As hospices seek new ways to engage patients further upstream, a rising number are diversifying their services to include home-based primary care, along with palliative care and other care models. Evidence indicates that these primary care programs carry substantial benefits for patients and families and can have a significant positive impact on a hospice’s bottom line.
These programs have been shown to reduce costs, reduce unwanted high-acuity care at the end of life and enable patients to enter hospice earlier in the course of their terminal illness.
When it comes to length of stay in hospice, providers’ missions dovetail with their financial interests. As of 2017, nearly 28% of hospice patients died within seven days of admission, according to the U.S. Centers for Medicare & Medicaid Services. Nearly 13% expired during their second week of hospice care. More than half of hospice patients are enrolled for fewer than 30 days.
“Diversifying from hospice into primary care at home is smart for a number of reasons. There is a huge unmet need in the community for longer term, team-based primary care for people with serious illness,” said Eric De Jonge, M.D., chief of geriatrics at Virginia-based hospice provider Capital Caring. “Hospice teams are very strong at taking care of people who have serious illness, but they often get them too late. I think the way to get them at the right time is to move upstream for even the last several years of life and apply that interdisciplinary approach to primary care. Then there is a natural transition into hospice at the appropriate time.”
Capital Caring for the past several years has worked to expand its service offerings, including the addition of a palliative care program, a physician training program, a telehealth program, and private duty personal care services. The organization recently established a home-based primary care program, as well as a partnership with the Lyft ride-sharing service to support patient and family transportation needs.
Engaging patients before they reach the last six months of life can help boost hospice utilization. Nationally, about 33.5% percent of deaths occur in a patient’s residence even though the vast majority of patients say they would prefer to end their lives at home. According to the National Hospice & Palliative Care Organization, hospice utilization last year among Medicare decedents was around 50%.
For example, Northwestern Medicine’s HomeCare Physicians (HCP) in Wheaton, Ill., saw 1,022 patient deaths between 2014 and 2018. Of those, 76% died in their homes and 76% died while receiving hospice, according to the white paper “Home-Based Primary Care’s Perfect Storm” by Thomas Cornwell, M.D., founder of HCP and CEO of the Home-Centered Care Institute (HCCI) in Shaumburg, Ill.
More patients need to have earlier access to hospice, according to Cornwell.
“Those short lengths of stay don’t really give them what they need for quality end-of-life care, and it is also very financially disadvantageous for the hospice to give all of those resources for such a short period of time — and then to do a year’s worth of bereavement care for the family — without getting a significant reimbursement,” Cornwell told Hospice News. “Even though my [physician] partner and I are only two of a 1,000 doctors in the hospital system, we have made close to 12% of all hospice referrals in the last 15 years. We are getting patients to hospice earlier. The majority are passing away at home, and they are not spending time in the hospital.”
One of Cornwell’s patients visited the emergency department 17 times and was admitted to the hospital 13 times during the year before she enrolled in home-based primary care, he said. After she enrolled, she did not visit the hospital a single time and eventually passed away in hospice after receiving eight months of care.
A key driver of service diversification among hospices is the emergence of new payment models that promise to give hospices the opportunity to engage patients further upstream.
CMS earlier this year announced that it would test coverage of hospice care through Medicare Advantage plans beginning in 2021. The carve-in, according to CMS, is intended to increase access to hospice services and facilitate better coordination between patients’ hospice providers and their other clinicians.
Medicare Advantage plans are offered by private insurance companies approved by the CMS, and include HMO, PPO, and fee-for-service plans among other options. The program represents an integrated care model that promotes coordination of services and provides incentives for quality and patient satisfaction. Beginning in 2020, the program will be available in all 50 states as well as U.S. territories.
Additionally, CMS in April announced that they would implement the Primary Cares Initiative in phases beginning in Jan. 2020, initially in 26 regions throughout the United States. The initiative includes several payment models including one specific to Seriously Ill Populations. Hospices and palliative care organizations are eligible to participate in the payment models provided they meet the program’s criteria. Participating health care providers would receive a bonus for reducing avoidable hospitalizations.
“There is a business incentive. If [a hospice] takes care of a population through primary care there are lots of new payment models that they can participate in including the new Primary Cares Initiative, direct contracting, and contracting with Medicare Advantage plans,” De Jonge said. “If you take primary responsibility for an ill population there is much more opportunity from a payment perspective, but the hospice has to make a cultural decision that they are going to take primary responsibility for a patient population over time, probably the last 10 years of life. That is a major mission and cultural shift for hospices.”
That level of change requires resources, and among the first investments a hospice should make is in personnel, according to Cornwell and De Jonge. Cornwell told Hospice News that a home primary care program would need a business leader in the C-suite as well as a clinical leader on the front lines of care.
Clinical staff must understand how to manage patients with serious illness across health care settings, and business staff must know how to operate and bill for primary care programs, De Jonge said. Negotiation with payers to develop value-based contracts is also an essential step, he told Hospice News.
The strongest approach may be to integrate the interdisciplinary primary care team with the hospice team.
“I don’t think that hospice should be its own silo, and I think that teams should come together and focus on caring for the patient at home and not have these separations,” De Jonge told Hospice News. “Then the patient has the same team for the last five years or so of their life, and there isn’t a disruption or transition of care. Then you get payment for hospice and payment for primary care, having the clinical team be the dominant driver and tapping into the different payment models that are available.”