Your patient, along with others, may be among the 60 percent missing their Medicare provided hospice benefit during their last year of life. Why? 

Most of us have more fear of facing death than we would like to admit. When I realized this for myself, as a practicing oncologist, I was determined to change. It required a new focus. It represented an additional, but small burden for me. Yet, burden and being a burden on their family is the greatest concern that patients face near the end of life. No one wants to become a burden on their family.

Is there a solution from our health care providers? Yes, hospice. With a small effort and direct communication we physicians can provide the key available resource that will empower our patients to plan and manage the most important time in their life, their last year. Hospice data supports the success of this team process in relieving this burden. In fact, hospice patients even live longer.

How is this possible?

It takes a team. Imagine an expert team assisting your office practice. You could think of it as a home based intensive care unit.
This team must be educated, disciplined, and well led. It needs your direction and orders supported by a pharmacist with specific knowledge in pain management. It needs a 24/7 medical director available to respond with orders for managing pain crises and suffering in the last hours of life.

There are times when an on-call partner is not comfortable with intensive home care. You could think of the team as a provider in the same way that you may presently depend on a hospitalist to assist you in the overall care of your patient. The reality of today’s time demands in your practice mean you have the option of being “extended” by a hospice team similar to a physician extender that is specifically focused on the care you want for your patient.

Fortunately, this makes you a member of the team which is not easy for every physician. Some of us have different practice styles and are more accustomed to practicing alone. This presents a challenge when team care is needed. Because we practice in a complex medical world we are always learning and changing in the best interest of our patients.

Who staffs the team? A medical director, primary nurse, social worker, chaplain, bereavement counselor and volunteer all visit the home or facility. Collectively they provide multiple hours of time each week with your patient.

The medical director, nursing director and pharmacist join the team in a weekly two-hour interdisciplinary team. The IDT manages and reviews the patients care. They then make recommendations to you, the primary admitting physician. The medical director is available to evaluate the patient in the home when difficult problems arise. Hospital admission under the hospice or another diagnosis may be recommended.

Any physician involved in their care is eligible for reimbursement under Medicare part B or other third-party provider. Besides acute hospital admission, a more often used alternative is respite care administered under a contract with a nursing home or hospital. All the orders and visits are provided by the hospice team rather than the physician because only the location of the patient has changed.

Respite care gives exhausted primary caretakers a reprieve for five days to rest and replenish. The last alternative leads us to our community goal to build a long over due “hospice house.” This type of facility primarily meets care and symptom management needs in the patient’s last two weeks of life.

Which patients should we be considering? Ask yourself, could this patient be in their last year of life? Next review the patient’s goals of care and order your hospice evaluation. One phone call from your nurse is the “enter” key. This designates you as the “admitting hospice physician” and guarantees your reimbursement.

Medicare has set eligibility criteria. These are assessed on a visit by the admissions nurse. The medical director certifies the information and provides a documentation letter when exceptions occur within the regulations. The mortality risk index (JAMA, June 9, 2004---Vol. 291, No.22) will be applied. You do not have to determine their prognosis or length of life, only that your patient may have a diagnosis that may limit their life expectancy to one year or less. Medicare has assigned the hospice medical director with that responsibility.

Which patients are most often missed? If you observe progressing disease symptoms and signs supported by lab values and note impaired nutrition/function (e.g. 10 percent weight loss in six months, increasing weakness, falls) you then have a comprehensive plan for managing their remaining life.

If their disease process happens to show no signs of progression over the next 90 days, Medicare revokes hospice until they again demonstrate progression of disease. Therefore patients may go on and off hospice service indefinitely.Throughout hospice services you continue to manage their disease treatment in your office if they remain ambulatory. There are now more frail and declining elderly patients than cancer patients on hospice roles in Springfield. So this is how families discover a hospice program that is so highly valued, for quality care and family support they designate memorials to hospice. Many are noted in obituaries each week.

Which type of hospice should the patient choose, profit or non-profit? Nationally 60 percent of hospices are non-profit yet until recently in Springfield it was only two of eight. However, it is most important to simply get hospice started because they provide palliative care services including transfusion and radiation therapy.

Their chaplains are so involved that they are often asked to participate in patients’ funerals. Social workers counsel family and facilitate often needed reconciliation among family members. Bereavement counselors provide follow up care and support groups for family as well as the entire community for as long as needed.  

Personally, I always recommend a non-profit hospice first even though all hospices offer dedicated mission driven professionals. Medicare is currently developing benchmark performance standards based on outcomes and quality of care measures for hospice. Reporting will soon be mandatory and available online.

 An important measure will be the frequent problem of “length of stay” less than seven days. Since effective hospice care requires a stay of at least 21 days to achieve the goals of this valuable service. This brings us back to that small burden of time it takes to identify those patients with advancing disease that may be better supported and cared for in their last year of life.