Study of Hospice-Hospital Collaborations

Study of Hospice-Hospital Collaborations Table of Contents Executive Summary 2 Introduction 3 Methodology 4 Results 6 Conclusion..17

2 Executive Summary A growing number of Americans in the hospital setting are in need of the types of services that palliative care provides. Hospices have significant expertise in delivering palliative care, but this expertise has not been fully tapped. There is growing interest in the hospice community to realize its full potential to meet the need for hospitalbased palliative care outside of the traditional hospice structure. This study, conducted by the Center to Advance Palliative Care in partnership with the National Hospice and Palliative Care Organization and the Hospice Association of America, investigated the extent to which hospice is expanding its reach beyond patients under the hospice benefit and identified information that can be used to facilitate the further development of hospital-hospice collaborations. The 667 respondents, representing a response rate of 22%, expressed strong support for hospital-hospice collaborations to attract more eligible patients into hospice care. In addition, 87% of hospices surveyed agreed hospices should work with hospitals to develop hospital-based palliative care services for patients who do not meet hospice eligibility requirements or who do not choose hospice care. Approximately one quarter of respondents reported offering palliative care services to patients who are not covered under traditional hospice benefits. Of those hospices that are not offering these types of services, four in ten hospices (42%) said they were actively exploring or planning such palliative care services, but had not yet implemented a program. An additional 43% expressed interest but have never tried to become involved in offering such services. The main reason cited by the hospices that offer palliative care services to hospital patients without traditional hospice benefits was the need for such services (97%). The major barrier to offering services, cited by both hospices offering these services and hospices not offering these services, was lack of reimbursement. The vast majority of all respondents believe that more hospice programs would provide palliative care to patients not under traditional hospice benefits if reimbursement for these services were provided.

3 Increased patient and family satisfaction, more hospice referrals, reduced length of hospital stay and decreased ICU use were cited as key outcomes of palliative care services. Introduction A growing number of Americans in the hospital setting are in need of the type of services that palliative care provides. Palliative care aims to relieve suffering and improve quality of life for patients with advanced illness, and their families. Palliative care is provided by an interdisciplinary team and offered in conjunction with all other appropriate forms of medical treatment. Palliative care programs structure a variety of resources medical and nursing specialists, social workers and clergy to effectively deliver the highest quality of care to patients with advanced illness. Vigorous pain and symptom control is integrated into all stages of treatment. It is now recognized that palliative care should not be an alternative to curative or life-prolonging treatment but should be offered in conjunction with such medical treatment. It is also recognized that this type of care is increasingly important as the health care system faces the need to find ways to effectively and efficiently treat the growing number of older adults with complex, chronic illness. Palliative care helps hospitals deliver this level of care, improve the continuity of patient care across settings, ease burdens on staff, increase capacity, lower costs and meet quality and pain accreditation standards. Hospices have significant expertise in delivering palliative care but this expertise has not been fully tapped. There are a number of reasons for this. Hospices were structured as an alternative to traditional curative treatment, providing end-of-life care outside of the medical system, so integration of the expertise of hospice within the hospital system has been a slow process. The traditional structure of the Medicare Hospice Benefit also has limited services to patients who have predictable illnesses and are in the last months or days of life. Ensuring hospitals benefit from the expertise of hospices is especially important because hospitals are where the most severely ill patients are being treated in the medical system. In addition, because most

4 patients are in the hospital due to a health crisis, hospitals are an excellent place to plan for the next phase in the care continuum. The reality of the health care crisis forces patients to confront the reality of illness and the decisions they need to make about their care. The hallmarks of palliative care communication and coordination, combined with excellent medical care ensure that hospital patients have smooth transitions between the hospital and appropriate services such as hospice. There is growing interest in the hospice community to realize the full potential of hospice to help meet the demand and need for palliative care outside of the traditional hospice structure. One strategy is for hospitals and hospices to collaborate. For a long time, hospices have provided inpatient palliative care within the hospital setting for their hospice patients who are eligible for and have elected hospice benefits under their Medicare or other health insurance coverage. Now they are interested in extending that care to more patients. There is also growing interest among hospitals in palliative care. The Center to Advance Palliative Care (CAPC) has launched a national effort to increase access to palliative care, in particular within the hospital setting, and promote hospital-hospice collaboration. CAPC conducted a national survey in partnership with the National Hospice and Palliative Care Organization (NHPCO) and the Hospice Association of America (HAA) to obtain information that can be used to facilitate the development of hospital-hospice collaboration. The survey investigated what palliative care services hospices are offering in hospitals and health systems beyond traditional hospice care as defined by the Medicare Hospice Benefit. The purpose was to establish a baseline measure for future growth. The survey also looked at motivators and barriers to offering palliative care services and establishing hospital partnerships. It explored whether or not these factors vary by type of hospice organization or any other characteristics. Methodology A six-page survey was mailed to 3,038 hospices in the United States and Puerto Rico on June 24, 2002. Mailing lists from two major professional membership organizations, HAA and NHPCO, were used to develop the sample. After merging the two lists, duplicate

