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Background: The evidence base for understanding hospice use among persons with dementia is almost exclusively based on individuals with a primary terminal diagnosis of dementia. Little is known about whether comorbid dementia influences hospice use patterns. Objective: To estimate the prevalence of comorbid dementia among hospice enrollees and its association with hospice use patterns. Design: Pooled cross-sectional analysis of the nationally representative Health and Retirement Study (HRS) linked to Medicare claims. Subjects: Fee-for-service Medicare beneficiaries in the United States who enrolled with hospice and died between 2004 and 2016. Measurements: Dementia was assessed using a validated survey-based algorithm. Hospice use patterns were enrollment less than or equal to three days, enrollment greater than six months, hospice disenrollment, and hospice disenrollment after six months. Results: Of 3123 decedents, 465 (14.9%) had a primary hospice diagnosis of dementia and 943 (30.2%) had comorbid dementia and died of another illness. In fully adjusted models, comorbid dementia was associated with increased odds of hospice enrollment greater than six months (adjusted odds ratio [AOR] = 1.52, 95% confidence interval [CI]: 1.11-2.09) and hospice disenrollment following six months of hospice (AOR = 2.55, 95% CI: 1.43-4.553). Having a primary diagnosis of dementia was associated with increased odds of hospice enrollment greater than six months (AOR = 2.62, 95% CI: 1.86-3.68), hospice disenrollment (AOR = 1.82, 95% CI: 1.32-2.51), and hospice disenrollment following six months of hospice (AOR = 4.31, 95% CI: 2.37-7.82). Conclusion: Approximately 45% of the hospice population has primary or comorbid dementia and are at increased risk for long hospice enrollment periods and hospice disenrollment. Consideration of the high prevalence of comorbid dementia should be inherent in hospice staff training, quality metrics, and Medicare Hospice Benefit policies.

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.

Objective: Characterize hospice staff practices and perspectives on discussing end-of-life care preferences with patients/families, including those desiring intensive treatment and/or full code. Background: Patients in the United States can elect hospice while remaining full code or seeking intensive interventions, for example, blood transfusions, or chemotherapy. These preferences conflict with professional norms, hospice philosophy, and Medicare hospice payment policies. Little is known about how hospice staff manage patient/family preferences for full-code status and intensive treatments. Methods: We recruited employees of four nonprofit US hospices with varying clinical and hospice experience for semi-structured, in-depth interviews. Open-ended questions explored participants' practices and perceptions of discussing end-of-life care preferences in hospice, with specific probes about intensive treatment or remaining full code. Interdisciplinary researchers coded and analyzed data using the constant comparative method. Results: Participants included 25% executive leaders, 14% quality improvement administrative staff, 61% clinicians (23 nurses, 21 social workers, 7 physicians, and 2 chaplains). Participants reported challenges in engaging patients/families about end-of-life care preferences. Preferences for intensive treatment or full-code status presented an ethical dilemma for some participants. Participants described strategies to navigate such preferences, including educating about treatment options, and expressed diverse reactions, including accepting or attempting to shift enrollee preferences. Discussion: This study illuminates a rarely studied aspect of hospice care: how hospice staff engage with enrollees choosing full code and/or intensive treatments. Such patient preferences can produce ethical dilemmas for hospice staff. Enhanced communication training and guidelines, updated organizational and federal policies, and ethics consult services may mitigate these dilemmas.

BACKGROUND/OBJECTIVES Psychotropic and opioid medications are routinely prescribed for symptom management in hospice, but national estimates of prescribing are lacking. Changes in Medicare hospice payment in 2014 provide the first opportunity to examine psychotropic and opioid prescribing among hospice beneficiaries, and the factors associated with use of specific medication classes. DESIGN Cross-sectional analysis of a 20% sample of traditional and managed Medicare with Part D enrolled in hospice, 2014-2016. SETTING Beneficiaries enrolled in the Medicare hospice benefit. PARTICIPANTS Medicare beneficiaries ≥65 newly enrolled in hospice between July 1, 2014 and December 31, 2016 (N = 554,022). MAIN OUTCOME Prevalence of psychotropic and opioid medication prescribing by class and factors associated with prescribing. RESULTS 70.3% of hospice beneficiaries were prescribed a psychotropic and 63.3% were prescribed an opioid. The most common psychotropic classes prescribed were: benzodiazepines (60.6%), antipsychotics (38.3%), antidepressants (18.4%), and antiepileptics (10.2%). Lorazepam (56.4%), morphine (52.8%), and haloperidol (28.6%) were received by the most beneficiaries. Prevalence of any psychotropic and opioid prescription was highest among beneficiaries who were female (76.7%), non-Hispanic white (76.6%), and those with cancer (78.9%). Compared to white beneficiaries, non-Hispanic black beneficiaries were less likely to receive nearly every class of medication, with significantly lower odds of receiving opioids (64.1% vs 57.9%; AOR 0.75, 95% CI 0.72-0.77) and benzodiazepines (61.6% vs 52.2%; AOR 0.66, 95% CI 0.64-0.68). Differences were seen across hospice diagnosis; those with cancer were more likely to receive opioids, benzodiazepines, and antipsychotics but less likely to receive antidepressants and antiepileptics. CONCLUSIONS Psychotropic and opioid medications are frequently prescribed in hospice. Observed variations in prescribing across race and ethnicity may reflect disparities in prescribing as well as patient preferences for care. Further work is important to understand factors driving prescribing given limited studies surrounding medication prescribing in hospice.

Background/objectives There is increasing recognition that place of death is an important component of quality of end-of-life care (EOLC) and quality of death. This study examined where older persons with and without cognitive impairment die in the United States, what factors contribute to place of death, and whether place of death influences satisfaction with EOLC. Design Cross-sectional secondary data analysis. Setting In-person interviews with community-dwelling proxy respondents. Participants Data were collected from 1,500 proxies for deceased participants in the National Health and Aging Trends Study (NHATS), a nationally-representative sample of community-dwelling Medicare beneficiaries aged 65 and older. Measurements Study variables were obtained from the NHATS "last month of life" interview data. Survey weights were applied to all analyses. Results Persons with cognitive impairment (CI) most often died at home, while cognitively healthy persons (CHP) were equally likely to die at home or in a hospital. Persons with CI who utilized the Medicare Hospice Benefit were 14.5 times more likely to die at home than in a hospital, and 3.4 times more likely to die at home than a nursing home. CHP who use this benefit were over six times more likely to die at home than in a hospital, and more than twice as likely to die at home than a nursing home. Place of death for CHP was also associated with age and race. Proxies of persons with CI who died at home rated EOLC as more favorable, while proxies of CHP rated in-home and hospital care equally. Conclusion Findings add to the scant literature identifying factors associated with place of death for older adults with and without CI and results suggest that place of death is a quality of care indicator for these populations. These findings may inform EOLC planning and policy-making and facilitate greater well-being at end-of-life.

