To enhance relationships with hospitals, dispel myths

Hospice director works to open eyes, minds

Sometimes all it takes is a myth to prevent hospices from developing a more productive relationship with hospitals. For example, hospital staff might think a patient has to have the potential for home care in order to take advantage of hospice services. Or, referring doctors might believe patients need an intact family system in order to receive hospice care or that patients need to sign a do-not-resuscitate order, says Carolyn Cassin, MPA, president and CEO of Continuum Hospice Care, which is part of Continuum Health Partners, a seven-hospital health care system in New York, NY. The system has hospitals in Manhattan and Brooklyn.

Hospice must understand hospital’s goals

Cassin speaks to hospital administrators and physicians to dispel myths and show how hospices can help hospitals meet their own goals. "Hospice [staff] don’t really understand the hospital system’s goals, objectives, and incentives," Cassin says. "We didn’t understand each other’s goals and missions and the value hospice could bring."

Hospital staff often see hospices, even when they are part of a health care system, as a sideline business — a charity care that is unimportant but nice to have, Cassin explains. "But they didn’t see us as essential to the mission, to the vision of the hospital," she notes. So as a former CEO of several hospice programs that were separate from hospitals — and now as the CEO of a program that operates within a health care system — Cassin has tried to find out what it is that hospitals want and need from hospices.

What are you doing for the hospital?

"I found out that their issues were length of stay [LOS], creating a positive bottom line for the hospital system, and providing high-quality care," Cassin says. "That was something our hospice had never cared about — whether we were providing anything positive for the hospital."

So Cassin initiated a philosophy change in which the hospice staff began to look at how hospice services could help the hospital improve its LOS and bottom line while providing better quality of service. She attended hospital operations committee meetings and participated in the sorts of programs in which other hospital leaders would be involved. She visited other hospitals in the system and is involved in a work group that meets monthly or quarterly to deal with various discharge and care issues. "Hospitals are huge; they have complicated systems," Cassin notes. "There are a lot of operational issues, like, How do we turn a hospital patient into a hospice patient?’"

Hospice staff volunteered to participate in a hospital LOS committee and helped to develop a project in which the hospice helps the hospital reduce LOS by taking patients who are inappropriate for continued hospital stay and putting them into hospice care, where they are better served, Cassin says. "The program was a huge success, and hospital administrators loved it and eventually looked at us in a different light," she says.

By more fully integrating hospice services and staff into the hospital, Cassin and other hospice administrators have helped to dispel misconceptions and shift thinking among both hospice and hospital staff. "What I’m trying to do is shift their understanding of hospice from it being a program where you send dying patients to a program that has an outstanding set of services that are the appropriate place for all patients at the end of life," Cassin explains. "That’s a very important shift in their thinking, because there is a range of services for people."

As an open-access hospice, Continuum Hospice Care provides hospice services to anyone who meets eligibility requirements and provides consent. This often is an eye-opener for physicians and hospital administrators, Cassin says. "Everyone has the same reaction, an observable reaction where their eyes open up and they say, I didn’t know that was hospice,’" she says.

Now that the health care system staff and hospice staff are working from the same page, Cassin is focusing on educating administrators at unaffiliated hospitals about the importance of hospice care. "I know and understand what their issues are, so I try to quit selling them hospice and pain and symptom control," Cassin says. "That’s not at the top of their list; they think they do great pain and symptom control."

Instead, Cassin stresses how the hospice can help them with their LOS and bottom line. "How can I help them to free up beds by getting people eligible for hospice out of their bed and into hospice?" Cassin says. "Their core business is not end-of-life care, and that resonates with them."

Another way Cassin promotes hospice care is by suggesting that hospital staff call the hospice in to explain its services to patients and families rather than try to explain it themselves.

Hospice can handle emotional issues well

There is no reason for hospital nurses to become experts at promoting hospice care when all that’s really necessary is for them to say, "I’ve got a great team of people who will come and see you and explain everything to you about hospice; it’s a great program, and you’re eligible for these services," Cassin explains. "Hospitals don’t have the time to get involved with all of the emotional issues, so the hospice can do this for them," she says. "I don’t encourage people to mention hospice if it will scare people," Cassin adds. "They can say, We have a program for patients in the same situation as you.’"

The main point is that hospices should be working more closely with hospitals to provide end-of-life care because hospices do the job better, she says. "If you can scratch below the surface of a good hospital, they’ll admit the truth: that they don’t have people trained in end-of-life care, and they don’t have the time," Cassin says. "There isn’t time to get around to everybody who may need to understand the changing goals of care and transition [to palliative care]."

While some hospitals have palliative care programs to which they’ll refer patients, there remains a reimbursable benefit for end-of-life care that should not be denied to patients, Cassin says. "We package it as, Let us be your end-of-life care experts,’" Cassin says. "The hospital wants to have the best emergency medicine and oncology services, and so we promote our service as a specialist program in palliative care with physicians trained in end-of-life care."

Study hospital data on diagnoses, deaths

After broaching the subject with hospital administrators, the next step is to take an objective look at potential hospital referrals by studying the hospital’s data on diagnoses and deaths, Cassin says. "I start with deaths and say, Let’s look at every death in the hospital and see which ones should have been in hospice care,’" she says. "We should be attending every death in the hospital."

While a hospice referral often wouldn’t have changed any of the services the hospital provided to the dying patients, hospice could have offered patients and families additional assistance, such as bereavement care, Cassin says.

There also is a group of patients who could have been given a terminal diagnosis in a previous hospitalization or earlier in their last hospitalization, and this would have meant they might have benefited from hospice care for weeks or months, Cassin says. For example, a hospital administrator may discover when examining death data that some categories of diagnoses have patients who are spending an average of 13 days in the hospital before they die, and the hospital is reimbursed for only half of that time, she says.

"So let’s look at those patients and figure out how to intervene when we first see the patient going downhill," Cassin says. "Let’s use these diagnoses as a trigger to get started, and if the hospice hasn’t been helpful and the hospital doesn’t see its LOS drop, then we’ll re-evaluate and figure out something else."

Typically, this approach results in the hospice making a formal agreement with the hospital to help identify patients eligible for hospice care, Cassin says.