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Although the Medicare Hospice Benefit mandates that hospices offer bereavement support services to families for at least 1 year following the death of a patient, it does not stipulate which services they should offer. As a result, little is known about what bereavement support services hospices provide, especially on a national scale. The current study recruited a national sample of hospice representatives who responded to an open-ended question that asked, “What types of bereavement support services does your hospice provide to families?” Seventy-six viable responses were recorded and content analyzed. Four overarching domains emerged: (a) timing of support, (b) providers of support, (c) targets of support, and (d) formats of support. Other notable findings included the underutilization of bereavement support services and the utility of informal support formats. These findings present implications for future study regarding which specific aspects of hospice bereavement support services are most beneficial to bereaved families.

Context: Many older adults discharged from an inpatient stay require postacute facility placement, which can be a barrier to hospice enrollment since the Medicare hospice benefit does not cover facility costs for patients under routine hospice care. Objectives: To evaluate the extent to which need for postdischarge facility care was a barrier to hospice enrollment for older patients with short life expectancy discharged from a palliative care unit. Methods: Retrospective cohort using a prospectively collected database of patients 65 and older with a life expectancy of Results: Of 817 included patients, 649 (79%) were discharged with hospice. Patients discharged home had a significantly higher rate of hospice enrollment than patients discharged to a facility—92% versus 71% ( P < .0001). On multivariate logistic regression analysis, discharge to home versus facility remained a strong predictor of hospice enrollment, with an odds ratio for hospice enrollment of 6.04 (95% confidence interval: 3.73-9.79). Conclusion: Need for postdischarge facility placement represents a barrier for hospice enrollment among older patients who are otherwise hospice appropriate. The structure of the hospice benefit may require modification so that these hospice appropriate patients can utilize the benefit.

Background: Over 10% of hospice patients experience a transition out of hospice care during the last months of life. Hospice transitions from home to hospital (ie, hospital-related hospice disenrollment) result in fragmented care, which can be burdensome for patients and caregivers. Nurses play a major role in delivering home hospice care, yet little is known about the association between nursing visits and disenrollment. Objectives: The study’s purpose is to examine the association between the average number of nursing visits per week and hospital-related disenrollment in the home hospice population. We hypothesize that more nursing visits per week will be associated with reduced odds for disenrollment. Design: A retrospective cohort study using Medicare data. Participants: Medicare hospice beneficiaries who were ≥18 years old in 2012. Outcome measured: Hospitalization within 2 days of hospice disenrollment. Results: The sample included 115 103 home hospice patients, 6450 (5.6%) of whom experienced a hospital-related disenrollment. The median number of nursing visits per week was 2 (interquartile range 1.3-3.2), with a mean of 2.5 (standard deviation ±1.6). There was a decreased likelihood of a hospital-related disenrollment when comparing enrollments that had Conclusions: More nursing visits per week was associated with a decreased likelihood of a hospital-related hospice disenrollment. Further research is needed to understand what components of nursing care influence care transitions in the home hospice setting.

Background: Medicare spends about 20% more on the last year of life for Black and Hispanic people than White people. With lower hospice utilization rates, racial/ethnic minorities receive fewer hospice-related benefits such as lesser symptoms, lower costs, and improved quality of life. For-profit hospices have higher dropout rates than nonprofit hospices, yet target racial/ethnic minority communities more through community outreach. This analysis examined the relationship between hospice utilization and for-profit hospice status and conducted an economic analysis of racial/ethnic minority utilization. Method: Cross-sectional analysis of 2014 Centers for Medicare & Medicaid Services (CMS), U.S. Census, and Hospice Analytics data. Measures included Medicare racial/ethnic minority hospice utilization, for-profit hospice status, estimated cost savings, and several demographic and socioeconomic variables. Results: The prevalence of for-profit hospices was associated with significantly increased hospice utilization among racial/ethnic minorities. With savings of about $2,105 per Medicare hospice enrollee, closing the gap between the White and racial/ethnic minority populations would result in nearly $270 million in annual cost savings. Discussion: Significant disparities in hospice use related to hospice for-profit status exist among the racial/ethnic minority Medicare population. CMS and state policymakers should consider lower racial/ethnic minority hospice utilization and foster better community outreach at all hospices to decrease patient costs and improve quality of life.