Hospice use reduces costly aggressive end-of-life (EOL) care (eg, repeated hospitalizations, intensive care unit care, and emergency department visits). Nevertheless, associations between hospice stays and EOL expenditures in prior research have been inconsistent. We examined the differential associations between hospice stay duration and EOL expenditures among newly diagnosed patients with cancer, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and dementia.In the Surveillance, Epidemiology, and End Results-Medicare data, we identified 240 246 decedents diagnosed with the aforementioned conditions during 2001 to 2013. We used zero-inflated negative binomial regression models to examine the differential associations between hospice length of services and EOL expenditures incurred during the last 90, 180, and 360 days of life.For the last 360 days of expenditures, hospice stays beyond 30 days were positively associated with expenditures for decedents with COPD, CHF, and dementia but were negatively associated for cancer decedents (all P.001) after adjusting for demographic and medical covariates. In contrast, for the last 90 days of expenditures, hospice stay duration and expenditures were consistently negatively associated for each of the 4 patient disease groups.Longer hospice stays were associated with lower 360-day expenditures for cancer patients but higher expenditures for other patients. We recommend that Medicare hospice payment reforms take distinct disease trajectories into account. The relationship between expenditures and hospice stay length also depended on the measurement duration, such that measuring expenditures for the last 6 months of life or less overstates the cost-saving benefit of lengthy hospice stays.

This policy analysis examines key aspects of two policies fundamental to work with terminal cancer patients: the Medicare Hospice Benefit and Medicare policy in palliative care. End-of-life care, affected by these policies, should address physical, emotional, and spiritual suffering for all vulnerable groups. Using Gilbert and Terrell’s framework, social allocations, social provisions, service delivery, and financing are examined to better understand each policy’s effects on equality, equity, and adequacy for terminally ill cancer patients. In practice, each has substantially socially unjust effects for cancer patients. Disproportionate advantages result for those who are white, have family caregiving support systems, those with higher socioeconomic status, and individuals with stable insurance coverage. The Medicare Hospice Benefit and Medicare coverage for palliative care need to be better understood by policy practitioners and all practitioners in health care settings. Advocacy can contribute to improved equity in end-of-life cancer care.

Hospice is a model of care that offers significant benefits to patients at the end of their lives, their families, and also to the primary care physicians who have diligently cared for their patients. As comprehensive care physicians, primary care physicians can benefit from a strong understanding of hospice and the Medicare Hospice Benefit. This article describes the history of hospice, palliative care versus hospice care, clinical appropriateness of the hospice patient, the regulatory guidelines of the Medicare Hospice Benefit, hospice reimbursement, primary care reimbursement, and employment opportunities in hospice.

Objectives Stroke and post-stroke complications are associated with high morbidity, mortality, and cost. Our objective was to examine healthcare utilization and hospice enrollment for stroke patients at the end of life. Materials and methods The 2014 Nationwide Readmissions Database is a national database of > 14 million admissions. We used validated ICD-9 codes to identify fatal ischemic stroke, summarized demographics and hospitalization characteristics, and examined healthcare use within 30 days before fatal stroke admission. We used de-identified 2014 Medicare hospice data to identify stroke and non-stroke patients admitted to hospice. Results Among IS admissions in 2014 (n = 472,969), 22652 (4.8%) had in-hospital death. 28.2% with fatal IS had two or more hospitalizations in 2014. Among those with fatal IS admission, 13.0% were admitted with cerebrovascular disease within 30 days of fatal IS admission. Half of stroke patients discharged to hospice from the Medicare dataset were hospitalized with cerebrovascular disease within the thirty days prior to hospice enrollment. Within the study year, 6.9% of hospice enrollees had one or more emergency room visits, 31.7% had one or more inpatient encounters, and 5.2% had one or more nursing facility encounters (compared to 21.4%, 70.6%, and 27.2% respectively in the 30-day period prior to enrollment). Conclusions High rates of readmission prior to fatal stroke may indicate opportunity for improvement in acute stroke management, secondary prevention, and palliative care involvement as encouraged by AHA/ASA guidelines. For patients who are expected to survive 6 months or less, hospice may offer goal-concordant services for patients and caregivers who desire comfort-focused care.

I review ethical and legal challenges for end of life (EOL) care in dementia. Is access to hospice care for dementia patients impacted by Medicare’s terminal prognosis requirement? Are dementia-specific advance directives warranted? How does state legislation affect dementia patients’ EOL options? Should dementia patients’ be able to refuse orally ingested food and fluids by advance directive? The difficulty of predicting time to death in dementia inhibits access to Medicare hospice benefits. Efforts have been made to create dementia-specific advance directives. Advance refusal of artificial nutrition and hydration are common, but the issue of oral ingestion of food and fluids by dementia patients remains controversial. Medicare’s hospice benefit should be made more accessible to dementia patients. State advance directive threshold definitions should be broadened to include dementia, and capacitated persons who refuse in advance orally ingested food and fluids should have their choices honored.

After three and a half decades of experience with the Medicare hospice benefit in the U.S., despite excellent quality outcomes in symptom management, patient and family satisfaction, and reduction in health care costs, only 12%-15% of beneficiaries' days during the last year of life are spent being cared for within the highly cost-effective interdisciplinary coordinated advanced illness care model known as hospice. Although there are many reasons for this, including difficulties in acknowledging mortality among patients, their families, and physicians, a significant cause of low overall hospice utilization and intractably low median lengths of stay, reflective of late admissions, can be attributed to increasingly difficult and highly variable prognostic determinations for most of the leading causes of death among Medicare beneficiaries. Medicare is the payer for most hospice care in the U.S. and requires certification of a prognosis of six months or less for a beneficiary to access hospice support. At the time of admission to hospice, two physicians must predict that a patient is more likely to die in the next six months than survive, based on clinical status. In addition to prognostic uncertainty constituting a barrier to timely hospice referral, the Centers for Medicare and Medicaid Services and its payer contractors have developed a robust and expensive retrospective review process that penalizes hospices when patients outlive their expected prognosis. The administratively burdensome and financially punitive review practices further delay or limit access to care for eligible patients as certifying physicians and agencies, fearful of the financial and legal repercussions of reviews and audits, are hesitant to take patients under care unless they are clearly in the dying process. This article will review pertinent history and address the core problem of access to a health care benefit built on a policy that requires far greater prognostic certainty than any clinician can reasonably ascertain and fails to take into consideration the favorable impact hospice care has on terminally ill patients in improving prognosis. This clinical conundrum that limits access of seriously ill people to high-value quality care is of profound importance to the U.S. Medicare population and also one with potential relevance to all complex and regulated health systems and to other models of care whose eligibility criteria are based on prognostication.

