Communicating the potential value of longer hospice stays to referral partners, patients and families has been a longstanding challenge for the industry.
This was among the hurdles that a startup like Heart N’ Soul had to overleap, according to CEO David Turner. He and co-founders Bishop Sandy McClain and André Lee, administrator, applied for a license to establish the hospice in 2020 as the virus was breaking out.
Reaching underserved populations can be a particularly challenging feat, with many coming on to hospice too late as a result of misconceptions among patients and clinicians in other fields, according to Keisha Mason, director of nursing at Heart’n Soul Hospice.
Turner and Mason told Hospice News that a “change of order” is needed to the hospice benefit when it comes to the six-month terminal prognosis. Such changes would strike a balance between longer stays, quality and compliance.
Both said that If regulators were to extend the timeframe for eligibility, more patients could reap the full benefits of end-of-life care, the two leaders said.
Hospice News recently spoke with Turner and Mason to break down some of the challenges and how hospices can respond.
Some hospices experienced hardships during COVID-19 pertaining to referral reach and length of stay. What was your experience in these two regards when it came to launching services in the past couple of years?
Turner: Heart’n Soul Hospice was literally in startup mode during the midst of the pandemic. Getting the word out about our existence and hospice was a big challenge for us.
What we’ve seen pre- and post-pandemic is that a lot of facilities were having difficulty themselves with census and that trickled into hospice. We’ve seen a shift to more patients that are homebound, although we do still have a pretty good mix of facility versus at-home patients now.
From what we saw not just here in Nashville, but also in other hospice programs that I’m familiar with, is that it looks like things are moving back towards pre-COVID days as far as length of stay – but they aren’t there yet. Across the board, most folks saw their average length of stay decrease pretty significantly.
Length of stays in the middle of a pandemic for some hospices dipped below 30 days during the really worst part of it. Here in Nashville, now we are back up to around 65 days as our average length of stay. Typically that hovered around 80 to 90 days, and we are seeing the trend moving in that direction.
Mason: It was a blessing and a curse to start in the middle of a pandemic. Some of it was definitely just trying to find new ideas in a way to be able to get into facilities and doctors’ offices. It was still a very virtual world. Once we started finding patients, then it was trying to figure out how to get our staff members their vaccinations and everything else that was going on with that.
Now that it’s falling into more of the aftermath world, it’s getting people to the point now to remember that hospice was and is a service. It’s almost back to the pre-COVID world of reminding other service providers that hospices are here, that we are an entitlement benefit and something that should be offered. We can help in making that judgment call over whether a patient is really palliative care ready or if they really are a hospice patient.
What are some innovative approaches to address referral relationships and length of stay challenges in a post-pandemic world?
Turner: The use of technology is both good and bad. It has its plusses, but it also has its minuses. It can streamline things and certainly keep people safer and maybe make them more comfortable during cases like the pandemic.
Zoom became a key player in what we did not just for referral sources but also potential job candidates. DocuSign became the most efficient as far as getting consent for services and other documentation completed.
But you lose a bit of the personal touch. I certainly understand the necessity for using technology to help grow, and market and educate the community.
Heart’n Soul was basically founded with the mission to care for anyone that needs us, but with a real focus on traditionally underserved portions of the population. When you start to talk about length of stay, the bigger challenge with those populations, because maybe they have not been given the the accurate information and education about what hospice really, truly is, and how it works. We fight the battle constantly of the super-duper late referral, so it’s an even bigger challenge for us with that population.
How do we impress upon the clinicians, the caregivers or the health care providers, and whoever it is making the referral to then help families to understand that while we are talking about end of life, we aren’t talking about it necessarily being imminent. You don’t have to wait until someone is actively dying before you can make a referral to hospice. As it relates to length of stay, the bigger challenge we have is trying to get people to fully understand and embrace that you don’t want to wait until the last minute.
We’re doing this one provider, one family at a time.
