![[Image]](pict216.jpg)
HOSPICE CARE
|Resume | Daily
Commentary| Contact
Us | Site
Search
| Home
Page |
There are three levels of hospice: in the home; respite care when the family
needs a break and the patient goest into a nursing home or hospital for a
brief stay; and continuous care, when the hospice team comes into the home
around the clock (varies in different areas since some institutions are set
up specifically for this purpose). A hospice team is an interdisciplinary
group or registered nurses, certified nursing affiliates, social workers,
a chaplain, and a volunteer; the law requires that each team have a volunteer
(Illinois). The nurses are to be expert in pain management. The team may
offer video tapes, reading material a manual with articles on every disease
process and how to control it. Not everyone is there at the same time- the
nurses come two or three times a week, the social worker once and the chaplain
as necessary.
HOSPICE CARE: From Norma Cousins in her Anatomy of an Illness, as to why hospitals create a need for hospices:
"Death is not the ultimate tragedy of life. The ultimate tragedy is the
depersonalization- dying in an alien and sterile area, separated from the
spiritual nourishment that comes from being able to reach out to a living
hand, separated from a desire to experience the things that make life worth
living, separated from hope."
HOSPICE: A federal rule requires hospitals to tell people about hospice services if they are being discharged with a terminal illness and are expected to die in the next several months. Here's what you should ask about the service in your area
There are about 2,000 hospices in the U.S. and about 1,600 are covered by
Medicare.
Of the 2.2 million Americans that die each year, about 80% end their lives
in hospitals; 300,000 die at home under hospice care.
HOSPICE CARE: (Answers 1996) Hospice returns the natural process of dying to the home or home like setting, amid familiar surroundings and the comforting presence of family. Hospice focuses on caring for the whole person, restoring dignity to the final days. Any terminal illness is appropriate for hospice are. Anyone who receives Medicare Part A can qualify for hospice care and pays for all covered costs under the following conditions
Medicare will pay for two 90 day periods and one additional 30 day period and an unlimited number of extensions if re-certified terminally ill. (Patients can be asked to pay 5% of costs for outpatient drugs or $5 per prescription and 5% of the Medicare rate for hospice care- though most hospices usually cover these costs. The individual costs include
Survivors have stated that the care shown them was tremendous and continued
even a year after death. death. The nurses/volunteers should be canonized.
For info, call the National Hospice Organization at 800 658-8898.
HOSPICES: (1996) Examined previously a number of times, it is the availability of terminally ill patients to die in dignity and peace. Hospices provide nursing care, medical equipment, drugs, physical and psychological therapy and social services. Medicare picks up about 80% of the cost, but private donations may pay the rest. Ideally, patients should enroll about three months before death. But patients are waiting almost to the last month before enrolling. In 1990, the average hospice patient died 36 days after entering a hospice and 15.6% died within a week. A study by the University of Chicago showed that only 14.9% lived longer than 180 days and about 8% lived more than a year. (A patient must have just six months to live in order to qualify for Medicare Hospice care).
Admittedly, some people are dying at home and wish to remain there as long as possible. But others are in a hospital. And as one pain specialist stated, "the hospital is a horrible place to die. No family, no community, no loved ones are present. And so for those facing death, it is not only symptoms or pain but existential suffering, loneliness, fear of abandonment, isolation, being a burden." And another said that "death is often not pretty or easy..."
So if you are going to use a hospice (recommended), why not go early and seek the peace of mind and body that it can provide.
HOSPICE CARE: 1998 (National Hospice Association) The daily cost for Medicare for skilled nursing home care is $426 versus $111 for hospice. About 90% of hospice care is based in the home.
NUMBER OF HOSPICE PATIENTS IN THE USA
1996 450,000
1995 390,000
1994 340,000
1993 275,000
1992 246,000
1991 210,000
HOSPICE: (1998) The average cost or hospice care at home is $96 a day compared with an average of $426 a day in the hospital during the last year of life. These are some questions suggested by Money Magazine to ask regarding hospice- you can also call the National Hospice hotline at 800-658-898
1. Does the program treat only terminally ill patients
2. Does the hospice provide a team approach to one's home health care
3. Has the hospice established connections with doctors, hospitals and pharmacies
4. Will a written plan for care be drawn up that spells out what the patient wants and how the hospice will help him or her achieve it
