Cost savings in hospice: final results of the National Hospice Study.

Medicare inpatient and home care costs over the last year of life of terminal cancer patients served in two types of hospices and in conventional care (CC) were compared as a part of the National Hospice Study (NHS). Both home care (HC) and hospital-based (HB) hospice patients had lower costs in the last month of life than did CC patients. HC patients substituted home care for inpatient care, yielding cost savings for lengths of hospice stay of up to 1 year. Although HB patients added home care to relatively high levels of inpatient care, their ancillary costs per inpatient day were significantly lower than those of CC patients. Thus, HB costs over the last year of life were also somewhat less than those of CC. The size of the savings associated with hospice care is sensitive to the type of hospice and the length of stay distribution of patients served; patients served longer have significantly higher costs in the last year of life.     

Family support for hospice caregivers

This qualitative study investigated family supports for primary caregivers of hospice patients, as perceived by both the primary caregiver and other family members involved in patient care. Family support was conceptualized in terms of (1) who offers support; (2) types of support; (3) frequency of support; (4) family communication; and (5) change in family relationship during the caregiving process. Twenty-four interviews were conducted with 10 primary caregivers and six family members identified by the caregiver as the person they could most call on for help. Interviews were conducted shortly after admission to hospice and approximately two months after the death of the hospice patient. Primary caregivers and other family members involved in care agreed that the primary caregiver provided most care. They also agreed that family members provided instrumental and emotional support, the frequency of assistance was appropriate, and families had grown closer since learning of the terminal illness. There was less agreement regarding family communication during the caregiving process. Implications for interventions with families of hospice patients are discussed.     

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.     

Determinants of hospice utilization among terminally ill geriatric patients

Terminally ill geriatric patients have been found to prefer the type of care provided by home health hospices to the life-sustaining technologies received in hospitals. Nevertheless, disproportionately few dying elderly patients enroll in available hospice programs despite their preferences for, and Medicare's coverage of, hospice services. This study examines several critical factors expected to facilitate or inhibit the utilization of home-based hospice services. Seventy-six critically ill aged patients, their physicians and primary caregivers (e.g., family members) were interviewed about their attitudes and actions regarding the treatment of dying patients. The results indicate that patients who acknowledge their terminal health status, whose physicians disclose the terminal prognosis to them and do not fear malpractice, whose primary caregivers know about hospice and believe the patient would be receptive to enrollment in such a program, have a relatively high probability of home health hospice utilization.     

The cost of home hospice care for terminal patients in Israel

This study examined and compared the cost of care provided to terminal metastatic cancer patients by home hospices and by conventional health services. The study population included 146 patients with metastatic cancer. Half received home hospice services, and the other half received conventional services. The average overall per-patient cost of care was, respectively, $4761 (operating costs included) and $12 434. On average, the costs were lower for older patients. A multiple regression analysis revealed that treatment units per patient, care framework, and patient age significantly contributed to explaining the cost variance. The findings suggest a financial advantage for home hospice care for terminal patients. This should be investigated further, as should the cost of informal caregivers and patient and caregiver satisfaction with the quality of care in both frameworks.     

Health services utilization and costs of care in terminal cancer: implications for hospice programs

This study examines utilization of health services and costs of care for cancer patients during the last 6 months of life broken down into 3 time periods, and the relationship with costs of patient characteristics and home care/home hospice use. The data were derived from a retrospective study of a random sample of 133 adult cancer deaths in Monroe County. Data sources included review of medical records, including hospital billing records, and interviews with physicians and surviving relatives. Sixty five patients (49%) used home care services; their total costs of care were somewhat higher than those of non-users even after controlling for age, marital status and length of the terminal care period. The implications of the upcoming hospice legislation are discussed in the light of these results.     

