Virginia-based Hospice of the Piedmont is sharpening its focus on home-based care services and unfurling several initiatives in this realm.

The future of end-of-life care delivery has increasingly shifted into the home, according to Nancy Littlefield, president and CEO at Hospice of the Piedmont. While demand for facility-based hospice care is also rising, sustaining these services has become increasingly difficult, she indicated.

Several hospices have shuttered their facility-based programs in recent years, with many citing financial headwinds as a leading reason fueling inpatient center closures. Financial strains were among the challenges that led to the difficult decision to close Hospice of the Piedmont’s Center for Acute Hospice Care, Littlefield said.

Established in 1980, Hospice of the Piedmont provides community-based hospice and palliative care in Charlottesville, Virginia, and across 12 surrounding counties. The hospice also provides bereavement support including a children’s program, Kids Grief & Healing. The organization’s average daily census is roughly 340 hospice patients and about 300 palliative care patients.

Hospice News recently sat down with Littlefield to learn more about how hospices are sustaining and growing their services in today’s economic and financial climate.

Photo courtesy of Hospice of the Piedmont

Can you expound upon what led to the decision of Hospice of the Piedmont’s acute hospice care center closure?

As regulatory and market pressures intensify, hospices are really needing to re-evaluate not just how we deliver care, but also what care we can financially, sustainably provide, specific to our acute care center. This is especially important with the unknown impacts of the [One Big Beautiful Bill Act] that recently passed. The hospice industry has a tremendous unknown with the impact of the bill.

It’s the anticipation of the unknown that could compromise that stability and caused us to react the way we did. When it came down to the evaluation of an inpatient unit, we’ve been able to sustain it with philanthropy. But we cannot make this inpatient unit financially viable at a significant loss, and that was the hardest part of the business decision. We have to protect the rest of what we do for our community. We needed to ask whether we were being fiscally responsible and good stewards of our dollars.

Our acute care center was a wonderful service for our community. Our space was leased as a 10-bed unit, which might be different from a lot of other nonprofit hospices. It started in 2016, and given its leased space cost to fund it, we really needed a higher level of care from a billable and financial standpoint for this general inpatient hospice care.

The business case originally for the unit was that it would carry an average daily census of six patients at that level of care. That’s higher reimbursement. Since it’s opened, despite the amazing care provided there, we just have not been able to fill that unit with the right number of patients at the general inpatient level of care, which is not unusual. But I think because of the other costs of the unit, because it’s a leased space, and with the changes in Medicaid reimbursement and other financial storms that might be on the horizon, it all contributes to it.

Among the reasons for the center’s closure was that it would give Hospice of the Piedmont an increased opportunity to concentrate more on home-based services. Can you elaborate on this focus and any other initiatives on the horizon?

By closing the unit, it allows us to continue to focus on the other services that we provide such as community outreach and education or our death doula program. We are looking for every opportunity to serve our community through all phases of a serious or life-limiting illness such as through palliative care for those who are not yet ready for hospice, and growing our hospice program.

There are still many opportunities to help people understand the benefit of hospice far sooner than when they are dying, and these community services can definitely help with that. It’s seeing what this wonderful team can do to help patients and caregivers manage serious illness.

Another focus area of ours at Hospice of the Piedmont is about making sure we are deploying caregiver resources, whether it’s through volunteer support, grief support groups or just regular phone calls.

What have you found as significant keys to sustaining and growing your palliative care program?

The program started roughly six years ago as a nurse practitioner-led program. It relies on philanthropic donations to help sustain it. I think it will always have to be that way because of the reimbursement gap between the resources we need to help support palliative care patients in the home and what is paid for in that care. We know approximately how much revenue we generate from a billable visit expectation.

Being a strong referral source for the needs within our community, being dependable and reliable to help patients with the greatest needs — that is what we try to shoot for. Where we see the greatest impact from a sustainability perspective is that by having a strong palliative care program, we are able to serve patients upstream of hospice and generate a much longer length of stay and satisfaction that makes it worthwhile.

These services help us build relationships with a care team for patients who really need it because their symptoms and treatments are really hard. Palliative care helps with that symptom management and provides care when they need it most. It also introduces patients already on our services to hospice to have a very strong continuum of care and warm handoff when they’re ready.

How do you foresee hospice care delivery taking shape in the future?

The successful hospice in the future will always keep their eyes on the patient and family and adjust the sales and business impact around that, whether that is with reimbursement changes and other things that impact their bottom line. You have to do it through the lens of that patient as well as their caregiver.

The future for hospice or palliative care organizations to do well is having an eye on quality, safety and making sure that access is open to anyone in need of services. It’s about the ability to get consistent, reliable, supportive care and preserving community resources that might very well go away with the bill that just passed. We can’t operate in a silo.

What do you see as the largest challenges facing hospice providers today? And how are you navigating these issues?

I see multiple challenges at different levels. There will be an increase in regulatory security, whether it’s a higher level of care for patients or the unfortunate need to [address] fraud and abuse. We need to be making sure we’re fully transparent and have checks and balances in place.

We also need to have enough staff to care for patients and always think about the patient, their families and the caregivers.

What keeps me up at night now is truly the unknowns of regulatory and reimbursement changes and the impacts those will make not just to the hospice industry, but the overall community and those who are underserved. It’s not an option not to care for people in our communities. So, how do we fiscally, responsibly manage our resources to help support that?