Hospices, Palliative Providers Innovate to Better Serve Rural Patients

Hospice and palliative care providers are exploring new methods and technologies to meet the needs of patients in remote rural areas.

Rural families have less access to hospice care programs than people in more concentrated populations, according to a 2015 study. Rural counties are less likely to have a Medicare-certified hospice than urban counties, and the service area of the nearest hospices may not extend far enough to reach some rural patients.

“Rural palliative care is different. The expertise that organizations have developed around delivering palliative care in other geographic areas doesn’t always naturally translate,” said Brian Mistler, chief operating officer of Resolution Care. “Also, a lot of the patient population that we see serve in rural communities don’t have the same privileges that some of the rest of us have. It’s hard to wrap our minds around the impact that lack of access to the social determinants of health and lack of socioeconomic status has on health care in general.” 


Resolution Care, a Eureka, Calif., palliative care provider operates a virtual hospice program that enables clinicians to support patients and families in real time. Resolutions has a number of tablets with data plans in circulation and other ways to support those with limited access in the rural communities they serve in the northern part of their state.

According to data from the Medicare Payment Advisory Commission (MedPAC), only 32% of those eligible for hospice care utilize the service in rural communities compared to 48% in urban areas.

Challenges related to delivering care for rural populations include geography, resources, and staff education and retention. Geographical challenges in rural areas consist of unpredictable access to patient homes due to weather, topographical features, poorly maintained roads, and long distances between homes.


Telemedicine is becoming increasingly important in hospice care for communities nationwide, but the technology may be making its biggest impact in rural areas where clinicians may have to travel significant distances to reach the patient.

“We leverage telemedicine, and we find that it works better for the patient population because they would rather be in their home most of the time they feel safer in their home. The windshield time for for our providers is one factor, but also it’s difficult for somebody in a rural population to get out of out of their house,” Mistler told Hospice News. “Maybe they don’t have an easy mode of transportation, or even if they do it takes an hour or more to get somewhere. They can get help via telemedicine much more quickly. I think that’s also true in urban areas in a way that we’ve not yet understood. I think that everything that we’re learning in rural populations could an incubator for more innovation in urban centers.”

Telehealth isn’t new to home-based hospice and palliative care, but it is rapidly expanding. The University of Kansas Medical Center piloted the first telehospice service in 1998. That attempt encountered serious challenges due to costs and prevailing attitudes about technology at the time. A second project in 2017 found its footing, which the medical center launched in collaboration with Hospice Services and Palliative Care of Northwest Kansas, Inc.

Between Aug. 2017 and Jan. 2018 Hospice Services engaged in 218 telehospice video encounters involving 917 participants, including staff and patients. The program yielded significant cost savings for the hospice, and participants reported that the program strengthens communication and relationships among staff and patients and family, according to a study on the project published in February.

“The future will be heavily embedded in telemedicine. The routine should be that patients can access help by phone or by computer anytime they need it, and that it would be there reliably,” said Diane Meier, M.D., executive director of the Center to Advance Palliative Care. “Right now if you have a crisis at three in the morning and call your doctor’s office, you get a tape that says ‘if this is a medical emergency, hang up now call 911,’ and so people do. They end up in the [emergency department] and end up getting admitted to the hospital, not because it’s the best thing for them, but because that’s the only thing the system can provide. That is bad for patients and bad for society.”

Policymakers are also examining ways to improve access to palliative care in rural areas.

The influential Ways and Means Committee within the U.S. House of Representatives has convened a Rural and Underserved Communities Health Task Force to consider health care delivery challenges in rural areas. The move comes as both chambers of Congress consider versions of legislation to expand hospice in rural locales.

The Rural Access to Hospice Act (S. 1190/H.R. 2594) was introduced in the Senate by Sens. Shelley Moore-Capito (R-W.Va.), Jeanne Shaheen (D-N.H.) and in the House by Reps. Ron Kind (D-Wis.) and Jackie Walorski (R-Ind.).

If enacted, the bill would remove a statutory barrier to hospice utilization in rural communities by allowing physicians in Rural Health Centers and Federal Qualified Health Centers to serve as attending physicians for patients in hospice. Both types of centers would be able to bill Medicare for hospice attending physicians services, which the law currently prohibits.

I think that payers and legislators recognizing the important differences in rural populations and recognizing the value of palliative care both from a quality of life and a moral dimension, as well as a cost saving dimension,” Mistler told Hospice News. “As those two things come together. I think that [expansion of palliative care] is inevitable.”

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