Hospice directors describe strategies for improving hospice referrals and LOS

Normalize hospice is one answer

Everyone in the hospice industry would like to see the current 1.06 million patients served by hospice increase to nearly 2 million, and they'd like to see the average length of stay (LOS) rise from nearly two months to over three or four months.

But how can the industry get from here to that ideal?

"Any societal change takes a couple of things, including a groundswell, a tipping point," says Carolyn Cassin, MPA, president and chief executive officer of Continuum Hospice Care of New York, NY.

"A million people had hospice care last year, and 50 percent of them had it for less than 20 days," Cassin says. "And 36 percent had it for less than seven days."

Perhaps when more Baby Boomers experience hospice care and their families are outraged by late referrals, things will begin to change, Cassin says.

"We have to raise everyone's consciousness, but there's not that level of outrage yet," Cassin says.

Also, physicians and other referral sources have to realize that they might not be the best people to explain hospice services to patients, she says.

"It's just like an organ transplant service, you don't try to explain it yourself," Cassin says. "Health care providers used to explain organ transplants to people, and nobody ever wanted to donate organs."

So providers stopped trying to explain it and let professionals explain organ transplants, and now organ donation is universal, Cassin says.

Likewise, doctors should let hospice nurses or social workers explain hospice services to patients, and this likely will improve patients' and families' comfort with the concept, Cassin says.

"Normalize hospice, and make it just another one of the fabulous services that the American health care system has to offer," Cassin says.

There also are specific programs and partnerships that hospices can form that will help improve referrals and LOS.

For example, the Hospice of Western Reserve of Cleveland, OH, was involved in an intervention project with an acute care, comprehensive cancer center, says David Simpson, MA, LSW, chief executive officer.

The project, which was part of a study called Project Safe Conduct, involved placing a nurse who is board certified in hospice and palliative care, social worker, and spiritual care counselor in the Ireland Cancer Center of Cleveland, where they met with families when they were diagnosed with advanced lung cancer, Simpson explains.

The project's stated goal was to promote a seamless transition from curative to palliative care for dying patients through the implementation of an integrated care path model and protocols.

"The day patients were diagnosed, they were introduced to the team," Simpson says. "And the team's whole purpose was to guide people through palliative and end-of-life care," Simpson says. "It might sound brutal to say, 'I need to introduce a patient to palliative care,' but it doesn't work that way."

What the team was able to do is talk with people while they still had time to talk, and they could ask them what their concerns are and what their fears were, Simpson explains.

Prior to starting Project Safe Conduct, the average hospice LOS for these patients was 10 days, and after the intervention it had increased to 43 days.1

Hospice referrals increased from 13 percent to 80 percent due to the intervention, and the hospital admission rate dropped from 3.2 before Project Safe Conduct to 1.05 for the patients enrolled in the program. Also, unplanned hospitalizations and emergency room visits dropped from 6.3 per patient to 3.1 per patient, and average daily medication costs dropped from $60.90 per patient to $18.45 per patient.1

The original project was for three years, and it received $1.1 million in funding, but after it ended, the cancer center continued to fund the three-person team, and now it's in its third year post-study, Simpson says.

"Our organization has a contract with the cancer center to manage the project, although the Safe Conduct staff are now on the payroll of the cancer center," Simpson says. "The hospice LOS has remained high, and the number of referrals to hospice remained high."

From the cancer center's perspective, the program has been positive, as well, he says.

"Even though we have more people coming into hospice care, the center has had more people coming on to clinical trials, and we don't know why," Simpson says. "And the center gets letters from people who thank them for this program."

Since the study ended, the cancer center has expanded it to include patients with some other types of cancers, Simpson adds.


1. Pitorak EF, Armour MB, Sivec HD. Project Safe Conduct Integrates Palliative Goals Into Comprehensive Cancer Care. J Palliat Med. 2003;6(4):645-655.