More Veterans Gravitating Toward Home-Based Hospice Care

Rates of hospice utilization were higher among veterans than other Medicare decedents, according to recent research. With more than half of veterans receiving care in the home, the findings reflect a growing industry-wide trend toward community-based care.

The study from the U.S. Department of Veterans Affairs (VA) Home Based Primary Care (VA-HBPC) found rates of home hospice utilization among veterans increased over an eight-year period from 2008 to 2016. Veterans were less likely to utilize end-of-life care in other settings, with roughly 11% dying in inpatient hospice units, 14% in hospitals and 11% in nursing homes.

More than 60% of veterans died at home compared to less than 50% of non-veterans in community-based settings, according to authors Suzanne Gillespie, M.D., and Orna Intrator. Intrator is professor of health services research and policy for the Department of Public Health Sciences at the University of Rochester in New York. Gillespie is associate professor of medicine in the Division of Geriatrics/Aging and associate professor of emergency medicine at the university as well.

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“The current study observed important trends in site of death and hospice use,” Gillespie and Intrator told Hospice News. “Hospice use at home increased at a higher rate than among all VA-HPBC patients and male, non-veteran Medicare decedents, while hospice in nursing homes was higher throughout the 2008–2016 period. Overall, hospice use by veterans has been increasing over time, with a marked uptick in 2009 when VA’s Comprehensive End-of-Life Initiative was first implemented.”

The VA began the Comprehensive End-of-Life Initiative in 2009 to improve the quality of end-of-life care among veterans and increase dying veterans’ enrollment in hospice for care more aligned with their goals. The initiative has led to an increase of roughly 7–8% increase in hospice use among veterans.

Community-based services have been on the rise in the health care space, as patients are more reluctant to receive institutional treatment due to the prevalence of COVID-19 infections in nursing homes, long-term care facilities and hospitals. Researchers indicated increased collaborative and interdisciplinary care as driving forces behind the uptick of hospice utilization among veterans. A rise in advance care planning and goals of care discussions with patients and their families was an additional finding.

“Integrated care where providers know the patients and have access to a range of care options that provide a continuum of care for frail, older adults,” said Cari Levy, M.D., director of palliative medicine and associate director of the Center of Innovation for Veteran-Centered and Value-Driven Research at the Denver VA Medical Center. “It allows for early identification of needs, matching services to those needs and advance care planning. This is leading to goal-concordant care and a reduction in use of unwanted treatments at the end of life.”

The study’s findings also indicated that increased integrated care could lead to fewer racial disparities in hospice utilization and advance care planning among patients and their families.

“We are seeing consistently across a number of studies now of VA decedents fewer racial disparities in site-of-death and advance care planning,” said Levy. “In this study particularly, there was no difference in site-of-death at home based on race. In [our] other work, completion of advance care planning did not differ across racial groups, which is very different from data on non-veteran populations.”

Hospice providers have increasingly focused on improving access to end-of-life care among historically underserved populations in African American, Hispanic and Native American communities, seeking to bridge racial divides and break down barriers of cultural and economic inequities.

The authors indicated that the study’s overall findings raise the question of whether greater access to hospice care is possible among non-veteran communities.

“The VA has led initiatives to facilitate patient-aligned primary care teams, to improve goals of care and advanced care planning conversations for veterans, and to ensure all veterans have access to palliative care services,” Intrator and Gillespie told Hospice News. “The VA has also worked to promote strong veteran community partnerships in recent years. These may all be important factors in promoting supportive care for veterans at the end of life. This finding raises the question of whether greater access to hospice care is possible for non-veterans.”

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