居家晚期患者临终关怀护理的探讨

目的探讨基层社区卫生服务中心在社区家庭病床对居家晚期患者开展临终关怀服务的可行性及方法。方法回顾性分析61例居家晚期患者的临终护理情况并进行讨论。结果居家晚期患者安详死去者占93%。患者家属满意率为98%。结论本着"以人为本"的原则,对居家晚期患者开展临终关怀护理服务,采用患者亲属参与、医护共同协商治疗护理方案,实施全方位的整体照护具有重大的社会意义。     

Hospice: social work's response to a new form of social caring

Social work's response to hospice, as a new form of social caring, is portrayed by a social work process paradigm, conceptualized from the practice and research experiences of the authors. Guidelines are suggested for working with patients, families, care providers, and other concerned persons through the four phases of hospice care. As changes occur in the patient and the hospice settings, the participants join together to bring about a satisfactory fit between the person needing care and the environment. By anticipating the needs and reactions of the terminally ill patient to each transition in the care process, the social worker assists in orchestrating proactive interventions through the continuum of hospice care. Future research studies are recommended for determining what difference social work actions make toward ensuring a "safe passage."     

An examination of the effect of reimbursement and organizational structure on the allocation of hospice staff time.

The unique needs of the terminally ill patient may require more planning and service coordination than those of the non-terminal patient. The hospice interdisciplinary team was a response to these additional needs. This paper examines the pattern of patient care and administrative activities of paid hospice staff by hospice organizational type and demonstration status in the National Hospice Study. Data gathered over a one year period revealed that demonstration hospices, in which all allowable costs were Medicare reimbursed, spent significantly more time in general and patient related administrative activities than non-demonstration hospices, which operated within existing Medicare cost limits. Staff in demonstration home care-based hospices reported significantly longer home visits than staff in non-demonstration hospices. In both groups, home care-based hospice visits were of longer duration than those home visits conducted by staff of hospital-based hospices.     

Hospice

Social work's response to hospice, as a new form of social caring, is portrayed by a social work process paradigm, conceptualized from the practice and research experiences of the authors. Guidelines are suggested for working with patients, families, care providers, and other concerned persons through the four phases of hospice care. As changes occur in the patient and the hospice settings, the participants join together to bring about a satisfactory fit between the person needing care and the environment. By anticipating the needs and reactions of terminally ill patients to each transition in the care process, the social worker assists in orchestrating proactive interventions through the continuum of hospice care. Future research studies are recommended for determining what difference social work actions make toward ensuring a "safe passage."     

Hospice and health policy

This article gives a review of the hospice concept of care. The importance of caring for the patient and family as one unit for the purpose of addressing needs of each, and the specific needs of the dying patient and of his/her family are discussed. The alleviation of symptoms and control of pain are of primary importance in terminal cases. Throughout the dying process the patient should be treated as a unique individual and his fear of isolation and abandonment must be overcome by the availability of personal attention. Although the patient receives a great deal of attention it is of vital importance to him/her that he/she is just as involved in giving as receiving. The family is both an agency and a recipient of care. It is the task of hospice care to allow the family to go on living. Feelings of anticipatory grief--of which a definition is given--have to be reduced; the most difficult time for the family is however when the patient is very close to death. It is stressed that real exchange of feelings between family and the dying person is of utmost importance for both, and should be encouraged by hospice care. The hospice staff should maintain contact with the family and close friends after the death of their loved one, to allow them ventilation of their feelings.     

