In-Depth Report: Open-Access Hospice On Rise

Pioneers in open-access trend cite benefits, as do relative newcomers

One hospice has 75-day length of stay

(Editor’s note: Hospice Management Advisor presents in this issue the first of a two-part series about how increasing numbers of hospices are adopting an open-access policy that welcomes all eligible hospice patients, regardless of treatment status and ability to pay. We spoke with pioneers of this trend, who discuss in the story below why they feel open-access hospice is the industry’s best hope for the future. The April issue of HMA will feature additional reporting about strategies for succeeding with an open-access policy and how hospices have made open access work financially.)

With hospitals and other health care providers beginning to horn in on hospice’s palliative care business, it’s time for the hospice industry to evolve in response to these developments. One effective way to do this is to adopt an open-access philosophy, in which a hospice seeks out and admits all eligible patients, experts say.

Open-access hospices start with the basic notion that all patients eligible for the benefits of a hospice program should be admitted with no barriers to their care, says Carolyn Cassin, MPA, president and chief executive officer of Continuum Hospice Care in New York. "It goes back to the fundamental criteria in law in 1982, which said first that in order to be a hospice patient, a patient had to be certified by a physician as having a life expectancy of six months or less given the normal course of a disease, and second that the patient had to want the benefit and provide informed consent," Cassin says.

Unfortunately, much of the hospice industry has introduced barriers that were not meant to exist, she notes. "In my experience, hospices have decided who they would and wouldn’t serve, as opposed to running a hospice more like an emergency room where anyone needing services can walk in," Cassin says. "Hospice in my opinion is no different than that."

It’s partly because of these barriers that common hospice referral sources now are looking into offering their own palliative care and end-of-life care services, thus eliminating the hassle of trying to find a hospice who will take care of all of the referrer’s eligible patients, hospice experts say.

"Long term care centers and nursing homes are saying, Maybe I want to provide this service, and why can’t I do palliative care and hospice?’" says Greg Grabowski, senior vice president of external relations and chief of the marketing and community relations office for Hospice of Michigan in Detroit. "One way for the hospice industry to stay out in front is with open access, managing their case mix and managing finances to cover this," Grabowski says. "Folks must band together."

Hospice of Michigan always has had an open-access philosophy, even though the hospice was part of a 10-hospice merger in 1994, says Dottie Deremo, RN, MSN, MHSA, chief executive officer of the hospice. Hospice of Michigan has about 800 employees and 1,000 volunteers, and had 7,500 admissions last year.

Hospice of Michigan’s 24 sites in 45 counties of lower Michigan provide 25% of all end-of-life care in the state, despite operating in a very competitive market where there are 53 competing hospices within seven counties in the greater metropolitan Detroit area, Deremo notes. "We accept everyone regardless of age, ability to pay, diagnosis, or expense of treatment," Deremo says. "We’ve gotten referrals from other hospices that wouldn’t accept a patient who’s getting palliative radiation or palliative chemotherapy. Their admission criteria would be so narrow that they’d have a number of barriers and say, We can’t accept you, but Hospice of Michigan will.’"

Many could provide open access, but don’t

The National Hospice Workgroup was formed seven years ago in San Diego as a think tank devoted to increasing access to palliative competencies of hospice care, says True Ryndes, ANP, MPH, president and chief executive officer.

The Workgroup’s 26 members include some of the North American pioneers in the hospice industry, and all believe in moving toward open access, although some are further along than others on the open-access continuum, Ryndes says. "Our intent is to help people who are suffering and in pain in the last phase of their lives, and that may mean by helping to get them admitted to hospice," Ryndes says. "We look at the internal and external barriers to hospice care."

Barriers may include patients and families who are not ready emotionally for hospice care, so many of the Workgroup’s members have created palliative care services, consulting services, and palliative home health to meet the needs of those patients, he says.

However, one of the chief barriers patients face at the end of life is erected by hospices themselves, experts say.

