On the 10th anniversary of the organization of the American Academy of Hospice and Palliative Medicine (AAHPM): the first 10 years

The American Academy of Hospice and Palliative Medicine (originally chartered as the Academy of Hospice Physicians in 1988) is an organization of physicians devoted to advancing hospice and palliative medicine in the United States. The academy's mission is "physicians dedicated to promoting quality hospice care for the terminally ill through medical education, research, and training." The academy obtained specialty recognition from the AMA in 1996 and became the first physicians' group to publish its position on physician-assisted suicide in 1991 and again in 1997.     

Effectively training the hospice and palliative medicine physician workforce for improved end-of-life health care in the United States

The widening gap between the demand for palliative care services and the supply of trained palliative care professionals has resulted in considerable end-of-life distress for patients. Without formal training in palliative medicine and end-of-life symptom management, physicians in the United States are less equipped to competently address seriously ill and dying patients' medical, emotional, and spiritual needs. Recent attempts within graduate medical education training deliberately seek to prepare a critical mass of physicians as the new hospice and palliative medicine workforce in the United States. In addition, healthcare reform proposals may re-define the National Health Service Corps (NHSC) post-graduate training over the next five years and the Hospice Medicare Benefit altogether. Healthcare policy options include steady changes at multiple levels of medical training -namely, medical school curriculum mandates, requiring all graduate physician residency training to foster patient-centered communication skills and discussions about advanced directives, and instituting palliative medicine proficiency Continuing Medical Education (CME) requirements for all states' medical licensing boards. Attracting qualified physicians to serve patients at the end of life, innovative medical school loan repayment programs and scholarships will also foster excellence in the field of hospice and palliative medicine. Correcting our current paucity of formal training in palliative medicine better utilizes hospice and restores patients' dignity at the end of life.     

Palliative care and hospice: one approach

The establishment of the first department of pain medicine and palliative care in a medical center in the United States is a significant marker in the development and impact of the palliative care movement. The integration of Jacob Perlow Hospice into this department is a milestone in the continued evolution of the hospice movement in the United States, and suggests that an interrelationship and interdependence between palliative care and hospice is one of the characteristics of change for the future.     

Introducing hospice into allied health curricula: a challenge for educators

Including hospice, as a concept of care, into existing allied health curricula is very important. Hospice should be integrated into the curricula of allied health programs. In addition to offering courses on hospice care, there are many novel ideas for exposing students to aspects of hospice care including grand rounds, self-instruction packets, journal clubs, honors program presentations, monthly forums, and clerkships. Federal funding is important to support and develop hospice training as well as other resources.     

Management strategies for palliative care: promoting quality, growth and opportunity

Over 20 years ago, hospice in the United States evolved to provide end-of-life care for terminally ill patients. However, three major barriers exist, which limit access to hospice care. The first two, cultural and regulatory barriers, are not under the direct control of hospices, although programs can be adapted to minimize their influence. The third, management focus, is controlled by hospice programs and has the greatest influence on access to care and quality of care. Under the influence of the Medicare Hospice Benefit and the peer pressure of managed care, many hospice programs use reimbursability as at least one criterion for determination of coverage of services. The fear is that limited reimbursement will cause some services and therapies to bring the programs to financial ruin. This case study shows the outcome of changing management focus away from restrictive policies about therapies and patient selection toward management of productivity and working capital. Some programs have contributed to growth and stability; the revenue thus produced has supported the new innovations. San Diego Hospice is now growing more than 30 percent per year in spite of competition and a fairly flat death rate in the community. This growth is attributed to finding and meeting unmet needs and making all decisions based on the right thing to do. Every staff member understands and supports the mission. The many programs within the agency contribute to fulfillment of the goal to transform end-of-life care. They are presented here as an example of what can be done with mission-based management.     

The development of a hospice junior volunteer program

In the United States, volunteer services are mandated by hospice Medicare guidelines; volunteers provide a very valuable service to patients, families, and other members of the interdisciplinary team. A hospice junior volunteer program can engage teens in the care of the dying in our communities. This article describes the development and implementation of a junior volunteer program at St. Thomas Hospice in Hinsdale, Illinois.     

What does hospice cost?

This paper presents the preliminary results of the economic analyses of the National Hospice Study (NHS), mandated by the United States Congress to investigate the implications of including hospice services in Medicare. Data were collected over an 18-month period from approximately 4,000 patients receiving hospice and conventional terminal care in 25 hospices and 12 conventional care sites. Subsequent analysis may lead to changes in the specific results, and some of the differences may be due to confounding variables that cannot be adjusted for. According to these data, hospital based (HB) hospice costs per day are 44 per cent higher than home care (HC) hospice costs per day ($95 versus $66, respectively). In addition, per patient hospice costs are 24 per cent more for patients enrolled in HB than in HC hospices ($5,890 versus $4,758, respectively). The proportional difference between HB and HC in cost per patient is smaller than the cost per day difference due to the shorter average HB length of stay, 62.3 days compared to 72.5 days for HC. Regarding the cost savings of hospice compared to conventional care, HC hospice costs are lower than conventional care costs regardless of length of stay. However, HB costs seem lower than conventional care costs only for patients with lengths of stay less than two months. Hospice and conventional care patients appear to differ with respect to predisposition toward intensive health care utilization. When this difference is explored more thoroughly in subsequent analyses, the estimated cost differential between hospice and conventional care may change.     

