North Dakota-based Hospice of the Red River Valley is focused on expanding its home- and community-based services among dual-eligible Medicare and Medicaid populations in need of greater support.

Serious and terminally ill patients in lower socioeconomic and underserved regions face several competing challenges in accessing health care, according to Tracee Capron, executive director at Hospice of the Red River Valley.

Developing a sustainable care delivery model that better addresses unmet needs among patients and their families requires significant investment, Capron said

“When we think about those dual-eligible Medicaid populations, it’s figuring out a way to reimburse for travel, the hours of care and have social service support and resources,” Capron told Hospice News. “These patients can have high health care costs when they can’t get to a physician. It’s sometimes [causes] needless suffering that we are trying to eradicate. The challenge is doing this with a financially sustainable infrastructure.”

Established in 1981, the nonprofit offers hospice care and grief support services to more than 27,000 patients and their families across a 55,000 square-mile geographic region in North Dakota and in western Minnesota.

Seniors 65 and older represent nearly half of the 80% of North Dakota’s population who are eligible to receive both Medicare and Medicaid benefits, according to a report from the U.S. Department of Health and Human Services.

Hospice of the Red River Valley recently received a $2 million grant from the North Dakota Department of Health and Human Services to expand access among underserved areas in the state.

The funds will help patients and families in predominantly rural areas in critical need of end-of-life support by paving the way for increased clinical capacity and nonmedical resources, Capron stated.

“We asked the state where they saw regions with the biggest challenges [and] we chose areas that are really struggling,” Capron said. “There are many places within North Dakota where there’s minimal — if any — care. It’s like a care desert of providers. We’ve developed and built an infrastructure to help meet their needs and be able to have house calls, [because] bringing a physician or provider into the home is critical in rural communities.”

In addition to hospice, Hospice of the Red River Valley also offers community-based palliative care and home-based primary care. The provider’s average daily census hovers around 440 patients on its hospice services, with roughly 80 patients receiving palliative care and more than 600 home-based primary care patients, according to Capron.

Access to a continuum of facility- and community-based health services is an important part of curbing costs and improving quality among underserved dual eligible populations, she stated.

The hospice in 2022 initiated plans to open an 18-bed inpatient facility in North Dakota. Dubbed Heather’s House, the center will have the capacity to serve three to six dementia patients. The center’s location was chosen with an aim to improve health disparities in rural communities in Fargo, North Dakota, and its surrounding region, Capron indicated.

A large factor in this expansion among rural-based Medicaid beneficiaries was recognition that these populations often incur higher health care expenses as they age, Capron said. Providers also face greater financial pressures trying to allocate staff and resources to these patients and their families, such as assistance with medical equipment and medication management, she added.

Travel is among the largest costs when it comes to dual-eligible hospice patients, according to Capron.

“You don’t get reimbursed for those travel expenses when we’re talking about dual eligibles,” Capron said. “The biggest fear was the high cost of transportation to patients. When you’re in rural areas, the travel rates of nurses go up and you often can only send one nurse to one patient for the whole day. We knew we needed an infrastructure upfront to allow us to provide things like medical transportation and nonmedical transport, which is a huge deal here.”

Rural communities across the country lack diversity, equity and inclusion when it comes to home-based care services, Capron said. Patients and families often do not receive the full scope of care needed in their homes, including respite services for caregivers.

Lower income rural-based patients generally have higher emergency and urgent care utilization at the end of life compared to others, Capron said. They often lack caregiver support and are not within close proximity to health care providers throughout their illness trajectories, she added. This can lead to added financial burdens on patients, families and the overall health system at large, Capron said.

“Families need to be educated on care plans [and] we need more consistent access to higher quality, trained people,” Capron said. “People need not just medical, but also psychosocial support and we need the manpower because it does take a village when you’re living with a chronic illness.”

Building the staffing capacity necessary to serve a wider base of patients is part of the financial lift involved in expanding services to dual-eligible rural populations, Capron stated. Training, education and onboarding costs are part of that equation. Another financial piece is the ability to have programs in place that help address social determinants of health, she added.

All told, it can take years for a provider to break even on the initial costs of expanding in underserved communities – a process that has been expedited by the recent grant, according to Capron.

Ultimately, the goal is to have more data that proves the value proposition of home-based services such as hospice and palliative care, Capron said.

“Easing suffering and seeing improvements in people’s lives is our return on investment,” Capron told Hospice News. “It’s [about] capturing your data, knowing where your needs are, where your resources are being spent and looking at the quality of what you can do for people and how this helps the health system as a whole. Everybody’s looking for ways to make health care more affordable. Hospice has the answers.”