5. Is support available 24 hours a day, seven days a week.
HOSPICE CARE: (NY Times 1999) Started in the 1970's as a voluntary charitable effort to help those near death and to avoid the endless and costly end of life procedures. The patients are offered comfort care- keeping patients free of pain and discomfort and assistance with spiritual, emotional and practical matters. The patient is in control- the hospice will try to follow the patients wishes. Hospice enables and encourages family and friends to participate in the end of life care. Most importantly , from my conversations with beneficiaries, hospice offers counseling before and after the loved one's death and advice and aid to caregivers who may suffer both an emotional and financial toll. Lastly, hospice utilizes teamwork through the use of medical professionals, home health aides, social workers, chaplains, volunteers and others to make the process of dying as "acceptable" a product of life as possible.
In 1983 Medicare began paying for hospice care- which subsequently fostered a bunch of for profit entities that, in some cases, found loopholes to falsify care. Currently only 25% of hospices are non profit.
Hospice care costs about $100 per day- less than a hospital stay ($400+ per day) and the main reason for its use. The average stay is 55 days and most of the 455,000 Medicare and private patients are cared for in their own home. But the average stay in a hospice program for nursing home patients was 166 days- and that is where most of the problems lie as certain agencies have submitted bills for ineligible patients. A federal study noted that about 33% of all nursing home hospice patients are ineligible, primarily because most are not terminally ill (having six months to live). .
As such, the budget has ballooned far out of control. In fact, hospice is the fastest growing area of the Medicare budget costing about $2 billion a year. BUT THAT'S ABOUT DOUBLE WHAT WAS SPENT JUST FOUR YEARS AGO.
Rate of hospice use per 1000 older Medicare beneficiary deaths. (2000)
RESULTS: Overall, 155 of every 1000 older Medicare beneficiaries who die use hospice before death. This rate is significantly higher among younger older persons (P < .001), non-blacks (P < .001), persons living in wealthier areas (P < .001), and persons in urban areas (P < .001). Areas with a higher proportion of non-cancer diagnoses among hospice users have higher rates of hospice use for both cancer and non-cancer reasons than areas with a majority of hospice users having cancer diagnoses (P < .001). Hospice use is higher in areas with fewer hospital beds per capita (P < .001), areas with lower in-hospital death rates (P < .001), and areas with higher HMO enrollment (P < .001). Rates of hospice use are also positively related to average reimbursements for health care (P < .001) and to physicians per capita (P < .001). In the largest metropolitan statistical areas (MSAs), rates of hospice use vary more than 11-fold from a low of 35.15 (Portland, ME) to a high of 397.2 per 1000 deaths (Ft. Lauderdale, FL).
HOSPICE Short article by Caregivers.com (2001)
Children and Hospice: (2002) Although nearly 10,000 children die of conditions such as cancer each year, fewer than 10% of the nation's 3,000 hospice programs provide end-of-life care for children, and "only a handful are specifically geared toward kids. " Children with terminal illnesses often spend the last days or weeks of their lives in a hospital, "hooked up to machines, as doctors try everything they can to head off the inevitable." By contrast, many adults with terminal conditions receive hospice care to help make them "as comfortable as possible, often at home," and to provide support to them and their families.
You do not want to die in a hospital if you can avoid it.
Home Hospice Programs Connie Ford, RN, MPA (2003)
Hospice (2003) care has grown into a multibillion dollar industry since the first hospice opened in the U.S. in the 1970s. More than 3,100 programs served roughly 700,000 patients in 2000, and the Medicare benefit, which pays for the majority of hospice services, is expected to reach an estimated $3.8 billion in 2002.
Home Hospice Programs (2003) By Connie Ford, RN, MPA
Home Hospice Programs Are Getting Stronger
Home Hospice Programs Are Getting Stronger
Hospice: (Yale 2005) Families that delay enrolling the terminally ill in hospice programs may suffer from increased depression following the death of those patients.
one interpretation could be that "people who get to hospice late may not be getting adequate counseling preparing them for the death of their loved ones."
Medicare data from 1990 indicate a median enrollment time of 36 days, with more than 15% of patients dying within seven days of enrollment, the study points out. That compares with enrollment times of longer than two months previously.
