Making home hospice a better reality

Hospice care providers who also offer palliative care services can help make the transition to hospice smoother when the time comes. “You're not changing electronic health records,” Pantilat said. “You have the same agency. You have the same phone number to call. You're not necessarily changing care teams. All of that simplifies and promotes continuity of care for patients.”

Pantilat encourages hospital-hospice partnerships to better manage end-of-life care. UCSF's Palliative Care Program partners with several local hospices.

“From a hospital perspective, partnering with multiple hospices, especially ones offering a range of services – including home-based palliative care – would be particularly smart. It gives you the most flexibility in matching the service to the patient,” Pantilat said.  

Getting a proper diagnosis that meets Medicare-hospice criteria is another critical component to earlier hospice enrollment. A systemic review of predictions of survival in palliative care found physicians overestimate how long a seriously ill patient has left to live by twice the actual life span.

“If palliative care is provided, that's the best bridge to getting care sooner,” said Kathy Brandt, principal of the KB Group, a hospice and palliative care industry consultancy. “They are the experts at knowing when to refer someone to hospice.”

Pantilat believes that also involving the payer from the beginning is important to the success of innovative end-of-life care models. “Hospitals and hospices can’t just partner together to achieve maximum results – they need the person actually paying the bill,” he said.

For its hospital-hospice partnerships, UCSF's Palliative Care Program developed value-based contracts with payers to bill on a per member, per month basis.

“This allows us to provide interdisciplinary care without having to depend on a doctor or nurse practitioner to visit the home to bill for service. It’s a win-win,” Pantilat said. “That's where health systems can reach out to their hospice partners to develop these home-based palliative care programs.”

In California, a palliative care law that took effect in January 2018 mandates community-based palliative care services for adults with serious illness, on both a managed care and fee-for-service basis. Pantilat says that he sees the greatest value in managed care models.

“I worry about the fee-for-service system, where only a doctor or nurse practitioner can bill for the service,” Pantilat said. “The doctor or nurse practitioner is important to care. But if you want hospice patients to stay at home, the social worker may be the single most important person on that team, because they help people understand what resources they're eligible for.”

Staying enrolled in hospice is another piece of the care puzzle. Often an acute crisis that's not easily managed by family caregivers forces the hospice patient to use the emergency room, triggering a hospice disenrollment. More than 10 percent of hospice users disenroll before death. And more than half of all who disenroll end up hospitalized, resulting in higher healthcare costs for the patient, though not necessarily a better quality of life.

Pantilat said that telehealth, the use of video conferencing to address non-urgent patient needs and concerns, can help improve efficiencies in care. Up to 50 percent of UCSF's palliative care visits are now done through telehealth.

Brandt says she's also seeing more hospices using HIPAA-compliant teleconferencing to augment their in-home services. Often breakthrough symptoms of pain, nausea or anxiety can be controlled with medications found in the patient's crisis care kit.

“Teleconferencing helps hospices asses whether to give advice to the caregiver. They also keep the patient safe and comfortable in the home, without having to go to the ER unless it's absolutely necessary,” Brandt said. “Assessing whether they need to send a nurse out to the patient's home immediately or whether it can wait is a way to provide more cost-effective crisis care.”

When a hospice diagnosis is given, the hospice care team tries to do everything they can to keep the patient comfortable, physically, emotionally and spiritually. Emily Van Etten, development specialist at NHPCO, said that many patients have final wishes, such as seeing out-of-town family and friends one last time, but can't afford the extra expense. Van Etten oversees the National Hospice Foundation's Lighthouse of Hope Fund, which provides hospice agencies with patient wish-fulfillment grants of up to $2,500. “Hospice providers are really attuned to making patient lives better,” Van Etten said. “Their focus is on helping patients make the best days of the time that they have left.”