The COVID-19 pandemic has exposed gaps in hospice and serious illness care that impact providers and patients alike, illustrating the need for change in care models to expand and address various social determinants of health. Some stakeholders in the hospice and palliative care space have called for updated public policies to close these gaps and provide stronger support of patients’ aging in place.
Aging in place has been a priority for patients and families, and it has been increasingly important in keeping high-risk hospice and palliative care populations safe and healthy during the novel coronavirus pandemic. While critical in continuing to reach patients and families during a national health emergency, providing home hospice and palliative care has been challenged by roadblocks resulting from the outbreak.
“The pandemic has exacerbated issues around social isolation and loneliness for those remaining at home,” said Tom Koutsoumpas, co-chair and co-founder of the Coalition to Transform Advanced Care (C-TAC). “Fortunately, actions taken by [the U.S. Centers for Medicare and Medicaid Services (CMS)] and Congress have allowed more people to have access to medical services remotely and non-medical supports like meal delivery. The hospice and palliative care community has gotten creative with service delivery and adapted very quickly to the situation, ensuring that those we serve are able to stay in their homes and communities where they want to be.”
Not only does aging in place improve seniors’ quality of life, but CMS and other payers also encourage it as a way to help reduce health care costs by decreasing the need for hospitalization or nursing home stays. However, this involves a range of costs that extend beyond medical care coverage.
“Aging in place requires that you have secure housing and that you have adequate, mostly unpaid, help,” said Joanne Lynn, M.D., policy analyst in Altarum’s Program to Improve Eldercare headquartered in Ann Arbor, Mich. “Or, if you have to use paid help, that you have enough assets to pay for that help. We really need to rethink how we deal with long-term care in old age and how we support caregivers, along with those who have no family or substantial volunteer help. We need to be honest about what we are willing as a community to do to support frail, elderly people — remembering that it includes us. The policies we put in place affect us downstream, and we need ways for people to protect themselves against the cost.”
Social determinants of health such as housing, income, transportation and access to meals are crucial to a senior’s ability to age in place, but the COVID-19 outbreak has illuminated disparities in access, availability and affordability among surging unemployment rates and an economic downturn. With many patients strained in reaching loved ones, lack of caregiver support has shown to adversely impact hospice utilization. Providers have called for public policy changes to help expand patient care models and provide improved access to social determinants of health.
“Long-term services and supports play a key factor in addressing the social determinants of health,” Koutsoumpas said. “Individuals with functional limitations need support to be able to perform their activities of daily living so that they can engage with their communities and maintain their quality of life. It’s critical that older Americans and those who are seriously ill receive services, but we also need to recognize that individuals can’t always rely on an unpaid caregiver.”
Highlighting the importance of addressing social determinants, the U.S. Center for Disease Control and Prevention (CDC) released guidance for improving social and physical environments to advance equity and bridge gaps of disparity in hospice care access and utilization. In its Healthy People 2020 report, the CDC offered guidance for providers on programs and policies that could “improve community well-being.”
Technology and internet access have been added to the list of vital patient needs, especially amid state closures and social distancing measures to prevent risk of COVID-19 exposure. Telehealth has become the primary gateway for providers to remain connected to hospice and palliative care patients and families under temporary CMS waivers in utilization restrictions during the pandemic. While no permanent policy changes have been announced to expand telehealth long-term, hospice leaders have advocated for the temporary changes to be made permanent.
“In the COVID era we’ve accelerated and improved our use of telemedicine in helping people to construct a caring bridge,” said Michael Fratkin, M.D., founder and CEO, ResolutionCare. “It’s clear to me a number of different ways how much better than ‘real life’ doing this was, both in terms of [patient] satisfaction and the ability to meet the needs of our people without having to give anything up. The whole world is sort of looking at it as a necessary compromise, but there’s some very interesting, practical reasons why [telemedicine] is superior to dragging them into a clinical setting or visiting them at home and relational reasons why this works so much better. It invites us to take a step a little closer in a very different experience.”
While expanding the availability of telehealth may improve access to hospice and palliative care, aging in place will remain challenged by inequities of social determinants of health. The bigger picture of provider patient care models will need to incorporate patient and family nonmedical needs rather than compartmentalizing them as separate and outside of care.
Allocating the funds to provide resources to address social determinants of health will require public policy changes in addition to some resourcefulness of hospice leaders and providers, according to stakeholders in the space. This could include allowing hospices to participate in value-based payment models, such as those set to begin in 2021 — the Medicare Advantage hospice carve-in and Primary Care First, including the Serious Illness Population model.
The U.S. Centers for Medicare & Medicaid Services (CMS) in 2019 announced that Medicare Advantage plans would begin covering supplemental nonmedical benefits in 2020. When the carve-in takes effect next year, participating hospices may have access to those supplemental payments. Exploring opportunities to provide nonmedical services, including complementary therapies and programs to address social determinants of health, can open new revenue streams for hospices, which currently rely on capitated per diem payments via the Medicare Hospice Benefit.
“The beauty of value-based payment is that you don’t define a cookie-cutter approach that manages a proportion of most people’s needs,” Fratkin told Hospice News. “You can make a deal in order to be responsive to the individual needs of each person and get out of that fee-for-service mentality for each and every case, every little thing we do, how we code it, how long it took. Get out of that and give us an amount of money that is associated budget and we’ll put everything we’ve got into getting out whole population to these desired outcomes of aging in place. You can avoid the wasted money that they spend on avoidable acute care utilization and undesired levels of intensity and redundancy by applying a very comprehensive model to the very sick people.”