While staring down tighter reimbursements and intensified regulatory scrutiny, hospices are becoming interested in health care system integration because of improved access, collaboration, operational support, and financial stability. Hospices and hospitals are increasingly joining forces to provide goal concordant care, reduce costs and prevent readmissions, while supporting growth for the hospice.
While most people wish to live their final moments at home, nearly 700,000 deaths still occur in hospitals, according to the U.S. Centers for Disease Control & Prevention.
Hospitals often are interested in collaborating with hospice organizations to improve patient satisfaction and quality metrics, such as decreased mortality, hospital readmissions, and intensive care unit (ICU) admissions. An integrated model positions a health care system well for a transition to the reimbursement model of bundled payments and accountable care organizations (ACO), according to Brian Bell, M.D., vice president and chief medical officer of Arkansas Hospice in Little Rock, Ark.
Hospices and hospital systems for the most part have been building three types of collaborations, including independent contracts, extensive contracts and contracts or agreements to support the development of end-of-life services.
“Joining the house of medicine is important because people are still dying in hospitals,” Todd Cote, M.D., chief medical officer with Bluegrass Care Navigators in Lexington, Ky., told Hospice News. “Acute care hasn’t always done a great job in end-of-life (EOL) care and hospice care is a continuum of care in America that hospitals can benefit from.” According to Cote, there are three hospice/hospital collaboration strategies that have proven successful.
The most common contract of this type is the traditional independent contract with the hospital to support the general inpatient level of care within the hospital while strictly following the conditions of participation mandated by the U.S. Centers for Medicare & Medicaid Services for the Medicare hospice benefit. Other kinds of independent contracts may involve a hospital-embedded hospice liaison to help patients transitioning out of acute care.
Extensive contracts for hospice and palliative care services within the hospital include inpatient hospice and/or palliative care units, small scale comfort suites, or palliative care consultation teams. While being within a health care system may be advantageous, often the hospice organization must develop a strategy to approach hospital administration.
Cote recommends hospice organizations begin with the health care system’s C-Suite and work to familiarize them with the Medicare hospice benefit if they are not already aware. He recommends entering the meeting ready to do the following:
- Ask what they need when it comes to caring for end-of-life patients
- Tell them you will let them know if you can help them and how – meet them on their terms, for hospitals, measurement is important. Let them know you can provide that.
- Discuss ways that you can collaborate toward patient and family satisfaction.
Contracts or agreements to support the development of end-of-life services is often an important first step toward collaboration. Traditionally, end-of-life education programs have been an effective vehicle by which a hospice can contribute expertise. Other possibilities include membership on the hospital ethics committee and/or palliative care advisory committee, ongoing conversations with hospital case management, or provision assistance in the development of an advanced directive program within the hospital.
Nurse practitioner Jaqueline Fournier, with Androscoggin Home Health and Hospice in Lewiston, Maine, said that the partnership between palliative care and acute care hospitals can be paramount. From her vantage point, Fournier said that the benefits to hospitals seeking a partnership like this go beyond statistics into real patient satisfaction. She noted that some of the most important work her organization does is providing education to patients, families, and other providers. Some of the other services organizations like hers provide include:
- Clarifying goals of care
- Symptom management
- Caring for the whole patient: working with pastoral care, social workers, therapy, nurses
- Code status clarification
- Completing advanced directives
- Helping patients with provider orders for life-sustaining treatment
- Education of patients, physicians, and health care teams
“There are a lot of misunderstandings out there. We may not get provider referrals or a patient or their family may not understand palliative care,” she said. “We need to break through these barriers with a true partnership and education for the patients and their families. We advocate for the patients and work to get them where they need to be.”
Cote echoed that there are sometimes barriers to true collaboration. “The larger the hospice, the more financial mobility,” he said. “Smaller hospices don’t always have that. Hiring a dedicated team to be embedded inside a hospital can be costly, however, those costs can sometimes be negotiated and split with the hospital system.”
Cote explained that it can sometimes be difficult for hospices to increase staff due to nursing shortages and nurses that are hired need to understand how to work well within a hospital hierarchy. Another barrier can be changes in hospital administration. “You may have a champion in the hospital that moves on and leaves you starting over with an administration that isn’t as willing to collaborate with your organization,” said Cote.
In the end, relationship building and quality patient care are key.
“Some patients can’t leave hospitals because of fragility of health or financial concerns,” said Cote. “While some hospitals are concerned with things like mortality rates, that should not be the primary motivator for this type of collaboration. Quality care and family satisfaction at the end of the patient’s life should be.”
Written by Audrie Roelf