of Umatilla County in Oregon, will now provide care to Pendleton, Ore., and its surrounding communities.

“In 2017 it came to our attention that the penetration rate for hospice in the Northeastern region of Oregon was about 6.5 percent, compared to the national rate of 45 percent,” WWCH CEO Topher McClellan told Hospice News. “We needed to expand and started planning. There were a lot of people in that area who were not being served.”

With this planning underway, WWCH was well positioned to step in after the area’s only hospital, St. Anthony Hospital in Pendleton, ended its hospice care program. The hospital sent letters in early Dec. 2018 to inform patients and bereaved family members that they would have to look elsewhere for hospice by the end of that month, according to The East Oregonian, a local newspaper. Reportedly, the hospital’s budget could no longer sustain its hospice program, requiring approximately 40 patients to seek a new hospice provider.

A top priority for the hospice was alerting the public as well as other health care providers that hospice services were once again available in their area. Of particular concern was the First Nations population, including the Confederated Tribes of the Umatilla Indian Reservation, among whom hospice services were considerably underused.

WWCH began partnering with the Yellowhawk Tribal Health Center in Pendleton, which provides primary care, dentistry, and other services to the reservation and other First Nations residents. A WWCH visited the clinic during summer 2018 to discussion communication with the tribes regarding hospice care.

In April, tribal representatives will come to WWCH offices to begin training staff on cultural practices and perceptions regarding the dying process, how it entwines with the tribes’ spiritual beliefs, as well as locals’ concerns about bringing health care workers they don’t know in their homes.

“One of the challenges we have is helping tribal members understand that we are here to help,” McCellan said. “One of our patients, a member of the Choctaw nation, explained to us that many in the First Nations community feel anxiety about bringing strangers into their inner circle or into their home environment. There is a lot of communication involved in building relationships with those families and earning their trust.”

Demographic disparities are a longstanding issue in hospice care. Nearly 87 percent of Medicare beneficiaries that received hospice care during 2016 were caucasian. Native Americans represented only 0.4 percent of hospice utilization that year.

A 2014 literature review by the U.S. Centers for Medicare & Medicaid Services found that, nationwide, a lack of cultural sensitivity among health care providers often dissuaded individuals among the First Nations from seeking hospice care, indicating that culturally sensitive care could increase access among that demographic.

Other barriers among the tribes included a level of discomfort with the presence of chaplains, particularly if the patient and family are not members of that faith. In addition, some see the involvement of social workers as threatening, associating them with government agencies perceived as disruptive.

For now, WWCH is focused on reaching tribal patients through its relationship with Yellowhawk, with clinic staff initiating the hospice conversation before connecting the patient with the hospice.

“After our staff have finished their cultural training we will be able to pivot and change our messaging specifically for the tribes, and hopefully have a bigger impact there,” McClellan explained.

To execute the expansion, WWCH needed more staff. Their service area extends more than 60 miles in Washington state and slightly less than 60 miles into Oregon. The region needed more coverage to ensure timely routine visits as well as fast response to patient calls.

During the week, primary hospice nurses do home visits assigned by region. The hospice hired additional nurses and a social worker to provide back up, particularly to support on-call nurses working nights and weekends. Back-up staff perform other clinical duties, such as chart audits, when not providing patient care.

The organization’s average daily census has grown; they are currently 10 patients above budget. However, the expansion is too new for the hospice to assess its full impact.

“We are in our first quarter and don’t have enough data, especially because the St. Anthony closure was so recent,” McClellan said. “Our objective is to reach 65 average daily census, while developing strategies to address census fluctuations. It’s wait-and-see for now.”