Longleaf Medical Director: Hospice Care Needs a Revolution 

A revolution is needed in hospice care, complete with a new mindset, updated care models and redesigned payment systems, Dr. Monisha Pujari, medical director for Longleaf Hospice, told Hospice News.

Pujari maintains that the health care system is not effectively managing the lengthy decline that precedes mortality, and that hospices can do more for patients in the home than many are currently doing. She discussed many of these issues in her June Ted Talk, “How to Die Well.”

Hospice News spoke with Pujari about her vision for hospice care and what it would take to make it a reality.

Dr. Monisha Pujari
Dr. Monisha Pujari, medical director, Longleaf Hospice

Could start by telling me a little bit more about your background and how you came to the hospice space?

I went to Mayo for internal medicine and started off after that in the hospital, so I was a hospitalist for a long time. In the hospital, I realized that I really loved the acuity of medicine, and I liked diagnosing, but I also liked prognosis, getting a sense of what was really going on with the patient.

Later, I was working for Kaiser [Permanente] here in Atlanta, and they had a palliative care program where you could grandfather into hospice and palliative medicine. I applied for that position and ended up doing the training and getting into palliative care. So I was doing hospitalist medicine and hospice and palliative medicine in the hospital side by side. In 2014, I made the jump fully to hospice.


That’s the bare bones of it. But, philosophically, all along, I felt like a lot of times we were missing the big picture on really what was going on. It seems like we didn’t have a good sense of managing decline, managing the precursors to actual transitioning. We were missing things and not seeing the big picture.

What does that big picture look like?

They still do this day in and day out in the hospital. You’ll bring somebody who is older to a surgery where the outcome is not at all what anyone expects, but the truth is, it should be expected. There are different ways to manage things. So it really got me thinking.

I’ve been full-time in hospice since 2014, out of the hospital, and I manage my patients very aggressively from a palliative standpoint, meaning that when they come on I pay very close attention to what is reversible, what is not, what in their decline can be stabilized and how should we stabilize it. What is their trajectory? What is the illness driving things forward? What are the symptoms that need to be managed?

With that, I have developed a really niche practice in my own way where I do it differently. If I need to run a drip on someone, we will run a drip. If I need to do a ventilator on someone, if we need to have a BiPAP, or non-invasive ventilation, or if we need different modalities, those will be done.

So I’ve gone from being inpatient trained and loving acuity to now realizing that hospice has the same acuity. I can manage quite a bit in the home. I would say the vast majority in the home. I know this because I also manage [General Inpatient Care (GIP)] patients in three hospitals, so I do manage high acuity in those hospitals. And what I do in the hospital, by and large, I can pull off in the home.

I just had a patient where it was similar. It was a GIP patient, but I managed her entirely in the home and allowed her to pass peacefully. Had she been on another service, she would have had to go back in [to the hospital], they would not have managed her that way. 

There really needs to be a revolution in the way that we’re approaching hospice.

I’ve made a transformation in my own career and in my own mindset. I believe that there are many instances where we should be managing mortality and high acuity in the home and doing it differently. The hospitals should be really for triaging, and and then hopefully successfully resuscitating and rehabilitating people. I conceive of a very different model. 

In your view, what are the outcomes such a revolution should be striving to achieve?

I am hoping for a revolution in hospice medicine. It really should be about managing decline, which happens to each of us at the end of our lives. If we shift away from the idea that we’re just managing the last couple of months in a patient’s life, but instead really shift into how we are managing the decline that we’re seeing and optimizing that, then it opens up the possibility of paying for things and having a different payer model.

If you look at a lot of hospices, they will relegate you to not even sometimes having an EEG kit in the home, working with a few medications. That works for some patients, but the vast majority need quite a bit more. So you have a system right now that is very delusional, in a sense, very minimalistic — not at all understanding the nuance and the breadth of how complex the care is at the end of life.

I would dare say that the care that I’m doing rivals at times the acuity that I had in the hospital, if we are managing hypotension or the beginnings of sepsis, or we’re managing terminal agitation. 

So when you start shifting into a new philosophy, then you start shifting into the idea of how do I pay for the new philosophy. It’s a more sustainable philosophy too. Right now, we are in a system that is not honoring ir or doing it the right way.

We need to shift into a system that understands how to pay for a lot more at the end of life than we’re doing now. Ironically, that is even cheaper than the hospital. Hospital stays are very expensive, on the order of tens of hundred of thousands of dollars. I could use some of those dollars to run multiple modalities in the home, if we had a payer system that understood that that was where we would get the most benefit.

Where we would get the most benefit is shifting the model outside of the hospital, back into hospice, back into the home and starting to think about how we pay for these things in the home. We are asking patients to stop medication and treatments arbitrarily, just to save dollars.

The problem is how we are managing our mortality. We’ll pour money into a patient who goes into the hospital, who uses $40,000, to $60,000, in the last three to six weeks of life, and then they ultimately still have to come into service with me in GIP.

What if that patient had been given to me earlier? It could have been kept in the home at a fraction of the cost.

When it comes to hospice, it’s almost an afterthought. I’ve heard the numbers. We want to minimize down to $6 a day per patient for meds. And I think that’s ludicrous. If you’re comparing my drip in the home setting, which cost a couple of hundred bucks for maybe a couple of weeks, versus me keeping someone in the in the hospital, we’re hemorrhaging money in one sphere, and we’re not hemorrhaging in the other that is doing right by the patient.

What would you say is the right way to approach this? What specifically do you think needs to change in order to kind of implement this vision that you’re describing?

We need to have Medicare interested being the primary driver, and they seem to be somewhat. With COVID, there was a push for understanding that care can be done in the home. Now they have the home health model. But I would love to pilot something where we had what I’m doing in the home.

We’ve done some good stuff in the home. We really ran some incredible modalities, where there was wound care and drips and respiratory management. It was maybe at times

like a little mini hospital, if not a mini ICU. Not every patient needs that, by the way. But for those who did, we ran some really good care.

It would be wonderful to show Medicare just comparatively, the costs of a GIP patient to an equivalent patient that we can manage fully in the home. Let’s show, side by side, the cost differential.

If we could pilot a program, then I think they could see apples to apples. This is markedly cheaper, and the quality is better. Our definitions of what value needs to be more nuanced. It needs to capture acuity. But you need cutting-edge thinkers pushing it forward.

The lack of attention to the nuances that you’re describing, what does that ultimately mean for patients and families?

Many people don’t get what they need. There are a lot of patients out there who are not getting high-level management. They’re not getting any management. They’re not having someone think about them in a way where it’s really honoring what’s going on.

We can do things differently. We like to think of ourselves as doing a great job. Many hospices are not really focusing on a simplistic model. A lot of people are not necessarily getting tailored end-of-life management, which really can be transformational.