Addressing social determinants of health and caregiver needs will be key to improving outcomes during a time when seniors lack both confidence and access to a range of medical and nonmedical services.

The swelling aging population and prolific staffing shortages are posing significant challenges in health care delivery. But the demographic and workforce trends aren’t occuring in a vacuum. A host of societal, geographic, psychosocial and financial considerations are involved in the access equation.

These issues have been top of mind for many hospice providers as they shape their care models around future patient demand and priorities. Hospices have increasingly diversified their services to better address a broader range of unmet needs among patients and their caregivers. Dementia support and Programs of All-Inclusive Care for the Elderly (PACE) have come to the forefront of these efforts.

Driving these trends forward is growing recognition around the leading barriers to equitable care, said Altonia Garrett, COO of Virginia-based Blue Ridge Hospice. Garrett is also executive director Blue Ridge Care’s Diversity, Equity, Inclusion and Belonging Committee.

““In envisioning the future of end-of-life care, it’s crucial to develop models that effectively support patients with a broad range of medical and nonmedical needs,” Garrett told Hospice News in an email. “We know that economic stability is a significant barrier for many. Addressing these social determinants is vital to dismantling the inequities in access and quality of end-of-life care. By understanding and acting upon these common threads, we can work toward a system that offers compassionate, equitable support to all individuals facing the end of life.”

Demand for change

About 82% of older adults indicated that they do not think the U.S. health care system is prepared to meet their evolving needs amid rising demand in a recent report from The John A. Hartford Foundation. The report included results from a survey of more than 5,000 Americans (with half aged 65 and older), and was developed in collaboration with Age Wave and conducted by The Harris Poll.

Nearly all respondents (95%) agreed that Americans should have access to quality health care, regardless of their age, income and ability level.

The findings suggest that seniors are dissatisfied with the current health care delivery system and are looking for drastic change, according to Terry Fulmer, president of The John A. Hartford Foundation.

“Older adults are stuck in a health care system that is not responsive to their goals and preferences,” Fulmer said in a statement shared with Hospice News. “It is not too late to pivot to age-friendly care, which prioritizes the needs and desires of older adults in their care plan. There are many innovative approaches to help older adults live every year to its fullest, not just increase the number of years they live.”

Moving the needle toward improved care requires a better understanding of the largest gaps of unmet needs, said Lisa Shugarman, senior fellow of health care programs at the nonprofit research organization NORC at the University of Chicago.

Hospices need stronger data to help steer their service strategies toward goal concordant, inclusive care delivery, but several hurdles exist when exploring evidence-based approaches, Shugarman stated. Her research spans 25 years of exploring holistic and innovative care approaches for seniors, including evaluation of PACE programs and methodologies, among others. She has also served as project director for the Medicare Care Choices Model.

“The challenge in doing this research is trying to understand the impact of innovative models and ways to apply the data,” Shugarman told Hospice News. “Claims data doesn’t always tell you the full story. It’s [understanding] what is the best combination of services for an individual given their characteristics, condition and goals. We need more data to learn more about the impact of these models to know where there are places we can improve.”

The case for PACE

Some hospices have dug deeper into the PACE program landscape as an avenue to reach patients further upstream and improve utilization and access.

These programs can help hospices provide better coordinated care and help patients and their families navigate a fragmented health care system and complex web of community resources, according to Liz Fowler, president and CEO of Bluegrass Care Navigators. The Lexington, Kentucky-based hospice provider launched a PACE program in 2022

These programs are an opportunity for hospices to evolve end-of-life care models that better address social determinants of health, particularly among some of the most underserved patient populations within their service regions, Fowler stated.

“PACE programs are more upstream and will hopefully allow us to care for more individuals earlier on and make connections with more diverse communities earlier as well when they see us as a trusted health care provider,” Fowler said. “The big thing with PACE programs is that they are for individuals with very high needs of complex care, and we readily address all their health care needs but also things like food, isolation and loneliness. You can do such a robust care plan [and] be more present in minority communities with more diverse, interdisciplinary staff.”

PACE programs could play a pivotal role in the changing landscape of end-of-life care, said Garrett. Blue Ridge recently rolled out a new PACE program, which began accepting participants earlier this month. Branded as Blue Ridge Independence at Home, the program is designed to offer a comprehensive suite of services that help seniors age in place.

The integration of these services is one of the most promising developments toward enhanced outcomes, Garrett stated. PACE programs allow hospice providers to form stronger collaborations with referral sources and community organizations, which can result in smoother care transitions and better ongoing assessment of patients‘ needs and preferences as their illnesses progress, she added.

By integrating with PACE services, hospices can focus on person-centered care, enhancing access and collaborating with community resources, paving the way for a more equitable and effective care system designed to better meet the needs of aging populations, Garrett said.

“The evolution of PACE in the hospice space represents a significant step forward in delivering comprehensive, compassionate care to those facing the end of life,” she said. “Unlike traditional hospice programs that often require a six-month prognosis, PACE recognizes the need for earlier access to comprehensive advanced illness care. This flexibility allows participants to receive necessary support sooner, ensuring they can live their remaining days with dignity and comfort.”

Dementia support gaining momentum

Among the innovations taking place in hospice is a focus on services that better support dementia patients and their families and caregivers.

This trend may accelerate in coming years. The U.S. Centers for Medicare & Medicaid Services’ (CMS) Guiding an Improved Dementia Experience (GUIDE) has opened reimbursement pathways for providers to improve quality of life. The model is designed to address care coordination, behavioral and functional needs.

More than 40 hospice- and palliative care-specific organizations are participating, including Bluegrass Care Navigators’ Palliative Care Center, as well as Lower Cape Fear Hospice, Hospice of Wake County, Hospice of the Western Reserve and Cedar Valley Hospice, among others.

Since its introduction in July 2023 the GUIDE model has illustrated two impactful considerations for hospice providers, according to Shugarman. On one hand, the model helps demonstrate the value proposition of hospice’s person- and family- centered approaches to care. On the other hand, the payment demonstration helps payers and providers alike to better understand

“The GUIDE model’s focus specifically on people with dementia and their families is incredibly valuable toward increasing access to services and care that is person-centered,” Shugarman said. “It has an element of groundbreaking this Medicare model by focusing on the caregiver and assessing their burden as well, putting services in place that will support them like respite care. The other interesting piece is tracking where a growing need is for community-based palliative and hospice care care. These providers can help address symptoms and pain, develop a plan of care and help support individuals who are seriously ill through the terminal stage.”

Hospices’ largest bargaining tool in the GUIDE model is their ability to support patients wherever they call home, which can alleviate financial burdens and potentially align better with patient preferences, Shugarman added. Hospices play a crucial role in preventing emergency department visits, hospitalizations and inpatient readmissions, she stated.

Respite care is a crucial part of hospice care delivery, which dovetails well with provisions of the GUIDE model, according to Fowler. Individuals with dementia are able to age in place with strong respite and supportive services for caregivers, she stated.

“Caring for someone with dementia is very stressful, especially as their condition progresses,” Fowler told Hospice News. “The more care and services we can provide in the home to folks with dementia, the better. We’re able to provide that through GUIDE, giving in-home respite help and solving those hurdles of transporting a patient to a facility, which for someone with dementia leads to agitation and anxiety, for them and their families.”