5 organizations were eliminated when possible. HAA and NHPCO contacted their members by e-mail and encouraged them to participate in the survey. 667 completed surveys were received by August 7, 2002, yielding a response rate of 22%. To assess how well this sample matches the hospice community, the survey sample was compared to two variables provided by NHPCO from a prior member assessment study. In both tax status and type of hospice, the sample population was similar to the NHPCO population. Table 1: Tax Status Audience For Profit Non Profit Public/Gov t NR Study Sample N=667 82 12.3% 556 83.4% 28 4.2% 1.1% NHPCO Population N=2419 471 19.47% Table 2: Type of Hospice 1 1609 66.52% 78 3.22% 261 10.79% Audience Study Sample N=667 NHPCO Population N=2419 Hospitalor Health Care Systembased 223 33.43% 617 25% Freestanding 287 43.03% 991 41% Home Health Agency 107 16.04% 431 18% NR Other/ Mult. Response 0 50 7.5% 291 12% 89 4% 1 For the type of hospice, respondents in both samples were allowed to check multiple categories.

6 Results Profile of Hospice Respondents Tables 3-8 profile the obtained sample by region of the country, hospice type, tax status, daily census, and whether the hospice is faith-based. Table 3: Region of Country Total NE MW South West 667 127 226 190 114 100.0% 19.0% 33.9% 28.5% 17.1% Non-respondents: 10 (1.5%) Table 4: Tax Status For Profit 82 12.3% Non Profit 556 83.4% Public/Gov t 28 4.2% No Response 1.1% Total 667 100% Table 5: Faith-Based Yes No No Response Total 96 541 30 667 14.4% 81.1% 4.5% 100% Table 6: Type of Hospice (multiple choice/responses) Freestanding 45% Hospital-based 25% Home health agency-based 24% Part of hospital/health care system 18% Nursing home 2% Table 7: Type of Hospice (responses with no multiple answers) Hospital- or health care system-based 223 33.4% Freestanding 287 43% Home health agency only 107 16% Total 617 92.4%

7 Table 8: Daily Census 1-25 patients 46% 26-50 patients 21% 51-99 patients 14% 100-199 patients 8% 200 or more patients 4% In analyzing the profile information, we found the following: There were more for-profit hospices in the South. The 14% of hospices reported to be faith-based were more likely to be in hospital/health care systems (29%). For-profit hospices, non-faith-based hospices and hospices in the South were much more likely to be freestanding. Over 90% report being Medicare certified, compared to 28% saying that they are Medicare home health agency-certified. Another 28% say they have other certification. There are a greater number of smaller hospices in the Northeast (55%) and Midwest (54%), and fewer in the South (31%). Hospital- and health care system-based, home health agency-based and not-for-profit hospices also tend to be smaller. Key Findings Delivery of Services in Hospice/Hospital Settings Most hospices provide inpatient care within hospital settings (89%). One quarter provides this care in nursing homes, while 11% offer it within a freestanding facility. For-profit hospices are twice as likely (50%) to offer inpatient care in nursing homes. Almost three quarters (73%) of the sample hospices deliver hospitalbased inpatient care using scatter beds. About one-third works within hospital-operated units, and 5% deliver hospital-based inpatient care through hospice-operated units. Although the vast majority of hospices are delivering care within hospitals, very few transfer patients in the hospital to inpatient hospice status. 68% say this occurs infrequently or never, while 7% (14% in the West region) report that they did not know this could be done.