The delayed admissions could be linked to a growing number of hospice-like services offered by many hospitals today and the availability of palliative drugs on the market. These drugs can be used to ease the pain of terminally ill patients and allow them to linger longer at home prior to their deaths.
ON YOUR BEHALF: Home Hospice Programs Are Getting Stronger By Connie Ford, RN, MPA
When you learn to die, you learn to live. That is the compelling theme of the well-known book, Tuesdays with Morrie. Learning to die is a personal process; no one else can do it for us. It is possible, however, that caring for another during his or her end of life pilgrimage may help with our own process of learning.
One day while touring a new senior housing complex, a local minister commented that the people he used to visit in nursing homes are now being cared for at home. His casual observations are pretty accurate. Nursing home professionals would not only agree, but they would also relate that their frail residents are living longer with chronic illnesses and require more care and caring than in years past.
Can nursing homes really provide the needed care and caring? Nursing home admissions for extended stays are declining. People are finding ways to stay at home. They desperately wish to preserve personal dignity. They also fear a loss of control, poor care and perhaps a painful death. Various state initiatives provide care services so people may successfully stay home and ‘age in place.’
When people encounter the end of life, we typically do not hear about fears relating to care and caring when hospice is helping the family. Hospice programs generally receive great accolades for their work. Hospice extends to some nursing homes so eligible residents can receive the program benefits. In an ideal world, one would think that hospice in a nursing home shouldn't be necessary; a nursing home should always be a premier residence for a ‘good death.’
Why do some nursing homes have arrangements with hospice programs and others don't? One possible reason is financial. Government programs such as Medicare and Medicaid pay a daily rate for hospice. When hospice provides a nursing home resident with end of life care, the nursing home becomes a partner with hospice. They share the daily payment and therefore receive less money than when they individually provide all of the care. Now more than ever, because of changes in government reimbursement and increasing insurance costs, nursing homes are struggling to survive.
Therefore, we must take an active role in assuring appropriate end of life care. There are several national efforts that are helping; two are especially relevant at this time. In 1999, a national foundation, the Milbank Memorial Fund, published an important document, Principles for Care of Patients at the End of Life: An Emerging Consensus among the Specialties of Medicine. As caregivers and as mortal human beings, it is reassuring to know that 14 major societies, including the American Medical Association and the Joint Commission on Accreditation of Health Care Organizations (JCAHO), have created policy that incorporate these principles. The principles for professional practice include:
Respect for the dignity of both patients and caregivers
Sensitivity to and respect for the patient's and family's wishes
Use of appropriate measures consistent with patient choices
Alleviation of pain and other physical symptoms
Assessment and management of psychological, social and spiritual/religious problems
Offering continuity. The patient should be able to continue to be cared for by his/her primary care and specialist providers
Providing access to any therapy, which may realistically be expected to improve the patient's quality of life, including alternative or non-traditional treatments
Providing access to palliative care and hospice care
Respecting the patient’s right to refuse treatment
Respecting the physician's professional responsibility to discontinue some treatments, when appropriate, with consideration for both patient and family preferences
Promote clinical and evidence-based research on providing care at the end of life
Your physician and/or the physician treating your loved one may not yet be familiar with these principles. Often doctors learn new information from patients and caregivers. There is no time like the present to share this information.
Another initiative is a major four part public television series from Bill Moyers, On Our Own Terms: Moyers on Dying in America. The first hour-long segment airs September 10. Accompanying the series is a national outreach effort to educate the public about end of life care. Improving care and caring during the final life passage is an aspect of this life event that society can impact.
Hospice Care by Peter Ganther (2006)
As caregivers to someone who is terminally ill, we must eventually think about end-of-life care for our loved ones. We want them to die in familiar surroundings with us and with dignity, and not in a cold and sterile hospital setting. Hospice care can help.
The term hospice dates back to the Middle Ages in Europe. Then it was used to refer to places o charitable refuge offering rest and refreshment to weary travelers. These homes were usually run by monasteries; the most famous of which, St. Bernard, is still a shelter for those passing over the Alps. During World War II, the special needs of the dying were recognized and this led to the modern hospice movement.
The modern hospice movement was started by a British physician named Dr. Cicely Saunders who established St. Christopher’s hospice outside of London. This hospice combined modern symptom and pain control techniques with compassionate care for the dying. These same basic principles apply to today’s hospices as well. The first hospice in the U.S. was organized in 1974 in Connecticut.