The Medicare Payment Advisory Committee (MedPAC) recommended that the per diem reimbursement for the Medicare Hospice Benefit change to a U-shaped scheme reflecting spending based on nursing visit frequency. This study investigated the change in drug cost over patients’ length of stay (LOS) as current drug cost trends are unknown and were not evaluated in the MedPAC proposed reimbursement scheme. An analysis of patient utilizers of a national pharmacy claims database from 2007 to 2010 was completed to determine the trend in average daily pharmaceutical cost per utilizer (PCPU) over the patient’s LOS. The average daily PCPU for 144 119 patients demonstrated a U-shaped curve. Indexed values in the first and last periods were significantly higher than in all other periods overall and by diagnosis ( P < .001). Although indexed medication costs showed a U-shaped curve, it is imperative that hospice reimbursement be adequately evaluated for all medication costs including variations within the diagnosis mix. Payer sources and hospices must work together to determine adequate reimbursement models that will provide patients with effective and efficient high-quality care through the end of life.

Background/Rationale: Persons with dementia often die in nursing homes (NHs); however, concerns exist about their low use of Medicare hospice. Methods: For 1999 through 2006 in all US states and DC we merged NH resident assessment data with Medicare claims and enrollment data to identify NH decedents with dementia and hospice use. We studied two groups, those with advanced dementia and those with mild-to-moderately severe dementia. Results: Across study years, 22.2% of all NH decedents had mild-to-moderately severe dementia and 19.6% had advanced dementia. In 1999, 14.5% of decedents with advanced and 13.2% with mild-to-moderately severe dementia accessed hospice, increasing to 42.5% and 37.9% respectively in 2006. Between 1999 and 2006, mean days of hospice stays increased from 46 to 118 for advanced dementia and from 39 to 79 for mild-to-moderately severe dementia. These mean length of stay differences resulted from a relatively lower proportion of short hospice stays (≤ 7 days) together with higher proportions of longer stays (≥ 181 days) among advanced versus mild-to-moderately severe dementia decedents. Hospice access and lengths of stay among US states varied widely. Conclusions: Over 40% of US NH decedents have mild-to-moderately severe or advanced dementia. For these NH decedents, access to and duration of Medicare hospice has increased. However, there is considerable variation in hospice use across US states.

The Medicare home health benefit and the Medicare Hospice Benefit (HMB) differ significantly in social work coverage, with social work being only 1%-2% of national Medicare home health visits compared to about 10% of national HMB visits. There has been some research on the frustrations of home care and hospice social workers. However, there is no research that compares home care and hospice social workers. The article presents results of convenience sample interviews of 34 home care social workers and 42 hospice social workers in New York City from August 2006 to October 2007. The analysis finds that, in contrast to home health social workers, hospice social workers feel more able to actualize their altruism professionally; their professional training is more relevant to actual practice; their patients and caregivers have fewer unmet psychosocial needs; and their care is less constrained, and actually enhanced to a great extent, by payer requirements.

Early indications are that the Medicare home health prospective payment system (PPS) has controlled Medicare home health expenditures. However, studies indicate many unresolved questions about whether PPS improves patient quality of care and is cost-effective. The article reviews effective home-based palliative care interventions and presents the views of seven home health care nurses regarding the impact of Medicare requirements on their care decisions for one chronic disease population—Alzheimer's disease. The article asserts the current failure to simultaneously address the cost and quality-of-life issues of home health Alzheimer's patients is analogous to the end-of-life care situation Medicare confronted in the 1970s prior to the Medicare hospice demonstration program that preceded the Hospice Medicare Benefit. The article asserts that a similar demonstration is appropriate to determine how PPS might better meet patient quality-of-life needs and the government's need to reduce costs.

Hospices are required to provide pharmaceuticals under the Medicare Hospice Benefit. Since there are no data describing these costs for hospice programs, this study analyzes data from a cross-sectional survey of 34 hospices concerning their pharmaceutical cost trends. Most respondents reported higher pharmaceutical-related costs between 1998 and 2002, but a significant minority reported that their costs had decreased. Pharmaceutical costs varied by patient setting, but long-acting opioids and continuous-infusion delivery systems were the two most significant contributors. A variety of mechanisms were employed to control drug costs.

The goal of the present study was to assess the validity of the Medicare hospice eligibility guidelines for dementia patients, as well as identify predictors that could more accurately identify prognosis in dementia patients referred to hospice. A retrospective chart review was conducted, including initial assessment and longitudinal follow-up of patients until the time of death. In addition, a second validation cohort was also followed. Participants consisted of 245 patients admitted to a large community-based hospice with a diagnosis of dementia, including a validation sample of 80 patients. The Kaplan-Meier estimation of survival and a Cox regression analysis (p > 0.05) revealed no significant relationship between the Medicare guidelines or any component of the guidelines and survival at six months for the initial and validation samples. Significant multivariate predictors of shorter survival in both the initial and validation sample include greater age (p = 0.02) and anorexia (p < 0.001), as well as a combination of anorexia and greater functional impairment (p = 0.005). Overall, the results indicated that the Medicare guidelines were not valid predictors of survival in hospice patients with dementia and should be altered to include empirically valid predictors. Advanced age, as well as impaired nutritional and functional status, was associated with shortened survival in these patients. The predictor variables identified are an initial step toward providing improved prognoses for advanced dementia patients, their families, and practitioners. Broader issues in improving access to hospice care for dementia patients are discussed.