8 Table 9: Transfer from inpatient hospital to inpatient hospice Very often 6% Often 15% Infrequently 42% Never 26% Didn't know they could do this 7% Serving Those Not Eligible for Hospice Care Table 10 shows that there was very strong support for hospicehospital collaborations to attract more eligible patients into hospice care. For-profit hospices showed the most support for this. There was also significant support for collaborations that would offer hospital-based palliative care for those not eligible for or choosing traditional hospice care. Hospices based in hospitals or part of a health care system were more likely to strongly support collaborations for hospital-based palliative care (60% strongly agree vs. 48% for other hospices.) The vast majority of respondents believe that more hospice programs would provide palliative care services to patients not under traditional hospice benefits if reimbursement for these services were provided. There were lower levels of consensus around the effects of kickback laws on hospital-hospice collaborations to offer palliative services to patients without traditional hospice coverage. While nearly half of the hospices felt kickback laws kept hospices from partnering, onethird was neutral and 18% disagreed.

9 Table 10: Support for Services Strongly Agree/ Agree Neutral Strongly Disagree/ Disagree Hospices should work more closely with hospitals to attract more eligible patients into hospice care. 97% 2% 1% Hospices should work with hospitals to develop hospital-based palliative care services for patients who do not meet hospice eligibility requirements or do not choose hospice care. 87% 9% 3% More hospice programs would provide palliative care to patients not covered under traditional hospice benefits if reimbursement were provided 92% 6% 1% Concern about anti-kickback laws keep hospices from partnering with hospitals to provide palliative care services not covered under traditional hospice benefits 46% 33% 18% New Opportunities One quarter of surveyed hospices reports offering palliative care services to patients who are not covered under traditional hospice benefits (see Table 11). Table 11 Region Type of Hospice Tax Status Total NE MW South West Hospital or HC System Free- Standing Home Health Agency For Profit Not for Profit Public/ Gov. Faith Based TOTAL 667 127 226 190 114 223 287 107 82 556 28 96 541 Yes 25.5% 22.0% 29.2% 19.5% 33.3% 33.2% 23.0% 20.6% 11.0% 27.9% 21.4% 36.5% 24.0% No 71.8% 73.2% 69.0% 78.4% 63.2% 64.6% 73.9% 79.4% 87.8% 69.1% 78.6% 62.5% 73.4% Yes No As Table 11 shows, hospices were more likely to offer hospital-based palliative care services if the hospice was:

10 In the West (33%); Hospital-based or part of a health system (33%); Not-for-profit (28%); Faith-based (37%); Had an average daily census over 100 (42%), and; Delivers inpatient care in a hospital (27% vs. 17%). Very few hospices (8%) report having separate corporate structures to provide palliative care for those not covered by traditional hospice benefits. Those that do are more likely to be those that are home health-based (14%). Table 12 shows that hospices not offering palliative care services to patients without the traditional hospice benefit designated a number of reasons for this, with lack of reimbursement mentioned by over 60%. Table 12: Reasons Why Hospices Do Not Provide Palliative Care to Hospital Patients Without The Traditional Hospice Benefit Lack of reimbursement 63% Don t know how to structure PC 34% Staff/nursing shortages 34% Don t know how to deal with regulatory issues 33% Different professional cultures 33% Hospitals not receptive 29% Not a priority 20% Lack of consumer demand 19% Don t know how to set up contracts 18% Hospitals offering PC on own 15% Don t know how to negotiate 14% Inconsistent with mission 9% The type of hospice did not influence reasons given for why hospices do not provide palliative care to hospital patients without the traditional hospice benefit. However, hospices in the West are less likely to indicate a lack of knowledge concerning how palliative care is structured (19%) or how to deal with regulatory issues (22%). Those in the West were more likely to cite staff/nursing shortages (47%) as a reason. Hospital-based hospices and those in health care systems were more likely to specify reimbursement (69%) and not knowing how to

11 structure PC programs (40%) as barriers. Freestanding hospices and those housed in home health agencies were more likely to say hospitals were not receptive to such partnerships (39% and 37%, respectively) compared to hospital-based hospices (8%). Interestingly, for-profit hospices were as likely to specify lack of receptivity on the part of hospitals as a barrier (63%) as they were to specify reimbursement (63%). Interest in Palliative Care Although only 25% of hospices indicated they currently provide palliative care to hospital patients not under traditional benefits, the majority of the remaining hospices not offering palliative care to hospital patients expressed interest in providing such services. Four in ten hospices (42%) said that they were actively exploring or planning palliative care services, but have not yet implemented any services. An additional 43% expressed interest but have never tried to get involved. Five percent of hospices reported having tried to offer palliative care services but were unsuccessful, while 6% said they had no interest. Chart 1 43% 5% 6% Actively exploring or planning palliative care services, but have not yet implemented any services 46% Expressed interest but have never tried to get involved Tried to offer palliatve care services but were unsuccssful Reported no interest