Hospice is not necessarily a place though. It is a system of caring for someone who can no longer benefit from aggressive treatment for their disease. In fact, treatment has become futile. The emphasis in a hospice situation is on palliative (easing without curing) care and pain treatment. Most hospice care not only treats the loved one, it counsels the families and caregivers as well. All of this is done through an interdisciplinary team consisting of highly trained volunteers, home health aides, dieticians, social workers, clergy (if applicable), nurses, and doctors. In addition to providing nursing care, hospices may supply physical therapy, drugs, and medical equipment. Most of the care is provided in the loved one’s or the caregiver’s home, but hospice centers are available in many areas.
Simply put, the hospice team is a compassionate group of individuals who address the emotional, physical and spiritual needs of patients and families alike. There is often a spiritual/emotional healing that happens when the patient and family begin to focus on living peacefully and with dignity rather than focusing on the condition or disease.
The therapy that the team provides is designed to relieve symptoms, use pain medications effectively, improve the quality of life, and prepare the loved one and their caregiver(s) and family members for death. Nothing is done to speed death, but it is allowed to happen naturally. The benefits are an increase in patient satisfaction, a reduction in costs, and the mitigation of family anxiety.
The decision to enter hospice is not an easy one. To some it feels like giving up, but it really comes down to accepting one part of the natural cycle of life. For many, dying at home peacefully is a better alternative than fighting in a hospital until their last breath. It is not for everyone, and, as much as possible, your loved one should decide for themselves.
One must qualify for hospice care. In most cases, a doctor must have diagnosed the patient as having a terminal illness that is most likely to cause death within six months. The patient can leave at any time. An example of this would be an improvement in the person’s condition to the point where they might want to start treating it again. Most insurance plans, including Medicare and Medicaid, pay for hospice care. Many times even those without insurance are still eligible. Costs are covered mostly through donations.
The immediate goal of the hospice team is to develop a “plan of care” for the patient. Before this can happen, the team meets with the patient’s personal doctor(s) and the hospice physician to discuss the patient’s history, current symptoms, and life expectancy. The team then meets with patient and family members. Available services, the philosophy of hospice, and expectations are considered here. Other topics at this meeting might include comfort and pain levels, equipment and medication needs, support systems, and financial and insurance resources. From these meetings a care plan tailored to meet the patient’s specific needs is developed. This plan is reviewed and revised regularly as a patient’s condition changes. Typically, counseling and bereavement services are available to family members for a year after their loved one’s death.
According to hospice Foundation of America, the following questions should be asked when selecting a hospice:
Does the hospice serve your area?
Is the hospice licensed (where applicable) and Medicare/Medicaid certified?
Does the hospice provide the services you want/need?
What does the hospice expect from you and your caregiver support system?
Will your insurance plan work with the hospice?
Does the hospice have a support program for caregivers?
Where is needed inpatient or respite care provided?
Is the hospice’s position on resuscitation, hydration and antibiotics consistent with yours?
What out of pocket expenses should you anticipate?
Is there a sliding scale payment plan for services not covered by insurance?
If your loved one is diagnosed with a terminal illness, this might be a good alternative for you. Your loved one’s comfort will be a priority, and they can pass on peacefully, surrounded by the people they have cherished most. Not only that, the whole family can benefit from the hospice experience through their bereavement counseling. You may learn a little more about death, and, in so doing, learn a little bit more about life.
The Business of Hospice Care (2006)
Hospice care occupies a specialized and growing niche in the healthcare economy as a comfort to the dying and their families, and a potential cost-saver for Medicare. With baby boomers now hitting their sixth decade, hospice is expected to become an even more important part of the healthcare landscape, according to Wharton faculty and industry analysts. How profitable are hospice-providers, what is their long-term business outlook, and what are the unique challenges that hospice companies face, given strict government regulation amid increasing demand for their services?
hospice organizations, including for-profit companies, served 1.2 million patients in 2005, and a third of the nation's 2.4 million deaths occurred in hospice programs. A handful of publicly held companies provide hospice care along with hundreds of smaller private, for-profit companies and well-established non-profit ventures. Medicare picks up more than three-quarters of the bill.