Need satisfaction in terminal care settings

Research comparing hospice and conventional programs of care for the terminally ill has identified few measurable differences in the care provided to patients and their families. Nonetheless, hospice recipients frequently express a higher level of satisfaction with their program of care. This study compared the ability of hospice and conventional care settings to meet the basic emotional needs of families during a member's dying and death from cancer. In addition, the relationship of basic needs satisfaction, perceptions about the nurse, and overall satisfaction with the program of care were explored. One hundred bereaved familial care givers completed a mail questionnaire concerning their perceptions of care at the site of a family member's death. The sites were (1) the home, with care provided by a Medicare certified, community-based hospice program: (2) a hospital affiliated with a Medicare certified, community-based hospice program; (3) a hospital with its own hospice program; and (4) a conventional (non-hospice) hospital. Analyses of quantitative data supported two hypotheses about significant differences between hospice and conventional care. The conventional care group demonstrated the lowest levels of basic needs satisfaction, satisfaction with the psycho-social support of the nurse, and overall program satisfaction. As predicted, overall satisfaction with care was consistent across hospice groups. However, home hospice care provided the highest quality of basic needs satisfaction and the highest level of satisfaction with the nurse. Significant Pearson correlations supported the hypothesis that overall satisfaction is negatively related to unmet basic needs (r = -0.69) and positively related to the psycho-social support received from nurses (r = 0.73).(ABSTRACT TRUNCATED AT 250 WORDS)     

Health Services Utilization and Costs of Care in Terminal Cancer:

This study examines utilization of health services and costs of care for cancer patients during the last 6 months of life broken down into 3 time periods, and the relationship with costs of patient characteristics and home-carelhome-hospice use. The data werc derived from a retrospective study of a random samplc of 133 adult cancer deaths in Monroe County. Data sources included revicw of medical records, including hospital billing records, and interviews with physicians and surviving relatives. Sixty-five patients (49%) used home care services; their total costs of care were somewhat higher than those of non-users even after controlling for age, marital status and length of the terminal care period. The implications of the upcoming hospice legislation arc discussed in the light of these results.     

The spirituality of dying. Pastoral care's holistic approach is crucial in hospice

Attention to the spiritual dimension of a person is essential in a holistic approach to hospice care. Although other hospice team members may be involved in matters of faith with patients, chaplains are the primary professionals concerned with the transcendent nature of life and the integrative role that spirituality plays in care for the dying. Understanding spirituality in a person's living and dying requires an understanding of religion and theology. Religion is meant to connect us to a caring community and to give us a place on which to stand--a tradition. Theology is a search for meaning. Spirituality is "the life principle that pervades a person's entire being ... and generates a capacity for transcendent values." The body cannot be touched without the spirit's being affected, and vice versa. Efforts to help patients toward wholeness necessitate helping them accept freely their whole lives. The chaplain is not limited to nor bound by religious language. The needs of the patient should determine the use of prayer or God-talk. Listening is one of the greatest spiritual gifts a chaplain can give a suffering patient. Being a companion is often all the chaplain can do. Pastoral care personnel are also sensitive to the needs of the hospice staff. The chaplain does not so much fulfill a role as represent a perspective based on concern and solicitude for the whole person, the whole family unit, the whole staff.     

恶性肿瘤患者临终关怀护理措施

目的阐述恶性肿瘤患者临终关怀的护理。方法主要从建立良好的社会家庭支持体系、临终患者不同心理反应期的护理对策、临终症状体征护理以及对家属的抚慰等方面,减轻晚期癌症患者的心理压力及躯体不适。结果本组120例患者通过临终关怀护理全组患者在精神和心理上均得到满足、焦虑和恐惧减轻,舒适度增加。结论临终关怀护理能减轻临终患者躯体、精神和心理上的痛苦,增加患者的舒适度,提高临终患者的生活质量,使他们安详、舒适、有尊严地走完人生最后旅程。     

The effect of inpatient hospice units on hospice use post-admission

The objective of this study was to determine whether having a hospice unit within the hospital increases the proportion of terminally ill patients who use hospice services (including home, nursing home, or inpatient hospice) post-admission. Using medical record data abstracted for 232 randomly selected patients with terminal cancer admitted to six community hospitals in Connecticut, we found that patients admitted to a hospital with a hospice unit were more likely to use hospice services (i.e., home hospice, nursing home hospice, or inpatient hospice) post-admission than patients admitted to a hospital without a hospice unit (unadjusted OR 5.7, 95% CI 3.1, 10.6). This effect persisted after adjusting for patient age, gender, marital status, documented discussions of prognosis, prior hospice use, and type of cancer.     