Over 20 years ago, hospice in the United States evolved to provide end-of-life care for terminally ill patients. However, three major barriers exist, which limit access to hospice care. The first two, cultural and regulatory barriers, are not under the direct control of hospices, although programs can be adapted to minimize their influence. The third, management focus, is controlled by hospice programs and has the greatest influence on access to care and quality of care. Under the influence of the Medicare Hospice Benefit and the peer pressure of managed care, many hospice programs use reimbursability as at least one criterion for determination of coverage of services. The fear is that limited reimbursement will cause some services and therapies to bring the programs to financial ruin. This case study shows the outcome of changing management focus away from restrictive policies about therapies and patient selection toward management of productivity and working capital. Some programs have contributed to growth and stability; the revenue thus produced has supported the new innovations. San Diego Hospice is now growing more than 30 percent per year in spite of competition and a fairly flat death rate in the community. This growth is attributed to finding and meeting unmet needs and making all decisions based on the right thing to do. Every staff member understands and supports the mission. The many programs within the agency contribute to fulfillment of the goal to transform end-of-life care. They are presented here as an example of what can be done with mission-based management.

Bien qu'il existe des soins palliatifs finances par le Medicare dans les cliniques depuis plus de 10 ans, on sait tres peu de choses concernant l'utilisation de cette aide gouvernementale dans les cliniques. Grâce aux resultats d'une enquete menee aupres des utilisateurs et aux statistiques du Medicare dans 5 etats des Etats-Unis, nous avons pu identifier et decrire les beneficiaires de soins palliatifs en clinique entre 1992 et 1996 et les types de soins palliatifs dispenses. Six pour cent de tous les patients hospitalises en clinique ont beneficier de soins palliatifs a un moment ou a un autre et en 1996, on a estime que 24% de tous les patients en soins palliatifs couverts par le Medicare ont beneficie de soins palliatifs en clinique. Parmi ces patients, qui ont recu des soins palliatifs apres avoir ete admis en clinique, 48% avaient 85 ans ou plus, 70% etaient des femmes, 94% etaient blancs, 76% n'etaient pas maries et 62% souffraient d'une affection principale non cancereuse. La duree moyenne du sejour etait de 90.6 jours avec une mediane a 35 jours et une duree tres frequente de 2 jours. Les soins palliatifs dans les cliniques americaines constituent un systeme de soins tres repandus qui semblent faire beneficier du systeme Medicare surtout les adultes plus âges de sexe feminin et non atteints de pathologies malignes. Les durees de sejour sont similaires a celles observees habituellement et la duree moyenne de sejour est substantiellement plus courte que celle rapportee auparavant par une etude gouvernementale orientee.

The objective of this study was to determine the effects of very high cost patients on hospice financial status. Ten Pennsylvania hospices dually certified by Medicare were randomly selected and agreed to participate. Patient age, sex, diagnosis, length of stay and payer were fairly uniform across hospices. Payments varied by diagnosis and payer. High cost patients were irregularly found in hospices; low cost patients were commonly and regularly distributed. Every hospice had at least one high cost patient. In one, the uncompensated payment for the 6.6 percent of patients defined as high cost ($7,300 and above) would have been 14.7 percent of total annual revenues. In another, uncompensated payments for high cost patients (9.8 percent) would have accounted for 17.2 percent of revenue. In 96.3 percent of the instances patients utilized less than the Medicare Hospice Benefit maximum allowable cost ($7,300); and, 98.8 percent of the time patients stayed less than the maximum allowable length of time of 210 days. A logistic regression model found long length of stay (p < 0.0001), Medicare hospice benefit as primary payer (p Between the time the study was planned and completed, Medicare instituted a reinsurance program allowing unused funds below the maximum allowable limit from one patient to be used for patients who exhausted their benefits. Thus, no study hospice was adversely affected by high cost patients. However, it should serve as an object lesson to Medicare in using prospective payment. A normal or near-normal distribution of patients by cost cannot be assumed for small institutions.