Hospices Can Leverage Mental Health Care for Better Quality, Growth

Hospices are increasingly offering expanded behavioral health services to improve care for patients suffering with serious mental illnesses (SMIs) at the end of life. Rising demand for these services comes at a strenuous time for hospices amid shifting payment policies and a worldwide pandemic. Investing to expand mental health programming poses both challenging financial risks and opportunities for growth.

An estimated 5 to 8 million older adults nationwide have one or more mental health conditions, according to research from a 2018 supplement to the Journal of the American Geriatrics Society, with projections that this number will triple during the next three decades.

Significant disparities exist in end-of-life care for those living with severe mental illness. Approximately 6% of the U.S. population suffers from a chronic or recurrent condition that requires intensive psychiatric treatment and significantly impairs functioning, according to research from the journal General Hospital Psychiatry. The unique needs of patients with serious mental illness can add layers of complexity to their care needs.


As this aging population reaches the end of life, a growing need has exposed gaps that hospices are well-poised to fill.

“Although mental health throughout the end of life has always been a focus of hospice care, we are encountering patients with higher intensity and frequency of Post-Traumatic Stress Disorder (PTSD), higher rates of having previous mental health treatment and increased suicide risks,” said Heather Prejean, executive director at Hospice of Acadiana’s Center for Loss and Transition. “The value of deeper integration of serious mental illness care for hospice patients and their families is immeasurable. The long-term return on investment is that the news of this type of holistic care will spread throughout communities and the demand for this more compassionate approach will only increase referrals.”

While mental health is often rolled into the psychosocial and spiritual aspects of hospice care, providers have room to grow when it comes to expanding specialized programs. Incorporating serious mental illness care brings value and increases quality, according to Bridget Earle, M.D., medical director of hospice at Atrium Health.


Psychiatric, psychological and therapeutic services in hospice are typically billed on a fee-for-service basis, or as part of Medicare Advantage or part of other bundled services under managed care arrangements. Mental health services provided under the hospice benefit are often tied to clinical social work services. Psychological or psychiatric care may also be contracted to agencies for patients in facility- and community-based settings.

“It would be great to have access to every subspecialty in the mental health world because one person or professional on a team can’t do it all,” said Vickie Leff, licensed hospice and palliative care social worker and executive director of the Advanced Palliative and Hospice Social Work Certification organization (APHSW-C). “It would be nice to have it as part of the [hospice] benefit to consult with them or use them for a brief time to step in and give guidance on the hospice team.”

Limited opportunities in reimbursement for mental health services represents a large barrier for hospices trying to improve access to these services for patients and families. Roughly 72% of hospice and palliative care provider respondents to the National Hospice and Palliative Care Organization’s 2020 Palliative Care Needs survey stated that funding opportunities to pay for integrated behavioral health would be most helpful to expanding resources.

“Hospices are pretty restricted in terms of what services get paid at what time,” Leff told Hospice News. “There’s a real doughnut hole of where our intersectionality can be with hospice, palliative care and mental health. How these worlds interact with one another is a huge hole. There are folks who have mental health issues at the end of life that really compromise the ability to provide the kind of care they need or want.”

Opportunities to boost access to mental health care can arise from the shifting value-based payment landscape, which will now include hospice providers with the onset of the Center for Medicare & Medicaid Innovation’s value-based insurance design model demonstration as of Jan. 1. The project, often called the hospice carve in, is testing the inclusion of hospice within Medicare Advantage plans. Through the carve-in, CMS intends to increase access to hospice services and facilitate better coordination between patients, hospice providers and their other clinicians.

“Managed care plans are going to have to continue to evolve their broad sets of thoughts and services for what helps people with physical and mental well-being at the end of life,” said Cameron Muir, M.D., chief innovation officer for the National Partnership for Hospice Innovation (NPHI) and chief innovation officer of Virginia-based Capital Caring Health. “If you take the hospice team — which is medical, clinical and counseling — each professional service provider can bill fee-for-service for their expertise. Put that all together and you’ve got both the biological and the psychosocial and all the behavioral and mental health components in one hospice or palliative care team. It’s blending all of it that is a true opportunity in fee-for-service.”

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