Download Hospice Care in the Aging Population Mary Rossio Concordia

Hospice Care in the Aging Population
Mary Rossio
Concordia University
February 20, 2015
Hospice care services are currently being underutilized among the aging population. A
stigma has been attached to hospice that is only for people that are dying of cancer with only a
few short days to live. When actually there are multiple hospice diagnosis’s for patients of 6
months or less life expectancy. The delay of initiating hospice services is common and from
that, the patient and their family is at a loss for end of life care and support. Thus being a great
opportunity to create a Health Belief Model to inform the public of the benefits of hospice care.
The definition of hospice and its services have evolved tremendously over the years from
its original beginnings. Hospice originated from the medieval era and was defined as a shelter
for the weary or ill travelers on a long journey. As of 2015, hospice has become more detailed in
aspects of care. Hospice is “care designed to give supportive care to people in the final phase of
a terminal illness and focus on comfort and quality of life, rather than cure”
(http://www.medicinenet.com/script/main/art.asp?articlekey=24267).
Hospice offers more than just care for the sick and dying. It provides assessments for the
patient, as well as supplies and medications for the patients comfort. All while managing pain
and symptoms. In addition, family education and bereavement services are included. Patients
can receive the services in a variety of settings. As most are aware, services can take place
directly in the patients or their loved ones home. What some might not be aware of is they can
also take place in nursing homes, assisted livings, supported living, and a designated hospice
home.
The most updated top hospice diagnosis by percentage as of 2011 are as follows:

Cancer 36.9%

Non-Cancer 63.1%

Debility Unspecified 14.2%

Dementia 12.8%

Heart Failure 11.2%

Lung Disease 8.2

Other 5.2%

Stroke or Coma 4.3%

Kidney Disease 2.1%

Non ALS Motor Neuron 1.6%

Amyotrophic Lateral Sclerosis (ALS) 0.4%

HIV/AIDS 0.2%
(http://www.nhpco.org/sites/default/files/public/Statistics_Research/2013_Facts_Figures.
pdf)
There are many myths and stigmas around hospice and what there diagnosis must be. One
common stigma is that all patients on hospice are dying of cancer and only have and have a very
short time frame to live. As you can see above, cancer does carry a large percentage but noncancer diagnosis are more common. Please note that there are more hospice diagnosis’s than
listed above that range from anorexia to osteoporosis.
Having a classified hospice diagnosis does not automatically qualify one for hospice. A
patient must meet CMS standards that vary for each individual disease or diagnosis. As asn
example, listed below is the criteria for a patient with Heart Disease/CHF. The patient must have
1 or 2 and 3.
1. Poor response to (or patients choice is not to peruse) optimal treatment with
diuretics, vasodilators, and or angiotensin converting enzyme (ACE) inhibitors.
Or
2.
The patient has angina pectoris at rest resistant to stand nitrate therapy and is not
a candidate for invasive procedures and/or has declined revascularization
procedures
And
3.
New York Heart Association (NYHA)* Class IV symptoms with both of the
following:

The presence of significant symptoms of recurrent Congestive Heart
Failure (CHF) and or angina at rest

Inability to carry out even minimal physical activity with symptoms of
heart failure (dyspnea and/or angina)
Supporting evidence for hospice eligibility:

Echo demonstrating an ejection fraction of 20% or less

Treatment resistant symptomatic dysrhythmias

History of unexplained or cardiac related syncope

CVA secondary to cardiac embolism

History of cardiac arrest or resuscitation
In the absence of one or more of these findings, rapid decline or comorbidities may also support
eligibility for hospice care. In addition to the document of the above, the physician must write
an order for the patient to be admitted to hospice. As well as have full consent from the patient.
If the patient is unable to provide consent due to medical reasons than the legal guardian must
provide consent on the patient’s behalf.
Some people may not consider hospice for fear of the cost. When in actuality, hospice
services are covered under Medicare Part A, Medicaid, and some private insurances. One can
also pay privately but this is not as common. Regardless of the form of payment, all diagnosis
still must meet the criteria mandated by CMS.
The Health Belief Model is a great way to change people’s behavior and attitude towards
hospice. Two concepts that influence people’s behavior are the perceived threat and expected
net gain. Perceived threats in relation to hospice are the denial of death by family and or patient,
and cost. Some fear that putting a loved one on hospice is giving up on them. Where net gain
can be clinical support for the patient, additional care, emotional support for the patient and their
loved ones, and guidance in preparation of their last days.
With the help of The Health Belief Model we can educate people on the net gains of
hospice care. “People are unlikely to act (adopt a health-protective behavior) in the absence of a
clear expected net gain” (DiClemente, 2013). This is where the challenge lies for public health,
the community, and health care providers. We must focus on educating, promoting and
encouraging people to take advantage of services that are available to them.
There have been multiple programs around the world that have been implemented to raise
the awareness for hospice care. Most of which currently target hospitals because of the large
patient base that can be reached and their influence on a patient’s path upon discharge. This
would be categorized under the Health Behavior Model. The good of this technique of reaching
decision makers but lacks the personal touch that may not exactly captivate one’s idea of net
gain. Other programs have focused on educating the interdisciplinary team. This would include,
nurses, social workers, clergy, community volunteers, etc. Another program was the enhanced
awareness of advanced directives. By educating and putting plans into place, people are
encouraged to make these difficult decisions ahead of time without the pressure of making a
difficult decision when the unfortunate time comes. This circling back to knowing what a patient
wants through the help of education and efficacy.
The program most geared to my opinions is Improving End of Life Care: A Public
Health Call to Action. This program is based around the Ecological Model of Behavior and
compares a good death from a bad death by educating the public about hospice. As notes, “at
present in the United States, at least half of all adults experiencing pain and suffering in the final
months and days of their lives at excessive financial cost and with intense resource utilization,
and these outcomes, ripple out beyond the dying person to their families, loved ones. Caregivers,
and communities” (Hess, 2009). It focuses on the negative of dying and how to help and or
avoid some aspects of a bad death.
The program in which I would like to share is called Dying with Comfort and Dignity: A
Community Stance. It would share common goals and strategies as listed above but in more
depth and a few new concepts. Although hospice criteria is based on health and not age, the
aging population has the most net gain to learn about hospice and what it has to offer. With that
being said, I would start with Medicare and Medicaid open enrollment. When one signs up for
Medicare especially they are provided with what services are covered and under which parts.
Hospice is covered under Medicare Part A. Upon completing the application, I would like to add
a check box of “to receive detailed information on hospice services”. I would also like to set up
clinics through the local health departments and established community groups such as The
Chamber of Commerce, to help complete Advanced Directives and Power of Attorney
paperwork. This will motivate in a proactive way to get people thinking about the future and
bring awareness to their loved ones about their dying wishes.
The next steps would include the education to the medical staff and how they can
approach their patients. In my physician related experience, physicians do not talk about hospice
for a variety of reasons. One being that they are uncomfortable talking about death to their
patients. Some people have been seeing the same physicians for many years and have built
personal relationships with them. Some physicians are not knowledgeable of hospice or even in
some cases do not believe in it for personal or cultural reasons. This is where we provide
training where they can earn credit for completing the course. Thus being a motivation for them
to learn more about hospice. Medical staff is responsible seeking continuing education
throughout their practice. This course would include how to speak about end of life care and
diagnosis’s that can be considered.
Hospitals also have a net gain for when patients go on hospice. Hospitals are being
critiqued on their readmissions rates. If patient enters the hospital within 30 days of discharge
for the same diagnosis, hospitals are being penalized. Not in all cases but in many, educating the
patient on hospice services and patients choosing to move forward with them will keep them out
of the hospital. The pilot could offer in house training to all staff including the physicians. The
hospice business is competitive because there are so many companies to choose from. There are
currently 5,500+ hospice companies that consist of for profit and non for profit. With that being
said, we can campaign with a hospice company to provide the training as well as inquire the cost.
Being such a competitive industry, I would imagine companies would be on board to promote
and educate on hospice services.
Due to years of myths on hospice and lack of formal education, the community could
stand to be brought up to date on all of the possible net gains of hospice. With the help of the
health department, community organizations, home health, and nursing facilities, we will hold
informative nights on Medicare services to the public. Although people may come for questions
related to other topics, we have the opportunity to inform them about hospice while they are
there. Based on evidence, the aging population is more responsive to newspapers, radios, and
community activities such as church or similar organizations. So these are the areas I would
extend my marketing to and look for community involvement.
Along with hospice services there are other services that can be considered. Palliative
care is covered under Medicare Part D and can be a consideration for many that are nearing the
need for hospice. Palliative care offers pain and symptom management and emotional and
spiritual support when you face a chronic, debilitating or life-threatening illness. So this can be a
pre-hospice step for those that are not ready for hospice due to denial or the desire to seek
aggressive treatment. Most palliative patients eventually transfer into hospice. So along with
hospice training we can incorporate other methods for care before hospice as well.
All in all, hospice services can be very beneficial to dying patients and their families.
With the help of the Health Belief Model and The Dying with Comfort and Dignity Pilot, we
have the power to change the perception of the public by minimizing the perceived threat and
maximizing their net gain. Our aging population is continuing to grow and hospice care is a
Medicare and Medicaid benefit that should be utilized if and when possible. Death is inevitable.
So there for, let’s plan for what we know is eventually coming at some point and allow ourselves
and our loved ones the opportunity to die with dignity and as comfortably as possible.
References
Centers for Medicare and Medicaid Services, 2015. Retrieved from
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/Hospice/Medicare_Hospice_Data.html
Grauel, Richard, 1996. Journal of Cancer Education, Educational Program in Palliative and
Hospice Care at the University of Maryland School of Medicine. Retrieved from
http://www.tandfonline.com/doi/abs/10.1080/08858199609528417#.VOdpLTbnb4g.
Guidelines for Hospice Admission, 2011. Passages Hospice.
Hess, Sally. Improving End of Life Care: A Public Health Call to Action, 2009. Retrieved from
http://www.jhsph.edu/academics/degree-programs/master-of-publichealth/curriculum/Sally%20Hess%20capstone%202009.pdf.
Hospice Care in America, 2012. Retrieved from
http://www.nhpco.org/sites/default/files/public/Statistics_Research/2012_Facts_Figures.pdf
Kinsella, Audrey, 2003. National Care Planning Council. Retrieved from
http://www.longtermcarelink.net/eldercare/hospice.htm.
Merson, Michael. Bradley, Elizabeth. Enhancing Awareness of Hospice Through Physician
Assisted Living: Public Health Perspectives, 1990. Retrieved from
http://hospice.com/jdt/789.html
National Hospice and Palliative Care Organization, 2014. Retrieved from
http://www.nhpco.org/about/hospice-care