The Effect of Inpatient Hospice Units on Hospice Use Post-Admission

ABSTRACT

The objective of this study was to determine whether having a hospice unit within the hospital increases the proportion of terminally ill patients who use hospice services (including home, nursing home, or inpatient hospice) post-admission. Using medical record data abstracted for 232 randomly selected patients with terminal cancer admitted to six community hospitals in Connecticut, we found that patients admitted to a hospital with a hospice unit were more likely to use hospice services (i.e., home hospice, nursing home hospice, or inpatient hospice) post-admission than patients admitted to a hospital without a hospice unit (unadjusted OR 5.7, 95% CI 3.1, 10.6). This effect persisted after adjusting for patient age, gender, marital status, documented discussions of prognosis, prior hospice use, and type of cancer.     

Anesthesia practitioner involvement, invasive treatments, and need in hospice pain management: a survey of patient care coordinators.

Pain management is one of the major concerns for the terminal patient. The hospice care team is a highly trained group of health care providers in the area of symptom control, including pain management, for the dying patient. Anesthesia providers also specialize in pain control. The purposes of this study were to survey hospice patient care coordinators to gain an understanding of anesthesia practitioners' involvement with hospice patients, hospice patients' access to anesthesia pain management services, and hospice patient care coordinators' attitudes toward the necessity of anesthesia pain management services for the hospice community. A questionnaire was developed to assess these issues. In general, the findings reflected minimal anesthesia practitioner involvement in the hospice community. Fifty-two percent reported that patients could benefit from invasive treatments offered by anesthesia practitioners. Forty percent responded that more patients could be considered as candidates for invasive pain management techniques if procedures were performed in the patient's home or hospice. Access to anesthesia pain management services was limited by distance to pain clinics and anesthesia practitioners, and more anesthesia pain management services were needed for hospice patients in smaller communities. Cost of anesthesia pain management was frequently proposed as a prohibitive factor.     

Terminal patients in Belgian nursing homes: a cost analysis

Policy makers and health care payers are concerned about the costs of treating terminal patients. This study was done to measure the costs of treating terminal patients during the final month of life in a sample of Belgian nursing homes from the health care payer perspective. Also, this study compares the costs of palliative care with those of usual care. This multicenter, retrospective cohort study enrolled terminal patients from a representative sample of nursing homes. Health care costs included fixed nursing home costs, medical fees, pharmacy charges, other charges, and eventual hospitalization costs. Data sources consisted of accountancy and invoice data. The analysis calculated costs per patient during the final month of life at 2007/2008 prices. Nineteen nursing homes participated in the study, generating a total of 181 patients. Total mean nursing home costs amounted to 3,243 € per patient during the final month of life. Total mean nursing home costs per patient of 3,822 € for patients receiving usual care were higher than costs of 2,456 € for patients receiving palliative care (p = 0.068). Higher costs of usual care were driven by higher hospitalization costs (p < 0.001). This study suggests that palliative care models in nursing homes need to be supported because such care models appear to be less expensive than usual care and because such care models are likely to better reflect the needs of terminal patients.     

Support in a time of need. The team approach at Mercy Medical Hospice addresses medical, emotional, and spiritual needs

Mercy Medical Hospice, Daphne, AL, uses an interdisciplinary team approach, which includes medical, nursing, social work, pastoral care, pharmacy, therapies, volunteer, and bereavement services. Mercy Medical has two home care offices and offers inpatient respite care for short periods, which is helpful for those who have an inadequate care giver system or need time to work out a better alternative to care in the home. An assessment of medical and nursing care needs, mental and emotional state, and psychological and spiritual needs is the first step after patients enter hospice. The entire team develops a care plan for the patient and family. Among the issues they address are education about the disease process, medication for pain control and symptom management, and how the patient and family cope with the patient's imminent death. Working with the dying and their families can be stressful for staff members, and they offer each other a lot of support. Working in hospice requires good stress management techniques, but staff feel that it is a calling that enriches their lives.