Use of the Medicare hospice benefit has been associated with high-quality care at the end of life, and hospice length of use in particular has been used as a proxy for appropriate timing of hospice enrollment. Quantile regression has been underutilized as an alternative tool to model distributional changes in hospice length of use and hospice payments outside of the mean.To test for heterogeneity in the relationship between patient characteristics and hospice outcomes across the distribution of hospice days.Medicare Beneficiary Summary File and survey data (2014) for hospice beneficiaries in North and South Carolina with common terminal diagnoses.Distributional shifts associated with patient characteristics were evaluated at the 25th and 75th percentiles of hospice days and hospice payments using quantile regressions and compared to the mean shift estimated by ordinary least squares (OLS) regression.Significant (p 0.001) heterogeneity in the marginal effects on hospice days and costs was observed, with patient characteristics associated with generally larger shifts in the 75th percentile than the 25th percentile. Mean effects estimated by OLS regression overestimate the magnitude of the median marginal effects for all patient characteristics except for race. Results for hospice payments in 2014 were similar.Methodological decisions can have a meaningful impact in the evaluation of factors influencing hospice length of use or cost.

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.

On January 1, 2016, Medicare implemented a new "two-tiered" model for hospice services, with per diem rates increased for days 1 through 60, decreased for days 61 and greater, and service intensity add-on payments made retrospectively for the last seven days of life.To estimate whether the Medicare hospice benefit's potential for cost savings will change as a result of the January 2016 change in payment structure.Analysis of decedents' claims records using propensity score matching, logistic regression, and sensitivity analysis.All age-eligible Medicare decedents who received care and died in North Carolina in calendar years 2009 and 2010.Costs to Medicare for hospice and other healthcare services.Medicare costs were reduced from hospice election until death using both 2009-2010 and new 2016 payment structures and rates. Mean cost savings were $1,527 with actual payment rates, and would have been $2,105 with the new payment rates (p 0.001). Cost savings were confirmed by reducing the number of days used for cost comparison by three days for those with hospice stays of at least four days ($4,318 using 2009-2010 rates, $3,138 for 2016 rates: p 0.001). Cost savings were greater for males ($3,393) versus females ($1,051) and greatest in cancer ($6,706) followed by debility and failure to thrive ($5,636) and congestive heart failure ($1,309); dementia patients had higher costs (+$1,880) (p 0.001). When adding 3 days to the comparison period, hospice increased costs to Medicare.Medicare savings could continue with the 2016 payment rate change. Cost savings were found for all primary diagnoses analyzed except dementia.

In 2015 an estimated 2.7 million people in the United States (1 percent of the population) died. Although decedents' illness experience varies substantially, important trends in care at the end of life are evident. To identify the most pressing health care policy issues related to end-of-life care, we present a comprehensive picture of the epidemiology and care patterns of people in the last stage of life. We identify three key trends in end-of-life care: increasing diversity in the primary diagnoses of decedents, increases in multimorbidity and illness complexity among people with terminal illnesses, and shifts in patterns of care at the end of life and in sites of death. This changing epidemiology of those in the last phase of life puts new pressures on the Medicare hospice benefit to ensure the availability of high-quality end-of-life care. In addition, health care policy makers must grapple with the fact that even with increasing use of hospice care, care intensity increases at the end of life. We highlight and discuss tensions that must be managed to ensure that high-quality care is accessible for people at the end of life.

Objectives To describe differences in hospice services for patients living at home, in nursing homes or in assisted living facilities, including the overall number and duration of visits by different hospice care providers across varying lengths of stay. Design Retrospective cohort study using hospice patient electronic medical record data. Setting Large, national hospice provider. Participants Data from 32,605 hospice patients who received routine hospice care from 2009 to 2014 were analyzed. Measurements Descriptive statistics were calculated for utilization measures for each type of provider and by location of care. Frequency and duration of service contacts were standardized to a 1 week period and pairwise comparisons were used to detect differences in care provided between the three settings. Results Minimal differences were found in overall intensity of service contacts across settings, however, the mix of services were different for patients living at home versus nursing home versus assisted living facility. Overall, more nurse care was provided at the beginning and end of the hospice episode; intensity of aide care services was higher in the middle portion of the hospice episode. Nearly 43% of the sample had hospice stays less than 2 weeks and up to 20% had stays greater than 6 months. Conclusion There are significant differences between characteristics of hospice patients in different settings, as well as the mix of services they receive. Medicare hospice payment methodology was revised starting in 2016. While the new payment structure is in greater alignment with the U shape distribution of services, it will be important to evaluate the impact of the new payment methodology on length of stay and mix of services by different providers across settings of care.

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.

With the implementation of the Affordable Care Act, the U.S. government committed to a transition in payment policy for health care services linking reimbursement to improved health outcomes rather than the volume of services provided. To accomplish this goal, the Department of Health and Human Services is designing and implementing new payment models intended to improve the quality of health care while reducing its cost. Collectively, these novel payment models and programs have been characterized under the moniker of value-based purchasing (VBP), and although many of these models retain a fundamental fee-for-service (FFS) structure, they are seen as essential tools in the evolution away from volume-based health care financing toward a health system that provides "better care, smarter spending, and healthier people." In 2014, approximately 20% of Medicare provider FFS payments were linked to a VBP program. The Department of Health and Human Services has committed to a four-year plan to link 90% of Medicare provider FFS payments to value-based purchasing by 2018. To achieve this goal, all items and services currently reimbursed under Medicare FFS programs will need to be evaluated in the context of VBP. To this end, the Medicare Hospice benefit appears to be appropriate for inclusion in a model of VBP. This policy analysis proposes an adaptable model for a VBP program for the Medicare Hospice benefit linking payment to quality and efficiency in a manner consistent with statutory requirements established in the Affordable Care Act.