Mason: We had to learn very quickly how to do outreach, and some of that was not hands on. It was how can we make our literature speak for us? It’s seeking that targeted audience and making sure that it’s the general populations we were looking to serve, as well as the underserved populations. How do you get that message through and say this is what we are and who we’re looking to serve?
Some hospices are using data to make the case for end-of-life care further upstream, such as cost-savings tied to reduced hospitalizations. How can hospices leverage data to prove their value proposition to referral sources and their service communities to reach patients sooner in their trajectories?
Turner: Data plays an important part. Hospitals and nursing homes don’t want to get dinged for readmissions.
When you can compile data and put raw data in front of them that says, this individual being enrolled in hospice is going to do two things for you. It’s going to lower your potential of that person having to go back to the hospital or facility, because now somebody is educating the family and explaining what’s going on and how all these things can be done bedside.
When hospice is involved, it gives an extra set of professional eyes and ears that can come in and see what’s really going on with that resident, as opposed to depending on their facility staff as they are fighting with staffing shortages.
Data can show the prevalence of readmissions is so much lower when someone is discharged either from the ER or from just as a regular patient on the unit, the chances of them coming back to the hospital are significantly lowered.
There’s also wonderful data out there from some studies that have shown the real cost savings of hospice. We’re still in the people business, though, so we don’t want to get too caught up in the numbers, but we do want to use the numbers where it makes sense. At the end of the day, it’s all about what’s best for that patient and family
Armed with those data, how do you balance reaching those patients sooner with the regulatory scrutiny around lengths of stay?
Mason: As a hospice clinician, when you get into the longer lengths of the stay, the question we always ask is if we discharge this patient will they go to the hospital. In most cases, the answer is yes. But it’s the burden of documentation that we always have. But if we discharge them, many of these patients end up going back and being readmitted to the hospital or emergency settings as they decline.
How can we use data to show this patient is still benefiting from hospice? If we take them off of hospice, how can families maintain this level of care? It’s a constant fight with the U.S. Centers for Medicare & Medicaid Services (CMS)] of illustrating whether they would rather pay high-cost hospitalizations or pay us.
There is this emerging tension between longer stays as a benefit to patients that saves Medicare money and a perception that these are indicators of fraud. Given the chance, how would you propose resolving that question?
Mason: Change the benefit to a year. This might be especially helpful for patients with longer-term illnesses, like Alzheimers, dementia and cancer patients tend to have longer stays.
Clinicians are having to do that extra documentation just to make sure that you’re having such a picture to say, “Ethically, I cannot discharge this person because they’re going to die. I just don’t know when. If you discharge them from hospice, it would almost be unethical and a travesty to do so.”
I’ve had patients that when you look at them on paper you wonder if they even have six months. A year later you’re wondering how they are still alive.
We all know there are bad hospice players out there, but most are not. It’s a fight to keep our census and give them quality. It’s just that with the six months or less, we’re doing the best we can to figure out whether they fit into six months and what that looks like. Some patients are at a point where they are no longer critically or terminally ill. There’s a reason they’re with us, especially for those longer ones that are so hard to determine what that looks like.
Turner: I think we would get such a better snapshot of the patient’s picture if the benefit went to a year or less instead. It would solve so many problems. Psychologically, for referral sources and families, you would find more people embracing the hospice benefit. Six months sounds like a really short amount of time and a lot scarier and more imminent than thinking of a year left of life.
Also, our payment structure over the years has changed to where hospice is paid more at the beginning now. For people who do stay on service, it costs the health system a little bit less. There are ways to configure this.
There is a provision in the Medicare benefit that you can have unlimited service periods, but the theory that is put on providers for their documentation so that you don’t run the risk of Medicare either asking for repayment or withholding payment, that is really, really challenging. And that’s another reason for giving that year for those that do survive it. That person probably could be discharged on the hospice benefit, but those cases are just so few and far between.