Barriers to hospice for children as perceived by hospice organizations in North Carolina

Despite improving organization of hospice for children with life-limiting illnesses, services may be underutilized. We asked representatives of all 76 existing North Carolina hospice organizations about barriers to serving children. Representatives of 61 agencies responded (80%). Hospices serving children differed from hospices not serving children on perception of barriers: 1) Lack of pediatric trained staff (8% vs 42%, p = 0.01); 2) lack of pediatrician consultation (23% vs 50%, p = 0.03); 3) lack of pediatric pharmacy (4% vs 32%, p = 0.006), and inconsistent plan of care between pediatrician and hospice (12% vs 47%, p = 0.01). Lack of pediatric referrals (78%) and families wanting to continue curative therapies while receiving hospice care (77%) were felt to be the most important barriers overall. Enhanced training of pediatric providers and a model of care which blends disease-specific treatment with hospice may improve access to hospice services for children.     

A community-wide volunteer-intensive hospice program.

Hospice of Frederick County has developed a volunteer-intensive community-model hospice program that is in many ways different from hospice programs that see themselves as a new specialty within the health care system. The intention of the program is to keep the patient and family in control of decisions and to work closely with existing health care providers selected by the family. Hospice of Frederick County believes hospice care is far more than professional health care. "The Board of Directors believes that hospice is a community concern. The compassion and caring which characterizes hospice belongs in the churches, neighborhoods, schools, workplace, service clubs...in all areas of community life. Hospice volunteers are people from the community who care so much that they are willing to receive special training and supervision to be friends to the dying, their families and their loved ones".     

Practical recommendations for ethnically and racially sensitive hospice services

Hospice providers have long understood that hospice services are disproportionately utilized by Caucasians compared with racial and ethnic minorities. In fact, it is clear that this disparity is increasing with time despite the development of literature that recommends making services more culturally sensitive and accessible to minority groups. This suggests a need for more concrete and practical recommendations to make hospice services accessible and amenable to minority groups. For implementation in hospice service organizations, standard recommendations require enhancement to increase outreach, improve understanding of cultural issues related to death and dying, improve communication with non-English speaking populations, and implement cross-cultural training programs. In addition, the self-awareness and ethnic identity of hospice workers themselves are elements of culturally sensitive care that frequently are overlooked when discussing hospice organizations. This article outlines some specific objectives for meeting the goal of improving hospice services for ethnic and racial minorities.     

Evaluation of a hospice program: effects on terminally ill patients and their families

Hospice care in the United States has grown rapidly since its introduction here from England in the mid-1970s. Surprisingly little evaluation of services has been made public, particularly with regard not merely to demographics but also the actual effect of hospice caregiving on patients and families. This article describes an attempt to identify the life dimensions that hospice addresses and the levels of discomfort or well-being of patients and families achieved in a hospice home care program. After assessing the changes in medical, psychosocial, and spiritual status for each of a group of hospice home care patients, the trend toward greater wellbeing of patients in the program can be delineated.     

An exploratory investigation of hospice marketing: How are palliative care providers marketing their services?

ABSTRACT

Hospice and palliative care is a recent, but fast growing, industry in healthcare. Demographics suggest that hospice care will only increase. The purpose of this article is to examine strategic marketing initiatives hospice organizations currently employ. Data were collected at a hospice regional conference, capturing opinions from hospice organizations located in North and South Carolina. The results show that many hospice organizations do not have a dedicated marketing staff person, have a limited marketing budget, do not fully utilize all strategic planning tools, and have yet to differentiate themselves via branding. Implications of these findings for hospice providers are discussed.     

The U.S. hospice movement: issues in development.

A grass-roots hospice care movement is underway in the United States modeled after recently popularized British hospice programs. Hospice care is intended to help the terminally ill maintain a personally acceptable quality of life until death. Attention should be given to ensuring the future viability of this service option by allowing for experimentation with and adaptation of existing models, and by integrating it with the overall health care system. Issues to be considered in integrating hospice care include utilization of existing resources, regional planning, standards and licensure, and reimbursement opportunities. Although hospice care may not have an immediate cost savings impact on the health care system, it could develop this capacity in the future. Such impact would not only assure a stable financial base for hospice care but would also affect bed use generally. Continuing dialogue among providers, consumers, and policy makers of various backgrounds is necessary to the effective and appropriate development of hospice care in the U.S.     