Today there are 2,900 Medicare-certified hospice programs. Medicare reimbursement for hospice care has grown from $68.3 million in 1986 to $8.3 billion last year and is expected to reach $9.5 billion in 2006. By 2030, as the baby boomers enter their 80s and beyond, Medicare projects hospice spending will climb to $45.6 billion.
CIBC World Markets projects spending on hospice care to increase 9.1% over the next five years. In addition to the aging of the population, CIBC notes that there is room for hospice programs to continue to grow into medical conditions beyond cancer (the illness that traditionally has been most often associated with hospice care). Growth is also likely by geographic region. In 10 states, including Arizona, Texas and Florida, more than 40% of the deaths occurring in the population over age 65 were under hospice care. By contrast, in 13 states, including Massachusetts and New York, and Washington D.C., hospice deaths occur in only 20% of the same population.
The market remains fragmented, with the top five publicly held hospice companies controlling 14% of the market. cost savings, but more recent reports have shown mixed results. According to a study published in 2004 in the Journal of Pain and Symptom Management, hospice care does reduce the costs of caring for patients with many forms of cancer, but the savings are not as clear-cut for other diagnoses, including dementia, chronic obstructive pulmonary disease and congestive heart failure, which increasingly are part of the hospice treatment mix.
Another study, which was conducted by the RAND Corp., found expenses were 4% higher for the last year of life among patients who used hospice services compared to similar patients who received traditional medical care.
On average, cancer patients who chose hospice care were about 1% less expensive for Medicare to treat, according to the study, which evaluated the cases of 250,000 people who died between 1996 and 1999. Savings were as large as 17% for patients with aggressive tumors such as lung cancer. For hospice patients who died from illnesses other than cancer, average costs were 11% higher than similar patients who received standard medical care.
Stephen Connor, vice president of research at the National Hospice and Palliative Care Organization, suggests that the higher costs for hospice patients is a result of delays in patients entering the program. The median length of stay is 22 days, but 35% of those who die under hospice care are only in the program seven days or less. "The biggest problem is people are with us for too short a time. Hospice adds value by providing quality care and preventive medicine," says Connor. "If the patient is in hospice seven days or less, it's too late to prevent that final hospitalization and we become an add-on cost at that point."
![[Image]](pict217.jpg)
A change in hospice: (NY Times 2007) The American health care system has long given patients a terrible choice: people told that they have a terminal illness must forgo advanced medical treatment to qualify for hospice care. Cancer patients have to pass up chemotherapy, for example, or patients with kidney failure must abandon dialysis.
Forcing patients into this either-or decision has prompted many who might benefit from a hospice program to instead opt for expensive hospital care that may end up costing Medicare and other insurers far more.
some hospice programs and private health insurers are taking a new approach that may persuade more patients to get hospice care for the last months of life. These programs give patients the medical comfort and social support traditionally available through hospice care, while at the same time letting them receive sophisticated medical treatments that may slow or even halt their disease.
Experts say that if the new approach catches on more broadly, more patients who would benefit from hospice care will actually enter hospice programs — and enter them earlier. And more patients, they say, could avoid the costly, crisis-ridden final weeks in a hospital that often still represent the American way of death.
In 2005, only about a third of the 2.4 million people who died in this country were in hospice care. Perhaps twice that many patients should have been in hospice programs
There are many reasons people are slow to consider hospice care — not the least of which is acknowledging that they are dying.
But Dr. Byock rejects the notion that the only point of hospice is to help people die. He says that by offering nursing care and palliative medicine to relieve pain and improve the quality of life, hospice care can benefit some people so much that they become well enough to leave the programs.
Medicare which spent about $9 billion on hospice benefits last year out of its total spending of $406 billion, requires patients to give up regular medical coverage if they enter a hospice program.
Medicare officials say that patients can opt for hospice care and then change their mind, resuming traditional coverage. And they say that nothing in Medicare’s rules prevents hospice programs from providing a full range of medical treatments.
But many hospice programs do not offer advanced medical treatments because they say they cannot afford to. Medicare pays a provider about $130 a day for routine hospice care in the home, regardless of the patient’s individual condition. The agency, which introduced the benefit in the mid-1980’s, based its rules on the assumption that it would be too costly to pay for both hospice care and for treatments aimed at prolonging life.
Many people in the field say that Medicare’s fixed-payment system discourages some hospice programs from accepting patients who need expensive treatment.