NHPCO data show hospice expanding nationwide, increase in average LOS

Short stays continue to be problem

The most recent data collected by the National Hospice and Palliative Care Organization (NHPCO) of Alexandria, VA, show some positive trends of expansion, with more than one million people receiving hospice care in 2004.

Also, there were 350 additional hospice programs nationwide for a total of 3,650 in 2004, and the average length of stay increased by two days to 57 days in 2004, according to the NHPCO's 2004 National Data Set (NDS).

However, there were some trends that continue to pose challenges for the industry; for example, the median length of stay remained at 22 days in 2004, same as in 2003, and the percentage of hospice patients who died in seven days or less was 35.1 percent, which was very close to the 36.9 percent recorded in 2003.

"The number of short-stay patients is not decreasing," says Stephen R. Connor, PhD, vice president, division of access for end-of-life care, research, and international programs for NHPCO.

"It'd be nice if this was a normal curve, but we have a whole bunch at the short end, and then it drops quickly," Connor says.

There are some market forces that could help improve the short-stay numbers and continue to push the average LOS upward, Connor notes.

"One of the things happening is more hospices are using what we think of as open access policies, where they are trying to get patients into hospice while they're still in treatment," Connor explains. "That trend moves the middle group of two-to-three months."

The problem with the short LOS is that it has been driven by the curative treatment restriction in Medicare hospice benefits, Connor says.

"Hospices wait to admit patients until they've discontinued all disease-modifying therapies," he says. "A lot of treatments are very expensive, like chemo, radiation, monitors for congestive heart failure."

But if hospices could get patients in sooner, then the increased revenue from earlier admission would offset the increased treatment costs, and it would promote better relationships with referral sources, Connor says.

Continuum Hospice Care of Continuum Health Partner in New York, NY, is an example of how well open access policies can benefit hospice referrals.

The hospice has a median LOS of 31 days, fully nine days longer than the national median LOS, and the average LOS is 61 days, says Carolyn Cassin, MPA, president and chief executive officer of Continuum Hospice Care.

"We believe we have pushed those numbers up because of open access," Cassin says. "We don't require anyone to give up anything to get into hospice care."

An even better indicator of how well the open access policy has worked is the fact that the hospice has decreased its percentage of people dying within seven days or less from 31 percent prior to open access to 21 percent now, Cassin says.

"That's the statistic I'm the most proud of in the organization," she says. "We've made it less of a brink-of-death benefit, so open access is working and people don't wait until they've finished chemo or radiation or made that psychological shift in their minds."

Hospice directors should be asking themselves why they have a six-month benefit that is only used for two months on average, Cassin says.

"There should be some general outrage at the federal government or regulatory agencies as to why this benefit isn't utilized," Cassin says.

NHPCO has encouraged open access policies for years, although it should be applied with a balanced approach, Connor says.

"It should be made on a case-by-case basis, with the physician, patient, family, and hospice team trying to understand the patient's goals," Connor says. "And if the goals are palliative, then you should provide the treatment—but you don't want to run your hospice into bankruptcy either, so find whatever balance works for your community."

Hospice LOS has begun to recover from some declining years in the 1990s after the government's Operation Restore Trust compliance investigations, Connor says.

About 15 years ago, the average LOS was 70 days, and then it began to decline after Medicare intermediaries instructed hospice programs to discharge any patients who looked like they might live more than six months, Connor says.

"After Operation Restore Trust, the percentage of 180 days-plus patients had decreased from 15 percent in the early 1990s to about 6 percent in the late 1990s," Connor says.

Although hospices now take it for granted that very few patients will survive the six month benefit period, from a statistical standpoint, having a rate under 10 percent of people living past a predicted six-month survival period means physicians are doing a good job of predicting how long people will live, Connor notes.

At the same time, physicians are making hospice referrals for people with increasingly diverse diagnoses. Fewer than half of the people served by hospice have cancer diagnoses, he says.