"Unfortunately, there are too many programs who have the capacity to practice open access. They have the money, but they just don’t do it," says Samira K. Beckwith, LCSW, CHE, president and chief executive officer of Hope Hospice in Fort Myers, FL. Hope Hospice received the Circle of Life Award in 2004 and the Circle of Life Citation of Honor in 2003 for its innovative program to improve the care of patients near the end of life. The awards are supported by the Robert Wood Johnson Foundation in Princeton, NJ, and are sponsored by the National Hospice and Palliative Care Organization (NHPCO), the American Medical Association, and the American Association of Homes and Services for the Aging.

"They hang on to what they think the old hospice model is, and they don’t want to change," Beckwith says. "I think those programs are wrong because hospice never started out to have barriers, but they feel comfortable in their own little box."

Beckwith experienced this barrier first-hand when her own mother was dying with Parkinson’s disease in another area of the country. Since it’s difficult to make a terminal prognosis with Parkinson’s, Beckwith had difficulty convincing hospices in her mother’s area to understand that the woman could benefit from hospice services.

An open-access hospice such as Hope Hospice would have accepted her mother as a patient with open arms, looking beyond her disease diagnosis to see how the woman was indeed dying and needed help, Beckwith says.

Hope Hospice is a good example of how a small hospice can succeed with an open-access philosophy. When Hope Hospice began operating under open access 10 years ago, the hospice had about 50 patients per day, Beckwith says. "Now our average daily census is about 800," Beckwith says. "So people who think that only large hospices can provide open access are wrong."

Through open access, Hope Hospice has increased its average length of stay (LOS) to about 75 days. Its case mix is about 40% cancer patients and 60% other diagnoses, Beckwith says. By comparison, the average LOS in hospice care is 55 days, according to statistics collected by the NHPCO.

Hope Hospice cares for 60% of the dying patients within its service area, which is one of the highest percentages in the country, Beckwith says. Nonetheless, many hospices have been reluctant to make the transition to open access, she says. "The open-access philosophy does have a long ways to go, and that’s why it’s exciting to have more and more recognition of open access in formalized programs," Beckwith notes.

For instance, open access has been a featured subject at conferences held by the NHPCO.

"I think a lot of hospices are recognizing that palliative care services are integral to meeting the needs within their communities, so we’re seeing a lot of hospice providers reaching out and offering either more palliative care or open access to bring patients to care earlier," says Jon Radulovic, vice president of communications for the Alexandria, VA-based NHPCO. "The face of dying America is changing, and more people are suffering from long-term ailments like ALS and Parkinson’s disease," Radulovic says. "Hospices are learning to respond to these patients and their families and are learning to reach out earlier in the disease trajectory."

NHPCO’s strategic business plan for 2005-2007 lists "access" as one of its two chief themes (the other one is "quality"). The plan states that the goal is to increase the "use of palliative and hospice care and integration of end-of-life care into the health care continuum."

Another sign that open access might be the trend of tomorrow is that one of the nation’s largest for-profit hospice chains provides a version of open access. VistaCare of Scottsdale, AZ, was founded with a modified open-access philosophy, says Roseanne Berry, MS, RN, co-founder and chief compliance officer. "We knew we wanted to admit all eligible patients, but we weren’t sure how to put that together with a business sense," Berry says. "We worked at it, but we weren’t as open as we are now, and the open-access philosophy started taking hold in 1998 within our company."

In 1998, VistaCare grew from six hospice locations to 46 sites within 30 days, says David Rehm, MSW, senior vice president. "We did a review of our mission criteria and decided to go ahead and do open access," Rehm says. "One of the issues is that size gives you a level of comfort in taking on that kind of risk."

Now VistaCare has 49 hospice programs operating in 14 states. The company’s average LOS is about 90 days, and its median LOS is about 31 days, Rehm says. According to NHPCO data, the national median LOS is 22 days. "Nationally, hospice services 35% of the eligible population," Rehm says. "We have some markets where we take care of almost everybody who dies in the market — above 90%."

This proves that if a hospice implements an open-access philosophy and does it effectively, then over time the hospice can assist just about everyone who is eligible, Rehm says.

Making the switch to an open-access philosophy is a process, not a task with a set end point, he notes. "It’s a transition that involves training, and it involves a culture change, an attitudinal change," Rehm adds. "It requires a different set of clinical skills in order to implement it, and it’s not a transition that every [employee] is able to make."