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Hospice agencies provide more services than agencies mixed with home health
Transition from home health to hospice requires collaboration
With both types of services focused on providing care to patients in their own homes, it makes sense that an agency offer home health and hospice services. In fact, as of January 2007, 21% of hospices were part of an agency that was certified as a hospice and a home health agency.1 But, is an agency that provides both services able to offer all services that a hospice patient needs?
Not necessarily, according to Shayna E. Rich, MA, an MD/PhD candidate and Ann L. Gruber-Baldini, PhD, an associate professor at Maryland School of Medicine in Baltimore. Rich and Gruber-Baldini are co-authors of a study that evaluated the level of hospice services provided in mixed (home health and hospice) and nonmixed (hospice only) agencies.2 A total of 760 Medicare- and/or Medicaid-certified hospice agencies were surveyed, with administrators answering questions about services provided. Study participants represented 393 mixed agencies and 367 nonmixed hospices.
"We expected to find that mixed agencies offered more services because they represented a larger pool of patients, but the data showed the opposite," says Gruber-Baldini. The data show that on average, mixed agencies provided about 19 of the 26 services evaluated by the study, while nonmixed agencies provided about 22 of the services, she points out.
Pastoral care and volunteers were more frequently offered by nonmixed agencies, while skilled nursing care and physical therapy were more common with mixed agencies, says Rich. "Hospices that were not a part of a home health agency tended to offer more complex, focused care for hospice," she says. "Nonmixed agencies seemed to offer more support for the patient and family for the bereavement aspect that is unique to hospice."
Although her agency is hospice-only, Linda Rock, MPH, executive director of Prairie Haven Hospice in Scottsbluff, NE, agrees that a home health agency might not place the same priority on all hospice services that a hospice-only provider does. "We can focus on care that is directly related to end-of-life issues because this is all we do," she explains. "We offer chaplains and volunteers to provide additional support to families, and a mixed agency might not have those resources."
Another area in which nonmixed agencies excel is palliative care, points out Rock. "We have increased our efforts to reach out to home health agencies in our area to offer consultations on pain and symptom management," she says. "By building these relationships, we can educate home health agencies and their patients to the value of hospice while improving the patients' outcomes."
One advantage that a mixed agency has compared to a hospice-only agency is the opportunity to transition a home health patient to hospice care, points out Rock. "The difficulty is that patients don't want to give up their home health nurse, but most home health staff members are not comfortable discussing end-of-life issues," she says.
Education key to successful transition
Even in a mixed agency, it is a challenge to get home health nurses to understand when to refer patients to hospice, admits Kim Kranz, RN, MS, vice president of operations for Home Nursing Agency, an Altoona, PA-based agency that offers home health and hospice services.
"We provide a lot of cross-education sessions for both sides of the agency so that staff members understand the differences in the two services and recognize opportunities to transition patients from one service to another," she reports. "OASIS [Outcome and Assessment Information Set] has made us look at how we do business by asking home health clinicians about the anticipated life expectancy of the patient when we start care." However, even with this question to prompt consideration of hospice, the biggest challenge is the mindset of the home health nurse compared to the hospice nurse, she says. "Death is not an anticipated goal in home health, so nurses don't want to consider that as an outcome for the patient," Kranz explains.
Although education has improved home health referrals to hospice, Kranz' agency is also using software tools to analyze patient information collected in OASIS to identify potential hospice patients, she says. "We have just started using this tool to analyze a patient's activities of daily life and life expectancy to identify patients who might be better served in hospice," Kranz says. The patient's physician is contacted before any discussions with the family, she adds.
Mixed agencies might cross-educate staff members, but it is rare to find a home health nurse who wants to learn to care for hospice patients as well, says Kranz. "There are different regulations for each service, different documentation requirements, and a different focus of care, so it is not practical to expect one staff member to see both types of patients," she says. The exception at Home Nursing Agency is the nurses who work on the night teams in smaller counties, Kranz says. "If there are not enough patients in a county to justify a home health night team and a hospice night team, nurses are hired and trained to provide care for both," she says.
Documentation and regulations don't cause problems for night team nurses because they are handling one crisis event, not developing a plan of care or following the patient through the entire episode, explains Kranz. "Because learning to care for both home health and hospice patients is part of the job description, nurses know when they apply for the position that they will see both," she adds.
While the hospice segment of a mixed agency might be described as a home health agency-based hospice, Mark Murray, president and CEO of The Center for Hospice and Palliative Care in South Bend, IN, describes his agency as a hospice-based home health agency. "Less than 10% of our patients are home health patients, but we keep our home health license current to be able to offer palliative care to patients who might not qualify for hospice," Murray explains. "We have a narrow focus in our home health service. We only accept patients who have a life-limiting illness with a life expectancy of up to one year."
Because his agency focuses on patients who are dealing with end-of-life issues, he offers all of the traditional hospice services, including bereavement and pastoral support to all family members, even if the patient is still a home health patient, says Murray. "This higher level of hospice service is better for patients and their families," he says.
1. Hospice Association of America. Hospice Facts & Statistics. Washington DC; 2008. Accessed at www.nahc.org/facts/hospicefx07.pdf.
2. Rich SE, Gruber-Baldini AL. Differences in services provided by hospices based on home health agency certification status. Med Care 2009; 47:9-14.