Importance Medicare hospice beneficiaries discontinue disease-modifying treatments because the hospice benefit limits access. While veterans have concurrent access to hospice care and Veterans Affairs (VA) Medical Center (VAMC)-provided treatments, the association of this with changes in treatment and costs of veterans’ end-of-life care is unknown. Objective To determine whether increasing availability of hospice care, without restrictions on disease-modifying treatments, is associated with reduced aggressive treatments and medical care costs at the end of life. Design, Setting, and Participants A modified difference-in-differences study design, using facility fixed effects, compared patient outcomes during years with relatively high vs lower hospice use. This study evaluated 13 085 veterans newly diagnosed with stage IV non–small cell lung cancer (NSCLC) from 113 VAMCs with a minimum of 5 veterans diagnosed with stage IV NSCLC per year, between 2006 and 2012. Data analyses were conducted between January 2017 and July 2018. Exposures Using VA inpatient, outpatient, pharmacy claims, and similar Medicare data, we created VAMC-level annual aggregates of all patients who died of cancer for hospice use, cancer treatment, and/or concurrent receipt of both in the last month of life, dividing all VAMC years into quintiles of exposure to hospice availability. Main Outcomes and Measures Receipt of aggressive treatments (2 or more hospital admissions within 30 days, tube feeding, mechanical ventilation, intensive care unit [ICU] admission) and total costs in the first 6 months after diagnosis. Results Of the 13 085 veterans included in the study, 12 858 (98%) were men; 10 531 (81%) were white, and 5949 (46%) were older than 65 years. Veterans with NSCLC treated in a VAMC in the top hospice quintile (79% hospice users), relative to the bottom quintile (55% hospice users), were more than twice as likely to have concurrent cancer treatment after initiating hospice care (adjusted odds ratio [AOR], 2.28; 95% CI, 1.67-3.31). Nonetheless, for veterans with NSCLC seen in VAMCs in the top hospice quintile, the AOR of receiving aggressive treatment in the 6 months after diagnosis was 0.66 (95% CI, 0.53-0.81), and the AOR of ICU use was 0.78 (95% CI, 0.62-0.99) relative to patients seen in VAMCs in the bottom hospice quintile. The 6-month costs were lower by an estimated $266 (95% CI, −$358 to −$164) per day for the high-quintile group vs the low-quintile group. There was no survival difference. Conclusions and Relevance Increasing the availability of hospice care without restricting treatment access for veterans with advanced lung cancer was associated with less aggressive medical treatment and significantly lower costs while still providing cancer treatment.

Context The Centers for Medicare & Medicaid Services Hospice Quality–Reporting Program introduced the requirement that hospices nationwide begin collecting and submitting standardized patient-level quality data on July 1, 2014. Objectives This study examined whether this requirement has increased hospice total costs, general costs, and visiting services costs. Methods We conducted a cross-sectional study using data from the 2012 and 2014 Medicare hospice cost reports linked to hospice claims. We measured total costs per patient day (PPD), general costs PPD, and visiting services costs PPD for freestanding hospices. We estimated the incremental costs of operating in 2014 vs. 2012 using hierarchical random effects models and adjusting for year, wage index, care volume, case-mix, and hospice and market characteristics, stratified by hospice ownership type. Results Both for-profit and nonprofit hospices reported higher total costs PPD and general services costs PPD in 2014 than 2012. Nonprofit hospices also reported higher general costs PPD in 2014 than 2012. In adjusted models, the total costs PPD in 2014 were $10.55 higher than in 2012 for nonprofit hospices and $6.43 higher for for-profit hospices. The increase in general costs PPD and visiting services costs PPD ranged from $3.15 to $5.87 by ownership and type of costs. Both for-profit and nonprofit hospices showed lower costs PPD for all types associated with more patients and longer length of stay. Conclusion Hospice costs increased after the Centers for Medicare & Medicaid Services Hospice Quality–Reporting Program quality data collection/submission requirement. Complementary studies need to understand whether increased costs brought additional benefits.

Between 2007 and 2015, Medicare hospice spending rose by 52 percent, from $10.4 billion to $15.8 billion. The rise was driven primarily by an increase in the number of patients in hospice care. Medicare spending on hospice care was $642 million, or 4.2 percent, higher in 2015 than it was in 2014. Spending and spending growth varied by geographic region and diagnosis.

Live hospice discharges represent a potential vulnerability in the Medicare hospice benefit. Little is known about how live discharges have varied over time.To identify trends in live hospice discharges between 2000 and 2012.Retrospective cohort study of Medicare hospice discharges.In this study, we examined live discharges in the first six months of 2000, 2006, 2008, 2010, and 2012. A live discharge was classified as a burdensome transition if hospice discharge was followed by hospital admission, and then there was a hospice readmission within 2 days of hospital discharge. The adjusted rate of overall live discharges and burdensome transitions was examined with a multivariate mixed-effects logistic model that adjusted for age, gender, race, and hospice primary diagnosis. The model contained an interaction term for year and hospice tax status.The unadjusted overall rate of live discharges increased from 13.7% in 2000 to 18.1% in 2012. For-profit hospice programs had an adjusted live discharge rate of 17.7% in 2000 and 22.7% in 2012. During the same period, the adjusted live discharge rate for nonprofit hospice programs increased from 15.2% to 16.3%. The overall rate of burdensome transitions increased from 2.9% in 2000 to 5.3% in 2012. Similar to the overall rate of live discharge, for-profit hospices had a higher rate of burdensome transitions (6.4%) than nonprofit hospices (4.0%) in 2012.Live hospice discharges and burdensome transitions increased between 2000 and 2012. For-profit hospice programs demonstrated larger increases than nonprofit hospice programs.

The Medicare hospice benefit provides quality end-of-life care for those with a prognosis of 6 months or less to live and their families. The utilization of the benefit has increased since its implementation in 1982. Eligibility requirements and conditions of participation guide the admission and re

Hospice began as a social movement outside of mainstream medicine with the goal of helping those dying alone and in unbearable pain in health care institutions. The National Hospice Study, undertaken to test whether hospice improved dying cancer patients' quality of life while saving Medicare money, found hospice care achieved comparable outcomes to traditional cancer care and was less costly as long as hospice lengths of stay were not too long. In 1982, before study results were final, Congress created a Medicare hospice benefit under a capitated per diem payment system restricting further treatment. In 1986 the benefit was extended to beneficiaries living in nursing homes. This change resulted in longer average lengths of stay, explosive growth in the number of hospices, particularly of the for-profit variety, and increases in total Medicare expenditures on hospice care. An increasingly high proportion of beneficiaries receive hospice care. However, over 30 percent are served fewer than seven days before they die, while very long stays are also increasingly common. These and other factors raise quality concerns about hospice being disconnected from the rest of the health care system. We offer suggestions regarding how hospice could be better integrated into the broader health care delivery system.