12 Offering Palliative Care Services Ninety-seven percent (97%) of the 170 hospices that offer palliative care services to hospital patients without traditional hospice benefits indicated that the need for such services was why they provided the services. Table 13 presents other reasons these hospices provide these services, along with percentages. Freestanding hospices were more likely to see this as part of their mission and a way to overcome access barriers. Those hospices that are hospital-based or part of a healthcare system were more likely to say that a hospital requested their assistance or involvement. Table 13: Reasons Why Hospices Provide Palliative Care to Hospital Patients Without Traditional Hospice Benefit TOTAL Hospital- Based or HC Systembased Freestanding Home Health Agency TOTAL 170 74 66 22 There is a need 96.5% 97.3% 97.0% 90.9% Hospice has expertise 90.6% 90.5% 90.9% 90.9% Part of mission 89.4% 85.1% 97.0% 77.3% Hospital asked us 56.5% 66.2% 48.5% 40.9% To overcome access 55.3% 50.0% 68.2% 36.4% barriers Keep others from competing 10.6% 5.4% 15.2% 18.2%

13 Table 14: Perceived Barriers to Offering Palliative Care to Hospital Patients Without Traditional Hospice Benefit Among Hospices Offering Those Services TOTAL Hospital- Based or HC Systembased Freestanding Home Health Agency TOTAL 170 74 66 22 Lack of reimbursement 73.5% 74.3% 68.2% 77.3% Different professional 49.4% 47.3% 48.5% 50.0% cultures Medical staff don't value 38.8% 44.6% 30.3% 50.0% Hospital management 31.2% 18.9% 40.9% 50.0% does not value Staffing/nursing 24.7% 25.7% 21.2% 31.8% shortages Don t know how to deal 19.4% 20.3% 22.7% 4.5% w/ regulatory issues Don t know how to 17.6% 20.3% 15.2% 13.6% structure Hospitals not receptive 16.5% 6.8% 28.8% 18.2% Hospitals offering on own 7.6% 4.1% 9.1% 13.6% Don t know how to negotiate w/ hospital systems 6.5% 4.1% 10.6% 0.0% As shown in Table 14, hospices that offer palliative care services to patients not under the hospice benefit cited reimbursement as a major barrier. This may be because they struggle to find reimbursement for the services they are providing outside the hospice benefit. Hospices that are hospital-based or part of a health care system were much less likely to perceive hospital management as not receptive (19%). Those based within home health agencies were less likely to see regulatory issues as a problem (5%). Table 15 provides a comparison of barriers faced by hospices offering palliative care services to patients without traditional hospice benefits and hospices that do not. Interestingly, those hospices that are successfully offering palliative services are more likely to cite the number one barrier reimbursement. They are almost twice as likely to specify differences in professional cultures (50% to 29%) their second barrier. Hospices offering palliative services are less likely to specify the remaining barriers, with none citing lack of consumer demand or difficulty with setting up contracts.

14 Table 15: Comparison of Perceived Barriers for Hospices that Provide Palliative Care Compared to Those That Do Not Hospices that offer Palliative Care Hospices that do not offer Palliative Care TOTAL 170 479 Lack of reimbursement 73.5% 62.6% Different professional cultures 49.4% 28.8% Medical staff don't value 38.8% -- Hospital management does not value 31.2% -- Staffing/nursing shortages 24.7% 33.8% Don t know how to deal w/ regulatory 19.4% 33.2% issues Don t know how to structure 17.6% 34.2% Hospitals not receptive 16.5% 28.6% Hospitals offering on own 7.6% 15.4% Don t know how to negotiate w/ hospital 6.5% 13.6% systems Lack of consumer demand 0.0% 18.8% Don t know how to set up contracts 0.0% 17.5% Half of the hospices offering palliative care services do so in only one hospital (52%). Larger hospices tend to provide the services in more than one hospital (see Table 16). Table 16: Number of Hospitals Where Hospices Offer Palliative Care to Patients Without Traditional Benefits, by Size of Hospice Average Daily Census (# PATIENTS) TOTAL 1-25 26-50 51-99 100-199 200+ TOTAL 170 69 34 23 20 15 89 48 17 11 4 3 One 52.4% 69.6% 50.0% 47.8% 20.0% 20.0% Two 15.3% 10.1% 20.6% 30.4% 25.0% 3 or more 21.2% 5.8% 17.6% 17.4% 50.0% 60.0% No Answer 11.2% 14.5% 11.8% 4.3% 5.0% 20.0%

