VA Study Finds Benefits of Concurrent Hospice, Home-Based Primary Care

Home-based primary care combined with hospice has led to greater family satisfaction among dying veterans covered by the U.S. Department of Veteran Affairs (VA) in recent years. These results signal potential opportunities for hospice providers looking to engage patients further upstream as they increasingly diversify services in a value-based world.

The VA’s home-based primary care (HBPC) program provides coordinated, interdisciplinary care to seriously ill and disabled veterans who wish to age in place at home. Receipt of hospice services while enrolled in the HBPC program was associated with higher satisfaction of end-of-life care, according to recent VA research published in the Journal of American Geriatrics Society.

A little more than half, or 52.6%, of nearly 4,000 veteran families surveyed reported that their loved ones received “excellent” quality of community-based hospice care within the last 30 days of life while enrolled in HBPC.

 The integration of community-based hospice care among veterans represents an opportunity to improve the overall experience of end-of-life care, according to researcher Daniel Kinder, health science specialist at the Veteran Experience Center. Kinder told Hospice News that performance on a number of quality metrics improved during the VA study.

Scott Shreve, national director of the Hospice and Palliative Care Program for the VA and the Veteran Engagement Center, echoed similar sentiments.

“The home-based primary care program is an example of transitioning along the trajectory of serious illness,” Shreve told Hospice News. “Sometimes we think of it as stepping off a cliff from primary care to hospice, when in reality most serious illness is transitioning over months or even years. The care needs increase gradually and incrementally.”

Unlike the Medicare hospice benefit, the VA does not require patients to end curative treatment in order to enroll in hospice. VA health benefits cover both concurrently.

This policy has helped increase utilization of hospice and palliative care in VA facilities and also helped improve performance on quality metrics.

Outside of the VA, a rising number of hospices have begun to offer or consider home-based primary care as an additional business line with the goal of reaching patients further upstream. These programs have been shown to reduce costs, reduce unwanted high-acuity care at the end of life and enable patients to enter hospice earlier in the course of their terminal illness.

If sustainable care and payment models were developed, many hospice patients could benefit from these combined services, some hospice leaders contend.

The U.S. Centers for Medicare & Medicaid Services (CMS) has explored the potential of concurrent care through the test of its Medicare Care Choices Model, which the agency launched in 2016. The model allowed participating hospices to provide services that are currently available under the Medicare hospice benefit, but cannot be separately billed under Medicare Parts A, B and D, while enrollees are also pursuing curative treatments.s

The demonstration ended on Dec. 31, 2021, and the agency will need time to analyze the results. But in 2020, CMS reported that the demonstration had reduced the agency’s costs by $26 million.

“When we look at the home-based care that the VA provides, it really does make sense to us,” said Angela Collins, chief operating officer of Las Vegas-based Nathan Adelson Hospice. “When that provider can warmly pass that individual to that next level of care, there is a continuum in a trust that’s built in. [We] wouldn’t pass off a patient to our hospice team if they didn’t think we gave great care.”

Historically, veterans have used hospice care at lower rates than the general population, but that may be starting to change. A 2020 HBPC study that found rates of home hospice utilization among veterans increased over an eight-year period from 2008 to 2016. 

​​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.

This is, to some extent, due to a concerted effort by the VA. The agency 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. 

“HBPC really does a great job of getting veterans into hospice,” said Darlene Davis, national HBPC program manager in the Office of Geriatrics and Extended Care. “We have long-term relationships with our patients, and we’re able to help make hospice not a bad word. It makes it a little more acceptable. But it’s still not well-reimbursed in the private sector. Some programs decided to take on providing this type of model of care, but it’s very limited.”

In the Medicare-funded hospice arena, a gradual move of reimbursement systems to value-based care models has the potential to accelerate providers’ ability to provide upstream services. These programs do come with some financial risk — leading hospices to carefully weigh their options. These could include launching their own new program or forging a new partnership with a primary care provider.

One challenging consideration is that some of these programs are in flux.

CMS rolled out the Primary Care First initiative last year, including its direct contracting components a few months later. Both programs focused on improving the quality and continuity of patient care as their illnesses progress, and presented opportunities for hospice providers, particularly those who offered additional services.

But CMS recently halted the direct contracting payment demonstrations, retooling the Global and Professional Direct Contracting (GPDC) model into a program called Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH).

The agency also eliminated the Serious Illness Population model, also announced in conjunction with Primary Care First.

Nevertheless, more demonstrations are likely on the way, according to the Center for Medicare & Medicaid Innovation’s recent strategy refresh. The agency and the Biden Administration now running it have reaffirmed commitment to testing value-based models.

The availability of concurrent or upstream care may help smooth a patient’s transition to hospice and allow them to receive services earlier in the course of their illness.

“People often don’t get on to hospice until the very, very end when they could have benefited from it much sooner,” Julie Sacks, president and chief operating officer of the Home Centered Care Institute, told Hospice News. “What we are seeing is that there’s just tremendous opportunity for hospice organizations to get involved in value-based care contracting opportunities and close one of the gaps that exists in the continuum of care. But what happens is hospices aren’t really that familiar with how to bill outside of the hospice benefit. It’s not that it can’t be done, it’s absolutely allowable and available.”

Currently, home-based primary care visits fall under Part B of Medicare fee-for-service models and can be billed similarly to an office visit, according to Sacks.

Whether or not a hospice decides to launch their own HBPC programs, bridging gaps in the care continuum is a priority for many providers. This will involve more consistent care collaborations across a siloed health system, said Sacks.