Objectives To compare patterns of emergency department (ED) use and inpatient admission rates for elderly adults with cancer with a poor prognosis who enrolled in hospice to those of similar individuals who did not. Design Matched case–control study. Setting Nationally representative sample of Medicare fee-for-service beneficiaries with cancer with a poor prognosis who died in 2011. Participants Beneficiaries in hospice matched to individuals not in hospice on time from diagnosis of cancer with a poor prognosis to death, region, age, and sex. Measurements Comparison of ED use and inpatient admission rates before and after hospice enrollment for beneficiaries in hospice and controls. Results Of 272,832 matched beneficiaries, 81% visited the ED in the last 6 months of life. At baseline, daily ED use and admission rates were not significantly different between beneficiaries in and not in hospice. By the week before death, nonhospice controls averaged 69.6 ED visits/1,000 beneficiary-days, versus 7.6 for beneficiaries in hospice (rate ratio (RR) = 9.7, 95% confidence interval (CI) = 9.3–10.0). Inpatient admission rates in the last week of life were 63% for nonhospice controls and 42% for beneficiaries in hospice (RR = 1.51, 95% CI = 1.45–1.57). Of all beneficiaries in hospice, 28% enrolled during inpatient stays originating in EDs; they accounted for 35.7% (95% CI = 35.4–36.0%) of all hospice stays of less than 1 month and 13.9% (95% CI = 13.6–14.2%) of stays longer than 1 month. Conclusion Most Medicare beneficiaries with cancer with a poor prognosis visited EDs at the end of life. Hospice enrollment was associated with lower ED use and admission rates. Many individuals enrolled in hospice during inpatient stays that followed ED visits, a phenomenon linked to shorter hospice stays. These findings must be interpreted carefully given potential unmeasured confounders in matching.

Context Older adults with advanced lung cancer experience high symptom burden at end of life (EOL), yet hospice enrollment often happens late or not at all. Receipt of medications to manage symptoms in the outpatient setting, outside the Medicare hospice benefit, has not been described. Objectives We examined patterns of symptom management medication receipt at EOL for older adults who died of lung cancer. Methods This retrospective cohort used the Surveillance, Epidemiology, and End Results—Medicare database to identify decedents diagnosed with lung cancer at age 67 years and older between January 2008 and December 2013 who survived six months and greater after diagnosis. Using Medicare Part B and D claims, we identified monthly receipt of outpatient medications for symptomatic management of pain, emotional distress, fatigue, dyspnea, anorexia, and nausea/vomiting. Multivariable logistic regression estimated associations between medication receipt and patient demographic characteristics, comorbidity, and concurrent therapy. Results Of the 16,246 included patients, large proportions received medications for dyspnea (70.7%), pain (62.5%), and emotional distress (49.4%), with lower prevalence for other symptoms. Medication receipt increased from six months to one month before death. Women and dual Medicaid enrolled were more likely to receive medications for pain, emotional distress, dyspnea, and nausea/vomiting. Receipt of symptom management medications decreased with increasing age and racial/ethnical minorities. Conclusion Symptom management medication receipt was common and increasing toward EOL. Lower use by males, older adults, and nonwhites may reflect poor access or poor patient-provider communication. Further research is needed to understand these patterns and assess adequacy of symptom management in the outpatient setting.

OBJECTIVES Palliative care services have the potential to improve the quality of end-of-life care and reduce cost. Services such as the Medicare hospice benefit, however, are often underutilized among stroke patients with a poor prognosis. We tested the hypothesis that the Medicare Shared Savings Program (MSSP) is associated with increased hospice enrollment and inpatient comfort measures only among incident ischemic stroke patients with a high mortality risk. DESIGN A difference-in-differences design was used to compare outcomes before and after hospital participation in the MSSP for patients discharged from MSSP hospitals (N = 273) vs non-MSSP hospitals (N = 1490). SETTING Records from a national registry, Get with the Guidelines (GWTG)-Stroke, were linked to Medicare hospice claims (2010-2015). PARTICIPANTS Fee-for-service Medicare beneficiaries age 65 and older hospitalized for incident ischemic stroke at a GWTG-Stroke hospital from January 2010 to December 2014 (N = 324 959). INTERVENTION Discharge from an MSSP hospital or beneficiary alignment with an MSSP Accountable Care Organization (ACO). MEASUREMENTS Hospice enrollment in the year following stroke. RESULTS Among patients with high mortality risk, ACO alignment was associated with a 16% increase in odds of hospice enrollment (adjusted odds ratio [OR] = 1.16; 95% confidence interval [CI] = 1.06-1.26), increasing the probability of hospice enrollment from 20% to 22%. In the low mortality risk group, discharge from an MSSP vs non-MSSP hospital was associated with a decrease in the predicted probability of inpatient comfort measures or discharge to hospice from 9% to 8% (OR = .82; CI = .74-.91), and ACO alignment was associated with reduced odds of a short stay (

For the provision of palliative care in the hospice setting in the United States, Medicare covers any care that is reasonable and necessary to manage palliative and hospice care at end of life. To be eligible for this Medicare hospice benefit, a beneficiary must be entitled to Medicare Part A and be certified by a physician to have a life expectancy of 6 months or less if the illness runs its expected course. Medicare covers medications, nursing care, and medical services including care by a physician, physical therapy, social work. This chapter briefly reviews the various aspects of the Medicare hospice benefit.

Care at the end of life is increasingly fragmented and is characterized by multiple hospitalizations, even among patients enrolled with hospice.To determine whether hospice spending on direct patient care (including the cost of home visits, drugs, equipment, and counseling) is associated with hospital utilization and Medicare expenditures of hospice enrollees.Longitudinal, observational cohort study (2008-2010).Medicare beneficiaries (N = 101,261) enrolled in a national random sample of freestanding hospices (N = 355).We used Medicare Hospice Cost reports to estimate hospice spending on direct patient care and Medicare claim data to estimate rates of hospitalization and Medicare expenditures.Hospice mean direct patient care costs were $86 per patient day, the largest component being patient visits by hospice staff (e.g., nurse, physician, and counselor visits). After case-mix adjustment, hospices spending the most on direct patient care had patients with 5.2% fewer hospital admissions, 6.3% fewer emergency department visits, 1.6% fewer intensive care unit stays, and $1,700 less in nonhospice Medicare expenditures per patient compared with hospices spending the least on direct patient care (p 0.01 for each comparison). Ninety percent of hospices with the lowest spending on direct patient care and highest rates of hospital use were for-profit hospices.Patients cared for by hospices with lower direct patient care costs had higher hospitalization rates and were overrepresented by for-profit hospices. Greater investment by hospices in direct patient care may help Centers for Medicare and Medicaid Services avoid high-cost hospital care for patients at the end of life.