15 Type and Structure of Palliative Care Services Hospices were asked to answer a series of questions based upon the hospital where they are most successful in providing their palliative care services to hospital patients without traditional benefits. These questions were designed to provide a description of the type and structure of palliative services being offered. The following summarizes the current nature of hospital-based palliative care services offered by hospices. 85% are in not-for-profit hospitals 81% are offered in community-based hospitals with an additional 10% in academic medical centers 31% are in faith-based hospitals 78% have no written agreement or contract covering the services to patients without traditional benefits Hospitals offering palliative care services have the following: 50% have scattered beds for hospice and palliative care services 27% have a designated unit/beds for hospice care only 8% have a combined palliative care and hospice unit 7% have a designated unit/beds for palliative care only 19% stated that the hospitals have none of the above characteristics Palliative care consultation services provided by the hospices are characterized as follows: 31% offer a consultative team of hospice staff only a characteristic that was more prevalent in the Midwest (46%). Large hospices are not likely to provide hospice-only consultative services (7%). 31% offer a consultative team of hospice and hospital staff 8% offer advisory/educational support to a hospital staff only palliative care team 6% of hospices offer physician-only consults (not part of a team) 4% of hospices offer a nurse-practitioner-only consult (not part of a team) 6% of hospices do not offer consultative services but plan to in the future (18% in the West) 2% of hospices do not offer consultative services and do not plan to in the future

16 Of the 121 hospices offering consultative services, the following were designated as professionals included in the team: Registered nurse 85% Social worker 75% Physician 71% Spiritual Counselor 64% Pharmacist 26% Nurse Practitioner 13% Clinical Psychologist 2% Other 17% Table 17 indicates how often hospices provide certain services as part of their palliative care for patients without traditional hospice benefits: Table 17: Type of Care Often Infrequently Never Assistance with goals of care and care planning 41% 40% 10% Counseling or spiritual care for patient or family 42% 43% 5% Bereavement Services 37% 44% 9% Pain management 55% 34% 4% Symptom management other than pain 45% 39% 7% End stage disease management 37% 45% 8% Hospices were asked to specify the sources of support for patients without traditional hospice benefits within designated palliative care units or for consultative services. Table 18 lists the sources of support indicated by the 170 hospices involved in palliative care services for non-traditional patients.

17 Table 18: Percent of Hospices Designating the Source of Support for Inpatient and Consultative Services Source of Support Inpatient palliative care unit or designated beds Palliative care consultation services Patient/3 rd Party Reimbursement to Hospital 10% 6% Patient/3 rd Party Reimbursement to Hospice 5% 10% Patient/3 rd Party Reimbursement to Provider 4% 12% Grant/philanthropic support 11% 29% Subsidies from the hospital 12% 25% Subsidies from the hospice 12% 39% Palliative Care Service Outcomes Hospices were asked to indicate outcomes that they believed were related to providing palliative care services for hospital patients without traditional hospice benefits. Of the 170 hospices involved in palliative care services for non-traditional patients, the percentages of these hospices that selected each outcome related to palliative care services are shown in Table 19.. Table 19: Outcomes of Palliative Care Services Outcomes Related to Palliative Care Services Percent of Hospices Specifying Outcome Has Supporting Data Increased patient and family satisfaction 69% 8% More hospice referrals 54% 9% Reduced hospital length of stay 48% 5% Decreased ICU use 43% 3% Decreased ER use 38% 2% Increased hospice length of stay 33% 4% Decreased hospice length of stay 5% 1% Fewer hospice referrals 1% 1%

18 Conclusion Preliminary results from this survey provide a picture of the current landscape in which hospices operate. The survey results can also serve as a baseline measure to monitor the growth of hospitalhospice collaborations. The survey identified important motivators and barriers that can be used to support the development of these collaborations. Of particular interest was the significant support for collaborations that would offer hospital-based palliative care for those not eligible for or choosing traditional hospice care. Importantly, a majority of hospices not currently offering palliative care to hospital patients expressed interest in providing such services. Reimbursement for these non-traditional services was the number one reason identified as inhibiting the delivery of these services. Respondents identified many outcomes related to the palliative care services that will facilitate the development of hospital-hospice collaborations.