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Noncancer diagnoses make length of service hard to predict
Average LOS increases while median LOS decreases
The typical hospice patient has changed over the years, primarily due to the increase in noncancer patients admitted to hospice. NHPCO Facts and Figures: Hospice Care in America, a report issued by the National Hospice and Palliative Care Organization (NHPCO), shows that noncancer diagnoses account for 58.7% of patients in 2007, a 2.8% increase over the previous year. It also shows that the average length of service (LOS) increased by almost 13%, to 67.4 days. At the same time, 30.8% of patients died within seven days or less of admission to hospice.
The number of patients dying in such a short time affected the median length of service (50th percentile), points out Stephen R. Connor PhD, vice president of research and international development for NHPCO. "In 2006, the median length of stay was 20.6 days and, in 2007, the median dropped to 20 days," he says. "There is more volatility in the LOS for noncancer diagnoses because it is harder to predict the prognosis for diseases such as heart disease, lung disease, and dementia than it is for cancer," Connor admits.
In the 1990s, average hospice LOS was in the 40s, he says. This length of service was the result of strict Medicare guidelines that were relaxed later to enable admission of noncancer patients with less predictable prognoses, Connor adds. "Now, the pendulum has swung the other way with hospices that have patients living longer in hospice care," he says. The increased length of service for some patients causes problems for some hospices as they hit the cap on their Medicare reimbursement limits, Connor points out.
Although NHPCO's report combines data from hospitals based at or affiliated with hospitals and home health with those from freestanding, private hospices, there is a difference in the two types of organizations, says Connor. "The greatest increase in average LOS occurs in freestanding hospices," he points out. "These hospices may be better at outreach and at educating referral sources to admit patients to hospice earlier than hospital-based organizations." This does place freestanding hospices at greater risk of reaching the Medicare cap if they don't watch their mix of patients, Connor adds.
The mix of long- and very short-term patients does present challenges for hospices, admits Gretchen M. Brown MSW, president and CEO of the Hospice of the Bluegrass in Lexington, KY, and chairperson of the NHPCO board of directors. "The greatest use of hospice resources occurs during the first few weeks of any patient's admission," Brown points out. Every member of the team must visit to perform assessments of the patient and family needs, so visits are made by nurses, social workers, chaplains, and volunteers at the time of admission in order to prepare a plan of care, she explains. Staff, equipment, and supply costs are highest immediately after a patient's admission, Brown points out.
Lengthy LOS requires recertification
Longer-term patients present different challenges, says Brown.
"Recertification after the initial 90-day period requires additional nursing visits and time for assessments," she points out.
If the patient is in a nursing home, there usually is less need for changes in medications or durable medical equipment throughout the patient's care until the nurse notices a decline, Brown says. Once the patient begins to decline, there is a need for more intense care with on-call visits, changes in medical equipment such as oxygen, and changes in medication for pain or other symptoms, she says.
Ideally, a patient is with hospice for one to three months, Connor says. Not only does that time frame enable the hospice team to give the best care to the patient, but it also gives hospice staff a chance to prepare the family for the patient's death, he says.
"A mix of long-term and short-term patients is important for many reasons," says Brown. The most important reason is the emotional health of staff members, she admits. "If you have a mix of patients, staff members don't have to deal with death every day," Brown points out. "In our agency, about 10% of our patients die in the first week of admission, about 50% are with us for one month, and the remaining patients receive service longer," she says. Staffing teams are assigned a mix of patients whose anticipated lengths of service differ to give them a chance to develop relationships with longer-term patients, Brown says.
If possible, staff members also should have a mix of diagnoses and ages, suggests Brown. Older patients have different needs than younger patients, and patients with multiple chronic conditions have more needs than patients with a single diagnosis, she points out.
Predicting length of service is difficult because physicians are not as good at predicting how long the patient will live as they used to be, Connor says. Although it is more complicated to develop a prognosis for a noncancer patient, it can be done, he says. He suggests that physicians look at each patient as an individual and answer the question, "Will you be surprised if this patient is gone in six months?" He adds, "Physicians don't have to be 100% accurate in their assessment. If they are 85 or 90% accurate, we'll be making sure that patients are admitted to hospice at the right point to ensure the highest level of care and support."
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To see a free full copy of the National Hospice and Palliative Care Organization report, NHPCO Facts and Figures: Hospice Care in America, go to www.nhpco.org. On the left navigational bar, select "What's New." Select "Research" and select "NHPCO's Facts & Figures on Hospice."