In 2011, 1.65 million individuals with terminal illnesses received hospice services, and 44.6% of all decedents in the United States had been under the care of a hospice.1 Hospice users and their primary caregivers are typically older adults. In 2013, an estimated 84% of hospice users were aged 65 and older and 41% were aged 85 and older.2 Primary caregivers, who help make decisions for terminally ill individuals, are most often their spouses or adult children who are aged 60 and older.3 Although most family members of individuals in hospice who die recover from initial reactions of acute grief and return to preloss functioning,4 an estimated 11% develop the mental health disorders of complicated grief (CG) and depression, with prevalence increasing slightly with increasing age.5–7 CG is characterized by symptoms of reactive distress to the death (e.g., disbelief or bitterness) and disruption in social relationships or identity.8 Criteria for major depressive disorder (depression) are well established,8 but diagnosis of depression after bereavement has recently undergone a significant change. The Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, allows diagnosis of depression within 2 weeks of bereavement, replacing the DSM, Fourth Edition, requirement that depression not be diagnosed until 2 months after bereavement.8 This change expands the population of individuals who might benefit from screening and treatment. In older adults, depression and CG are associated with greater risk of morbidity for most of the common diseases of later life, including chronic functional impairment, hypertension, sleep impairment, and suicidal ideation.9–18 For example, the risk of hypertension is 10 times as high in older widowed adults who meet consensus criteria for CG as in those who do not.19 As the U.S. population continues to age, it is likely that the impairment associated with depression and CG will create an even greater societal burden. Well-validated measures and effective individual and group psychotherapeutic treatments for CG and depression in older adults have been developed,20–22 yet older adults are less likely to seek bereavement support than younger adults,23 in part because of a cohort-specific stigma about the acceptability of using mental health care.24 Because hospices care for people before and during death, they are uniquely positioned to offer screening and referral services for CG and bereavement-related depression in older family caregivers. Receiving bereavement support in a setting to which older adults are already connected may make it use more likely.25 Moreover, Medicare, the primary payer for hospice care (providing coverage to 84% of people in hospice)1 requires that hospices offer bereavement services to family members for at least a year after the person in hospice dies in order to receive reimbursement under the Medicare Hospice Benefit.1 Although hospice provision of bereavement services has been described in detail,26–29 previous publications have not focused specifically on screening and referral practices for CG or depression. Accordingly, the current study used data from the National Hospice Survey to estimate the extent to which hospices nationally provide screening and referral services that address the mental health needs of family members of individuals who die in hospice. The associations between organizational and staff factors and the likelihood of offering screening and referral for CG and depression were also examined. Organizational theory posits that organizational structure can affect the type and quality of care provided.30 In this analysis, organizational factors considered included hospice profit status, chain affiliation, size, and geographical region. In keeping with previous work, it was hypothesized that larger hospice size would be associated with higher likelihood of conducting screening and referral.29 Because previous analyses did not find consistent associations between profit status, chain affiliation, region, and bereavement service intensity more generally,29 it was not expected to that any association would be found with these variables in the analyses. It was also hypothesized that the extent to which hospices provide screening and referral or bereavement-related mental health conditions would be associated with provider- level factors, such as level of provider training, volunteer availability, and interdisciplinary team meeting involvement. Consistent with theories that participation of and interactions among providers of a variety of backgrounds can enhance care,31–33 research has demonstrated that social worker and volunteer involvement, and interdisciplinary collaboration more broadly, are associated with better quality of care for people in hospice.22,34,35 Training requirements have also been associated with quality of bereavement care provision specifically,36 but these associations have not been adequately studied for hospice bereavement care. As previous findings and existing theory predicted, it was hypothesized that lengthier training requirements, interdisciplinary team attendance from a large range of providers, and a lower ratio of volunteer hours to number of individuals in hospice would be associated with higher likelihood of conducting CG and depression screening and referral. Findings from this study can provide a more-complete picture of how hospices may be screening for important bereavement-related mental health problems and helping family caregivers connect to appropriate care after the death. This information can inform future work to identify strategies to improve mental health screening or therapy in hospices, as well as in other settings with a large bereaved population.

A 7-point policy model is used to examine policy on hospice eligibility and election in the United States. Despite the growth of hospice, many eligible patients continue to lack access due to difficulties experienced by providers in discerning 6-month prognoses among chronically ill patients, the inability of patients to elect hospice alongside curative care, and limited reimbursement for hospice providers. Though the landscape of dying has evolved, with more deaths occurring later in life from chronic illness, Medicare hospice eligibility requirements have historically remained the same. Utilization would increase if hospice agencies were able to provide fewer restrictions by including ongoing treatments such as transfusions, intravenous nutrition, or palliative radiation. Hospices would be more likely to enroll critically ill patients who require some ongoing curative measures if Medicare reimbursement rates were higher, and patients would be more likely to seek hospice earlier if Medicare election policies were altered to allow concurrent care. Participation would also be increased by extending hospice eligibility past the traditional prognosis of 6 months. Though expansion in public spending of hospice care has been met with some opposition, current research suggests that potential savings due to decreased costs in acute care is promising.

Hospice use has increased substantially during the past decade by an increasingly diverse patient population; however, little is known about patterns of hospice use and how these patterns have changed during the past decade.To characterize Medicare hospice users in 2000 and 2010 and estimate the prevalence of (1) very short (≤1 wk) hospice enrollment; (2) very long (6 mo) hospice enrollment; and (3) hospice disenrollment and how these utilization patterns have varied over time and by patient and hospice characteristics.Cross-sectional analysis of Medicare hospice claims data from 2000 and 2010.All US Medicare Hospice Benefit enrollees in 2000 (N=529,573) and 2010 (N=1,150,194).As of 2010, more than half (53.4%) of all Medicare decedents who used hospice had either very short (≤1 wk, 32.4%) or very long (6 mo, 13.9%) hospice enrollment or disenrolled from hospice before death (10.6%). This represents an increase of 4.9 percentage points from 2000. In multivariable analysis, patients with noncancer diagnoses, the fastest growing group of hospice users, were approximately twice as likely as those with cancer to have very short or long enrollment periods and to disenroll from hospice.The substantial proportion of hospice users with very short or long enrollment, or enrollments that end before death, underscores the potential for interventions to improve the timing and appropriateness of hospice referral so that the full benefits of hospice are received by patients and families.