In the early 1990s, more than 90 percent of people served by hospice were cancer patients, and according to the 2005 NDS, cancer diagnoses account for 46 percent of hospice admissions.

"When hospices started in the United States, the primary diagnosis was cancer because that was far more predictable than other diseases," says Mary Taverna, president and chief executive officer of Hospice of Marin & Foundation in Larkspur, CA. Taverna is the 2005-2006 chair of the NHPCO board.

The trend to include different diagnoses is positive, Connor notes.

"We want to encourage this trend because we're serving the people who are dying, and we're less over-represented with cancer patients," Connor says. "Most people die of non-cancerous chronic conditions, including solid organ failure, dementia, senility, congestive heart failure, diabetes, etc."

While every hospice would like to see patients being referred before they have reached the last week of their lives, the fact that these dying patients are being referred at all is good news, Taverna notes.

"It goes along with a greater utilization of patient services," Taverna says. "And it's a matter of educating the medical community that an earlier referral to hospice is better than a late referral."

One of the main reasons why patients are referred so late is because of the discomfort on the part of physicians and some other referral sources to bring up the subject of hospice to patients and families, Taverna says.

"Hospices should work aggressively to better understand timely referral and to better understand how to transition patients from aggressive therapies that are no longer effective to palliative care," Taverna adds.

In many ways, the short-stay referrals are the result of how medical care has improved and changed nationwide, says David Simpson, MA, LSW, chief executive officer of the Hospice of Western Reserve in Cleveland, OH.

People who would have been obviously ready for hospice care 15 to 20 years ago are now the beneficiaries of a medical system where there are more interventions available, Simpson says.

"For example, 20 years ago it wouldn't be likely that someone would go through a third round of chemotherapy because chemo way back then was more noxious than it is today," Simpson says. "Overall, it's been improved so much that you propose a second or third round and it's more benign than it would have been."

So those patients who might be in line for a hospice referral have new technology and drug therapies to consider, and this keeps them less compatible with hospice care, Simpson says.

The key is to create a health care atmosphere in which conversations about hospice care are comfortable, and referrals are seen as a natural progression in the care continuum, he says.

The NHPCO NDS also shows increases in for-profit hospice programs, a rise from 29 percent in 2003 to 31 percent in 2004, and a drop in nonprofit programs from 67 percent to 63 percent. Government-run programs also increased from 4 percent in 2003 to 6 percent in 2004.

These statistics along with the overall increase in hospice programs may impact the type of care patients receive from hospices, Simpson suggests.

"I'm not so concerned about whether they're for profit or not-for-profit, but I am concerned about how our resources are being allocated into the program in terms of services," Simpson says. "And I think there is greater challenge for a for-profit entity to add things such as art and residential service."

For example, Hospice of Western Reserve has 12 full-time music and art therapists, while most small hospices would have difficulty funding even a part-time music or art therapist, Simpson says.

"My theory is that a community is better served by a consolidation of resources where economies of scale accrue," Simpson says. "So I'm not delighted with the notion that there are 300 more providers."

Need More Information?

  • Carolyn Cassin, MPA, President and Chief Executive Officer, Continuum Hospice Care, 1775 Broadway, New York, NY 10019. Telephone: (212) 420-2844.
  • Stephen R. Connor, PhD, Vice President, Division of Access for End-of-Life Care, Research, & International Programs, National Hospice and Palliative Care Organization,1700 Diagonal Road, Suite 625, Alexandria, VA 22314. Telephone: (703) 837-3149. Web site: www.nhpco.org/nds.
  • David Simpson, MA, LSW, Chief Executive Officer, Hospice of Western Reserve, 300 E. 185th St., Cleveland, OH 44119.
  • Mary Taverna, President and Chief Executive Officer, Hospice of Marin & Foundation, 17 E. Sir Francis Drake Blvd., Larkspur, CA 94939. Telephone: 415-927-2273.