Hospices need to get involved in hospital-based palliative care

Despite lack of Medicare payment, hospices can get paid

As end-of-life and pain management advocates raised the volume on the end-of-life care discussion, some hospitals responded by developing palliative care units to address the needs of their patients. Suddenly, someone else was treading on the domain of hospices.

Hospices have been slow to respond. Some dismiss the foray by hospitals as something quite short of the hospice mission. They reason that while hospital programs focus on symptom management, they fail to address weighty matters such as emotional and spiritual care.

Still, other hospice leaders grumble that Medicare has allowed other types of care providers to invade hospice territory with its restrictive regulations and narrow definitions of which services are reimbursable. Certainly, if hospices were to be paid by Medicare for providing palliative care services in hospitals, then hospices would do so.

It seems, however, this kind of sentiment is turning around. The National Hospice Organization changed its name to include "palliative care" in large part to address the growing need for palliative care outside traditional hospice settings. And a number of hospices are embracing palliative care in hospitals by becoming visible partners in developing inpatient palliative care units.

The Mount Carmel Hospice in Columbus, OH, has helped three Columbus-area hospitals establish inpatient palliative care units since 1995. Since then, they have treated more than 3,000 patients. Many of those patients found their way to hospices. While Medicare doesn’t provide reimbursement for the work it provides to the hospital, the partnerships translated into more timely referrals to the Mount Carmel Hospice and other area hospices.

In 1996, the Mount Carmel Hospice had an average length of service (LOS) of 38 days. With patients receiving hospice information sooner in inpatient palliative care units, an increasing number of patients are being admitted sooner and, as a result, LOS this year has soared to 50 days.

"The continuum of care has to be developed," resolves Mary Ann Gill, RN, MA, director of hospice and palliative care medicine for Mount Carmel. "What we’ve learned is that when you give knowledge away, you get so much back. By partnering with area hospitals, we’ve created a system that moves patients along the continuum."

At the Hospice of the Florida Suncoast in Lar-go, FL, partnering with St. Anthony’s Hospital is looked upon as return to what hospices did decades ago, before the industry became defined by what Medicare pays for.

"I think we’re going back to the broader end-of-life care we used to provide . . . to before Medicare when we would provide consults for palliative care," Mary Labiak, president and CEO of the Hospice of the Florida Suncoast. "Palliative care is nothing new. It’s a strength we have always had."

What both have helped create is an inpatient program that addressed the needs of the hospital’s sickest patients; dying patients whose care requires high-tech equipment that cannot be provided in the home; home care patients whose disease has not progressed enough to make them hospice eligible; and residential facility patients who are not hospice eligible.

Established relationships come first

Both Labiak and Gill say that hospices should establish partnerships with hospitals to bring palliative care to hospital patients. From a moral perspective, hospices have a duty to reach out to patients who need their care, both say. From a business perspective, it makes sense to tear down existing barriers that prevent hospices from reaching patients who otherwise would not be exposed to hospice care.

Doing so isn’t a simple proposition. It’s a combination of building relationships and sharing the hospice philosophy. It’s a delicate balance of competing hospital agendas and the hospice’s need to manage patient care.

For Mount Carmel Hospice, its palliative care partnerships began five years ago when hospice leaders asked: "Why are so many people who die in hospitals not receiving hospice care?"

"Before we began our palliative care partnerships, it was like holding a net outside the hospital hoping for patients," Gill says.

Even before the hospice and hospitals began looking earnestly at developing an inpatient palliative care program, the foundation for such partnerships was set down by years of relationship building. As both interacted, the hospice taking on patients referred by the hospitals and the hospitals learning about palliative care from the hospice, they found common ground to build their palliative care programs upon.

"Almost every hospital deals with end-of-life issues," says Gill. "If you establish a relationship with them and help them deal with these issues, you can eventually help them with their palliative care program."

A long-standing relationship with area hospitals also was the precursor to the Hospice of the Florida Suncoast’s program with St. Anthony’s Hospital. In fact, the hospice had been providing palliative care to area hospitals, says Labiak.

"We have always worked with area hospitals," she adds. "Now instead of scattered beds, we’re bringing them together in one place."

Hospitals and hospices that have nurtured their relationship have the inside track to establishing an inpatient palliative care unit. Now it is a matter of building a program that reflects the tenets of hospice care.

"Our greatest concern was that not only should the skills [needed for palliative care] transfer, but also the philosophy," says Labiak.

Left to their own devices, hospitals would likely implement palliative care programs that focus solely on symptom management. While a patient’s pain may be treated better compared to traditional hospital care, hospital staff lack the expertise to provide emotional and spiritual care.

A hospice’s role in developing an inpatient palliative care program is that of consultant. In essence, what hospices will be called upon to do is to provide training. Just as hospices would train new workers and volunteers, they will need to train hospital nurses and medical staff in treating the whole patient, how to recognize patients who would benefit from palliative care, and how to educate patients about their end-of-life options.

The hospice also will play a role in providing care. Arrangements will differ, depending on agreed-upon goals. One of the important details that needs to be ironed out is who will provide which services, such as whether hospice nurses will provide direct patient care in the palliative care unit or act as advisors, and the role other members of the interdisciplinary team will play. Involvement could range between acting as mere consultants to providing care in something similar to a hospice inpatient facility.

"It takes a lot of joint planning," says Gill.

According to the National Council for Hospice and Palliative Care Services, no matter what the structure or level of hospice involvement, hospital palliative care units should incorporate the following guidelines:

• The palliative care approach should be an integral part of all clinical practice, available to all patients with life-threatening illness.

• Appropriate management responsibility and consultative arrangements are required to ensure that key palliative care issues are addressed at trust level between patient and caregiver.

• Departmental policies should specify a minimum requirement of palliative care training for each category of staff, including nonclinical staff in contact with patients.

• All specialties should agree on clinical standards for palliative care; they should incorporate awareness of the psychosocial needs of patients and family/caregivers.

• There should be greater emphasis on the palliative care approach in both basic and post-basic education for all health care professionals

No matter the level of involvement, there will be cost incurred by the hospice. And while Medicare will not reimburse for palliative care outside the hospices, eligibility rules. Medicare rules are clear on covered benefits. Without a six-month terminal illness diagnosis, coverage is excluded. Further, services provided in a hospital are the billing responsibility of the hospital, because it is the hospital that owns the building, beds, equipment, and pays for staff who provide care.

But all this doesn’t mean hospices can’t get paid. "Where there is a will, there is a way," Labiak says.

One option is to charge hospitals a case rate for the palliative care it provides in its facility. If the rate isn’t enough to cover costs, grants and charitable contributions can make up the difference. Hospices still must be careful not to run afoul of fraud and abuse regulations. They cannot give away their services or provide care for free, because the arrangement could be construed as a scheme to induce referrals.

Still, fair-market price might not be enough to cover costs. Gill points out the financial benefit of having patients referred to hospice sooner — allowing the hospice to spread out the cost of care over a longer period of time — is a payment of sorts. Gill says her hospice now accepts patients who will stay longer and benefit more from hospice care, rather than caring for them just days before they die, when care is most intensive and expensive.

"Palliative care units give us the opportunity to assess patients, and give physicians help in assessing patients to make better decisions. We can train hospital discharge planners about hospice referrals, talk with the patient to find out what their end-of-life wishes are, and explain to them the benefits of hospice," Gill says. "This is brand-new work being done. We’re changing the culture of hospitals."