In the United States, 5% of the population is responsible for nearly half of all health care expenditures, with a large concentration of spending driven by individuals with expensive chronic conditions in their last year of life. Outpatient palliative care under the Medicare Hospice Benefit excludes a large proportion of the chronically ill and there is widespread recognition that innovative strategies must be developed to meet the needs of the seriously ill while reducing costs.This study aimed to evaluate the impact of a home-based palliative care program, implemented through a hospice-private payer partnership, on health care costs and utilization.This was a prospective, observational database study where insurance enrollment and claims data were analyzed. The study population consisted of Home Connections (HC) program patients enrolled between January 1, 2010 and December 31, 2012 who subsequently expired (n=149) and who were also Independent Health members. A control group (n=537) was derived using propensity-score matching. The primary outcome variable was overall costs within the last year of life. Costs were also examined at six months, three months, one month, and two weeks. Inpatient, outpatient, ancillary, professional, and pharmacy costs were compared between the two groups. Medical service utilization and hospice enrollment and length of stay were also evaluated.Cost savings were apparent in the last three months of life—$6,804 per member per month (PMPM) cost for palliative care participants versus $10,712 for usual care. During the last two weeks of life, total allowed PMPM was $6,674 versus $13,846 for usual care. Enhanced hospice entry (70% versus 25%) and longer length of stay in hospice (median 34 versus 9 days) were observed.Palliative care programs partnered with community hospice providers may achieve cost savings while helping provide care across the continuum.

Through the Medicare Hospice Benefit (MHB), hospices submit claims containing information that allows policy makers to identify outcomes with large variation across hospices. Identifying outliers that have poor outcomes can help policy makers improve the MHB and increase the quality of care being provided. Our research identifies hospices that are outliers in the provision of hospice services along five different quality indicators (QIs): Provision of General Inpatient care days, Provision of skilled visits at the end of life, Average lifetime length of stay, Live discharge rates, and Nursing minutes provided per day. QIs are calculated using 100% of Medicare hospice claims from January 1, 2010 through September 30, 2014. For each indicator, hospices are grouped into deciles. We count how many times a hospice appears in the highest three deciles for each indicator to determine which hospices are outliers. Out of 3,946 hospices, there are 15 hospices which are in the highest three deciles for all five indicators. 235 hospices are in the highest three deciles for four or five indicators. The majority of hospices in the highest three deciles for four or five indicators are located in the south census region (72.3%). 8.8% of for profit hospices have four or more QIs in the three highest deciles compared to only 1.8% of other hospices. The average spending per beneficiary for hospices with four or more QIs in the highest three deciles is $27,365 compared to $15,441 for hospices with 3 or fewer indicators in the highest three deciles.

Hospice is a model of care for patients nearing the end of their lives that emphasizes symptom management, quality of life (QOL), and support of the patient and caregiving family through the death of the patient and the family's bereavement. It is associated with high patient and caregiver satisfaction and appears to not shorten lifespan for appropriately referred patients. Patients with advanced heart failure are being referred to hospice care more often than in the past, but the majority of deaths occur without this benefit. Hospice care in the USA is defined by the Medicare Hospice Benefit and associated regulations. Hospice is appropriate for patients with an expected survival prognosis of 6 months or less, and multiple predictive factors and tools are available to assist in prognostication. Management of symptoms and specific drug therapy options are discussed. For many patients, deactivation of electronic cardiac devices is appropriate when the goals of care are comfort and QOL. Ongoing collaboration of the referring physician with the hospice agency and staff offers opportunities for seamless and quality care.

This paper examines the association of charitable donations with quality of care proxies for nonprofit hospice providers in the United States (US). An estimated 1.45 million patients received hospice care in the US in 2008. Medicare hospice spending exceeded $10 billion in 2007 and is expected to more than double over the next 10 years. Using Guidestar and Medicare Hospice Cost Report data, we find donations are positively associated with proxies for nurse and social worker quality of care, but not with our home-health aide quality proxy. This research adds to our understanding of charitable contributions in hospice provider organizations.

Hospice offers holistic support for individuals living with terminal illness and their caregivers. Some individuals receiving hospice services experience a slower decline in health as than expected, resulting in a ‘live discharge’ from hospice. A live discharge affects both patient and caregiver(s).The current study (N=24) explored the experiences of caregivers of adults with dementia who experienced a live discharge from hospice. Findings emphasize the comprehensive services covered under the Medicare Hospice benefit and those lost after a live discharge. Implications for social workers supporting caregivers are discussed, including the need to view the patient-caregiver unit during a live discharge.

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.

Since the hospice benefit was introduced into the Medicare program, utilization has increased steeply. Previous research suggested that the use of hospice care is growing most rapidly in nursing facilities; however, little was known about the characteristics of the Medicare beneficiaries who receive hospice care in nursing facilities or the hospices that provide care in this setting. A synthesis of research from the U.S. Department of Health and Human Services, Office of Inspector General (OIG) examined Medicare hospice care provided in nursing facilities. Findings are based on analysis of Medicare hospice claims data and medical record reviews. OIG findings suggest that some hospices may be seeking out beneficiaries with particular characteristics, including those with conditions associated with longer but less complex care. Such beneficiaries are often found in nursing facilities. By serving these beneficiaries for longer periods, the hospices receive more Medicare payments per beneficiary, which can contribute to higher profits. The OIG's recommendations for reform include modifying the payment system for hospice care in nursing facilities and targeting monitoring efforts on certain hospices.

Context The proportion of patients disenrolling from hospice before death has increased over the decade with significant variations across hospice types and regions. Such trends have raised concerns about live disenrollment's effect on care quality. Live disenrollment may be driven by factors other than patient preference and may create discontinuities in care, disrupting ongoing patient-provider relationships. Researchers have not explored when and how providers make this decision with patients. Objective The objective of this study was to ascertain provider perspectives on key drivers of live discharge from the Medicare hospice program. Methods We conducted semistructured telephone interviews with 18 individuals representing 14 hospice providers across the country. Transcriptions were coded and analyzed using a template analysis approach. Results Analysis generated four themes: 1) difficulty estimating patient prognosis, 2) fear of Centers for Medicare & Medicaid Services audits, 3) rising market competition, and 4) challenges with inpatient contracting. Participants emphasized challenges underlying each decision to discharge patients alive, stressing that there often exists a gray line between appropriate and inappropriate discharges. Discussions also focused on scenarios in which financial motivations drive enrollment and disenrollment practices. Conclusion This study provides significant contributions to existing knowledge about hospice enrollment and disenrollment patterns. Results suggest that live discharge patterns are often susceptible to market and regulatory forces, which may have contributed to the rising national rate.

