How Effective are Hospices in Spreading the Science of Palliative Care?

 Medicare-certified hospices are the principal organizational model delivering palliative care to those with life-limiting illnesses.  A close look at NHPCO's Annual Facts and Figures (2020 version recently published) reveals much about the hospice industry and the spread of the science of palliative care.

The industry continues to be subscale, hindering the development of clinical proficiency. For example, more than half of US hospices admit fewer than 2 patients per week (same as five years earlier). See here for previous blog post arguing the case that proficiency in health care is related to volume. Furthermore, more than 25% of hospices have been newly certified in the last few years, another important consideration in the development of proficiency. One might argue that the number of people utilizing the hospice benefit to receive palliative care has been growing (in 2018, more than 50% of Medicare decedents received palliative care through a certified hospice), thus justifying a greater number of hospices in the country, but the % growth in the number of hospices in the US exceeds the growth in the number of Americans utilizing the Medicare hospice benefit.  I suggest  that the large variations in late-life care will continue until the hospice industry gains in scale. (read here for more on clinical variations in late-life care).

On a more promising note from the 2020 NHPCO report, the  percentage of short-stay patients (those receiving palliative care through the hospice benefit for seven days or less) dropped to 27.9%, from 35% five years ago.  So an issue (timely use of hospice benefit) some thought intractable 10 years ago (read here) may be gradually improving.

As always, your insights and feedback are invited.

Exemplary Performance in Late-Life Care - How Much More Do We Know Than 10 Years Ago?

 

The post below (Improving Late-Life Care...) appeared in 2010, pondering what outcomes constituted exemplary performance within a community as it pertained to late-life care practices.  Over the intervening decade, the analysts at DAI Palliative Care Group have been gathering a few more insights. 

To name a few:

• Palliative care specialists within these communities recognize life’s completion can present serious financial challenges. Their competencies "extend" into resourceful coordination of reimbursement so that access to care is not limited by unaffordable services.
• Palliative care leadership in these communities believe in "positive dissatisfaction, that is, they always strive to do better.  They are insistent upon measuring quality, closely monitoring outcomes, implementing improvements, and tracking patient and family satisfaction. 
• These community exemplars commit themselves to the three As of access: affordability, availability, and awareness.  

We'll explore these communities, and practices, in more detail in future posts. In the meantime, your thoughts and reactions are appreciated.

Improving Late-Life Care - Do We Know Exemplary Performance?

We're starting to learn more about late-life care, thanks in large measure to the Dartmouth Atlas Project.

For example, in a recent report  Trends and Variation in End-of-Life Care for Medicare Beneficiaries
with Severe Chronic Illness (read here),  we learned more about the final 30 days of life of a patient with cancer. More than half (54.7%) were hospitalized during that period. 5.6% received life-sustaining procedures. Half of the final month was spent in hospice (11 days) and an acute-care hospital bed (4 days). Interesting, but without context. Likely, the past 10 years has seen considerable improvement in these measures. How much more improvement should we expect? Can hospitalizations be cut in half? If so, what might be the most effective methods? A transitional care document , like POLST? A provider reimbursement structure where collaboration, rather than procedures, is more highly valued? A community palliative care officer who's accountable  for late-life care across settings within a specific community or region? Any of these, or all of them?

And how much better can the health care system do to encourage earlier referral to palliative services, so that greater than 11 days out of the final 30 can be spent under hospice care?  As always, your ideas and opinions are invited.

The Power of Palliative Care - Has Potential Turned Into Accomplishment?

Using publicly available data, such as the Dartmouth Atlas, annual NHPCO Facts and Figures reports, and MedPacDataBooks, the DAI Palliative Care Group  has been preparing late-life care performance profiles for our clients and selected audiences. See here, here, and here for previous blog posts on this subject.

These performance profiles have been measuring and tracking the performance of communities, hospitals, and states, using key indicators of palliative care,  since the early 2000s. By identifying exemplary performers, our reports have inspired individual and institutional providers, collaboratives, as well as entire communities, to aim higher, thus  strengthening the power of timely palliative care interventions  to improve late-life care in the United States.  Our analysts have recently produced another report  which tracks outcomes over time for  a set of key indicators.

Several highlights of the report:

-fewer Americans are dying in the hospital.  In 2007, 31.7% of  US deaths occurred in a hospital. The high-performance benchmark , that is, 10% of communities across the nation achieved this performance level, was 22.5% for that year.  In 2017, 20.1% of deaths occurred in a hospital. So, over the span of a decade, the nation's performance moved from average to high-performing.  How much more potential for improvement is there?  The cities of Sarasota, Fla. and Asheville, N.C., which were high-performers in 2007, are now at 14.2 and 14.1% respectively.

-Americans spend less time in a hospital during last six months of life.  An American who died in 2007 spent almost 13 days in a hospital during the last six months of life. In exemplar communities, that figure of days in hospital was almost 30% less (9 days).  Ten years later (2017), the national figure had dropped to 8.1.  Once again, a significant improvement.

-fewer Americans in 2017 were admitted to intensive care (14.7%) during their last six months of life than 10 years earlier (19.2%). Again, impressive improvement.

Undoubtedly, many factors contribute to these improvements. Surely, one factor has to be the greater accessibility to timely, high-quality palliative care.

I'm interested in your thoughts.