Characteristics of patients receiving hospice care at home versus in nursing homes: results from the National Home and Hospice Care Survey and the National Nursing Home Survey

This study examined 1170 deceased home hospice patients from the 1998 National Home and Hospice Care Survey and 617 deceased nursing home hospice patients from the 1997 and 1999 National Nursing Home Surveys. T tests and Bonferroni adjustments for multiple comparisons were performed to assess differences in characteristics of patients receiving hospice care at home versus in nursing homes. We found that the nursing home hospice population differs significantly from the home hospice population in the United States. Nursing home hospice patients were more likely to be older, have Medicaid as their primary payment source, have dementia and other noncancer primary diagnosis, and receive dietary/nutrition service, medication management, and physician services than home hospice patients.     

The benefits and difficulties of academic collaboration

People working in academia and in hospice organizations can help each other succeed while serving the needs of the people in hospice care. This is especially important in times of tight budgets for all concerned. Hospice organizations would benefit from educating themselves about research and participating as partners in research activities. Collaborating researchers must be willing to discuss their research with members of hospice organizations and explain how it is to be structured, conducted, and how it can improve services. Researchers can make scientific investigation and its findings more user-friendly and understandable. The hospice organization can set up forums that promote dialogue between hospice professionals and researchers at meetings, conferences, and symposia that will benefit the academic group, hospice organization, and, ultimately, people in hospice care.     

“How Dare You Question What I Use to Treat This Patient?”: Student Pharmacists’ Reflections on the Challenges of Communicating Recommendations to Physicians in Interdisciplinary Health Care Settings

A growing number of pharmacists practice within interdisciplinary health care teams, leading pharmacy educators to place increased emphasis on the development of interprofessional collaboration skills. In the pharmacist–physician relationship, pharmacists’ medication therapy recommendations (MTRs) are a recurrent and significant interprofessional activity, one that can be challenging for both seasoned and student pharmacists. Drawing on in-depth ethnographic interviews with pharmacy preceptors and advanced student pharmacists, we identify and describe an important distinction between pharmacist-initiated MTRs and physician-initiated MTRs as contexts for interprofessional collaboration. We describe and illustrate a range of social, professional, and communication challenges that students experience in each context, as well as some strategies they use to navigate these challenges. Using the theoretical framework of dialectic tensions, we argue that the pharmacist–physician relationship is characterized by a tension between assertiveness and deference. We also offer recommendations to pharmacy preceptors, who can use this article to enhance the experiential education of pharmacists.     

Hospice Care: What Services Do Patients and Their Families Receive?

OBJECTIVE: To determine the degree to which patients and families enrolled with hospice received services across key categories of palliative care, the extent of hospice-level variability in services delivered, and changes over time in services delivered. DATA SOURCE: Nationally representative sample of 9,409 discharged patients from 2,066 hospices in the National Home and Hospice Care Survey. STUDY DESIGN: Observational, cross-sectional study conducted from 1992 to 2000. The primary outcome is the receipt of services across five key categories of palliative care: nursing care, physician care, medication management, psychosocial care, and caregiver support. DATA COLLECTION: Data were obtained via interview with the hospice staff member most familiar with the patient's care, in conjunction with medical record review. PRINCIPLE FINDINGS: In 2000, 22 percent of patients enrolled with hospice received services across five key categories of palliative care. There was marked variation across hospices in service delivery. One-third of hospices provided patients and families services in one or two of the five key categories of palliative care, whereas 14 percent of hospices provided services across five key categories of palliative care. In multivariable analysis, the odds of receiving any additional hospice service was significantly greater in later compared with earlier years (odds ratio=1.10, 95 percent confidence interval 1.01-1.20). Nevertheless, the percentages of patients in 2000 receiving medication management (59 percent), respite care (7 percent), and physician services (30 percent) remained low. CONCLUSIONS: Hospice care for patients and families varies substantially across hospices. Whereas some hospices provide services across the key categories of palliative care, other hospices do not provide this breadth of services. Greater understanding of the causes of variation in service delivery as well as its impact on patient and family outcomes and satisfaction with end-of-life care is a critical subject for future research. Changes in Medicare's reimbursement policies may help hospices increase the range of services provided to patients and families.     

A syllabus for fellowship education in palliative medicine

Recent years have seen significant growth in palliative medicine training programs and positions. There are plans to pursue palliative medicine specialty status with the American Board of Medical Specialties and accreditation of fellowship programs with the American College of Graduate Medical Education. A work group of program directors, supported initially by the Cleveland Clinic and then by the American Board of Hospice and Palliative Medicine, has recently published standards for fellowship training. Despite this, fundamental questions remain about defining the field and delineating the knowledge and skills expected following completion of specialty training. In this article, we describe the first fellowship program in palliative medicine (PMP) in the United States, developed and supported by the Cleveland Clinic Foundation. The program has been implemented as part of the Harry R. Horvitz Center for Palliative Medicine, founded in 1987 as the first comprehensive integrated US program in this field. This training program, in existence since 1989, features a traditional rotational structure with an inpatient primary care service, inpatient consult services, and an outpatient consult/hospice service. This article outlines the syllabus developed for this fellowship, given what we believe to be the essential knowledge base for the field of palliative medicine.