Background: Over 10% of hospice patients experience at least 1 care transition 6 months prior to death. Transitions at the end of life, particularly from hospice to hospital, result in burdensome and fragmented care for patients and families. Little is known about factors that predict hospitalization in this population. Objectives: To develop and validate a model predictive of hospitalization after enrollment into home hospice using prehospice admission risk factors. Design: Retrospective cohort study using Medicare fee-for-service claims. Participants: Patients enrolled into the Medicare hospice benefit were ≥18 years old in 2012. Outcome Measured: Hospitalization within 2 days from a hospice discharge. Results: We developed a predictive model using 61 947 hospice enrollments, of which 3347 (5.4%) underwent a hospitalization. Seven variables were associated with hospitalization: age 18 to 55 years old (adjusted odds ratio [95% confidence interval]: 2.94 [2.41-3.59]), black race (2.13 [1.93-2.34]), east region (1.97 [1.73-2.24]), a noncancer diagnosis (1.32 [1.21-1.45]), 4 or more chronic conditions (8.11 [7.19-9.14]), 2 or more prior hospice enrollments (1.75 [1.35-2.26]), and enrollment in a not-for-profit hospice (2.01 [1.86-2.18]). A risk scoring tool ranging from 0 to 29 was developed, and a cutoff score of 18 identified hospitalized patients with a positive predictive value of 22%. Conclusions: Reasons for hospitalization among home hospice patients are complex. Patients who are younger, belong to a minority group, and have a greater number of chronic conditions are at increased odds of hospitalization. Our newly developed predictive tool identifies patients at risk for hospitalization and can serve as a benchmark for future model development.

This study expands current knowledge of factors associated with initiation of hospice care by examining prehospice patterns of medical care leading to Medicare hospice use and the relationships to hospice episode characteristics. Data from the Atherosclerosis Risk in Communities (ARIC) study cohort offer the ability to control for measures that are not available in Medicare claims data, including marital status, nursing home residency, and education. For 1248 ARIC participants who used hospice (2006-2012), participant level trends in the number of hospital days per 30-day period over the year prior to hospice initiation were generated using a fixed-effects model. Logistic regression was used to estimate the associations between increasing hospital use over the year prior to hospice enrollment with key patient characteristics (diagnosis, age, and comorbidity) and episode characteristics (short hospice stay ending in death, long hospice stay, and live discharge). Participants with severe comorbidity (measured as a Charlson comorbidity index score greater than 5) had higher odds of increasing hospital use prior to hospice (odds ratio [OR] = 3.28, confidence interval [CI] = 2.25-4.78). Increasing hospital use did not vary by diagnosis but was associated with reduced odds of a live hospice discharge (OR = 0.55, CI = 0.34-0.88) or long stay in hospice (OR = 0.44, CI = 0.24-0.79) and increased odds of a short stay in hospice (OR = 1.92, CI = 1.36-2.71). The evidence that care patterns prior to hospice use are associated with hospice outcomes could facilitate development of interventions to improve timely hospice referral.

Hospice developed in the United States in the 1970s as a way to address unmet needs for end-of-life care: support for pain and symptom management provided in the location and manner that the patient and family prefer. In Europe and Australia, hospice is available from the time of diagnosis of an advanced life-limiting illness onward, but in the United States, the Medicare hospice benefit restricts eligibility for these services to patients who no longer receive curative treatment. We provide background and analysis of the first Medicare hospice demonstration in 35 years that will test the concurrent provision of curative and hospice services for terminally ill individuals with a life expectancy of six months or less. This demonstration is a harbinger of potential policy changes to hospice and palliative care in the United States that could reduce barriers to end-of-life care that aligns with patient and family preferences as the demand for care increases with an aging population.

Palliative care is associated with decreased treatment intensity and improved quality for individual patients at the end of life, but little is known about how hospital-wide outcomes are affected by the diffusion of palliative care principles.We examined the relationship between presence of palliative care programs and hospitals' average treatment intensity, as indicated by mean intensive care unit (ICU) length of stay (LOS) and days under Medicare hospice coverage, in the last six months of life among Medicare beneficiaries aged 67 and over with serious chronic illness.We linked hospital-level data from the American Hospital Association Annual Survey, National Palliative Care Registry, and Dartmouth Atlas of Health Care to examine hospital-level treatment intensity for chronically ill Medicare beneficiaries who died in 2010. We used propensity score-adjusted linear regression to estimate the relationship between palliative care programs and hospitals' mean ICU LOS and hospice length of enrollment.Among 974 hospitals meeting inclusion criteria, we compared 295 hospitals with palliative care programs to 679 hospitals without. Hospitals with palliative care programs were higher volume, more likely to be teaching hospitals, and have oncology services and less likely to be located in rural areas. In propensity score weighted analyses, the mean ICU LOS in hospitals with palliative care was shorter by 0.23 days (standard error [SE] = 0.26), but this was not statistically significant (p = 0.76). In addition, the mean length of hospice enrollment among beneficiaries served by hospitals with palliative care was longer by 0.22 days (SE = 0.61), but also was not statistically significant (p = 0.76).Hospital-based palliative care programs alone may not be sufficient to impact ICU LOS or hospice length of enrollment for all chronically ill older adults admitted to hospitals. Future work should measure hospital-wide palliative care outcomes and effects of core palliative knowledge and skills provided by nonpalliative care specialists.

Objectives Prior studies associate hospice use with reduced hospitalization and spending at the end of life based on all Medicare hospice beneficiaries. In this study, we examine the impact of different lengths of hospice care and nursing home residency on hospital use and spending prior to death across 5 disease groups. Methods We compared inpatient hospital days and Medicare spending during the last 6 months of life using hospice versus propensity matched non-hospice beneficiaries who died in 2010, were enrolled in fee for service Medicare throughout the last 2 years of life, and were in at least 1 of 5 disease groups. Comparisons were based on length of hospice use and whether the decedent was in a nursing home during the seventh month prior to death. We regressed a categorical measure of hospice days on outcomes, controlling for observed patient characteristics. Results Hospice use over 2 weeks was associated with decreased hospital days (1-5 days overall, with greater decreases for longer hospice use) for all beneficiaries; spending was $900-$5,000 less for hospice use of 31-90 days for most beneficiaries not in nursing homes, except beneficiaries with Alzheimer's. Overall spending decreased with hospice use for beneficiaries in nursing homes with lung cancer only, with a $3,500 reduction. Discussion The Medicare hospice benefit is associated with reduced hospital care at the end of life and reduced Medicare expenditures for most enrollees. Policies that encourage timely initiation of hospice and discourage extremely short stays could increase these successes while maintaining program goals.