“Hospice is a very structured benefit," said Jordan. "It provides a very full package of end-of-life services for the patient and their family. Palliative care is a little bit more of a through-composed philosophy that is embedded in hospice care but also finds itself in many different layers of the healthcare ecosystem, even before a patient is ready for hospice. The palliative care view is a philosophy rather than just an explicit payer benefit."

Hospice is a benefit created by CMS initially, focusing on end-of-life care for patients who are not expected to survive past six months. Of note, there's not a strict timeframe on this where people get cut off. The key is that their attending physician does not anticipate they will live longer than six months from the date they are certified or re-certified for hospice services. (Personal note: My father-in-law was appropriately enrolled in hospice services for almost two years – likely because he was the beneficiary of hospice care!)

Jordan reminds us that the hospice benefit includes many services aiding patients and their families. "Everything from the clinical care and the physician care and oversight during that period where they're on hospice, as well as things like durable medical equipment, if they have needs to have a bed in the home, things like that, all the way through bereavement care for their family, even after that patient might have expired. And so, hospice is a full package approach to end-of-life services, end-of-life care." 

There's a palliative component to it. "When you think about palliative care and the definition of palliative," Jordan goes on, "the things come to mind like symptom management, disease education, things like that are all core components and tenets of good quality hospice care. But then at the same time, palliative care often happens well before and should happen well before a patient might be ready and appropriate and admitted to hospice care."

Does the provision of the above services make a difference for patients and families? Subjectively, yes, from my perspective. We've also heard for a long time in the medical literature about the benefits of hospice care in the quality of life for terminal patients. An article in JAMA's January 2024 edition objectively confirmed my palliative care experience based on my N of 4. Dr. Beckelman et al. 1 published a study on palliative care in 306 patients with heart failure, COPD, and interstitial lung disease.

Their findings showed that compared with usual care, participants in the palliative intervention reported significantly improved quality of life on the Functional Assessment of Chronic Illness Therapy–General (FACT-G) measure at six months, plus health status score improvements, decreased depression, and decreased anxiety.

Better experience AND better measures of disease impact on life. Win-win.

The appropriate use of palliative care and hospice benefits is one of VBC's many double bonuses. In addition to improving patient experience, they also both lead to a decreased cost of care through avoidance of acute care spend in the ED and inpatient services.

The best way to be in tune with patient goals and preferences for chronic disease management and end-of-life issues is through Advanced Care Planning, preferably done annually at the Medicare Annual Wellness Visit (Links to ACP articles). This can start the discussion before there's a pressing health matter, getting patients, families, and physicians comfortable with the conversation. 

Once a patient with a late-stage chronic condition who is not imminently terminal moves the conversation to more symptom control, comfort care, and avoiding the ED for disease management, the physician can adjust to a more palliative approach or bring on a palliative care service. They can help direct the care to achieve the patient's stated goals.

As the patient's condition progresses, the palliative services provided can be coupled with the hospice benefit, and hospice care can be initiated in the home. This is usually where primary care is transitioned from the PCP to the Hospice Service. Should symptom control become too much to handle in the home, a patient can be moved to a hospice facility.

I asked Jordan if there was any hesitancy within his organization to use the words "palliative" or "hospice" when discussing the issue with physicians or patients. I've worked with other organizations where these words were considered taboo, and to avoid mindset roadblocks for patients and physicians both, they would switch them into "comfort care" or "chronic condition care" or something similar.

His answer? "We try not to shy away from the term hospice." He pointed out that high-profile hospice patients like former president Jimmy Carter have helped soften the landing of the word on the mainstream's ears.  

He goes on, "We want to help the patient realize it's not an admission of defeat, but really an understanding of where your disease is progressing, what's going to get you the best care to meet your goals, and what's going to help you live the best in the time that you have left. It's so much about the education of what's really behind this type of care. As long as you have an eyes-wide-open approach to your priorities as a patient and your family's priorities, I think it helps make the decision and helps 'undirty' the word of hospice." 

The expert's opinion – you can avoid some of that verbiage fear by laying a good foundation and then putting up the right supports around it.

Think of palliative care in your late- or end-stage chronic disease patients, like those with COPD, HF, ESRD, or chronic neurologic conditions like Alzheimer's, Lewy-Body Disease, and others. Help them understand their condition so they can help you understand their goals and wishes for care. As things progress and needs increase, look to the hospice benefit for additional support.

1 Bekelman, MD, MPH, David B.; William Feser, MS; Brianne Morgan, BSN; Carolyn H. Welsh, MD; Elizabeth C. Parsons, MD; Grady Paden, MD; Anna Baron, PhD; Brack Hattler, MD; Connor McBryde, MD; Andrew Cheng, MD; Allison V. Lange, MD; David H. Au, MD, MS . "Nurse and Social Worker Palliative Telecare Team and Quality of Life in Patients With COPD, Heart Failure, or Interstitial Lung Disease: The ADAPT Randomized Clinical Trial" JAMA. 2024;331(3):212-223. doi:10.1001/jama.2023.24035

One of their tools is a medical respite program, specifically for their adult Medicaid patients, where they partner with Westbay Community Action (https://westbaycap.org). After acute care events (medical and/or mental health), patients are identified as potentially at risk from a housing perspective and assessed as to their appropriateness for a stay in a place that gets them a bed, kitchen, and bathroom. This is augmented with security, breakfast, lunch, dinner, and social service support, including meetings to learn and refine self-care skills. 

They started this intervention in May 2023 with contracting for just three spots from Westbay, and those filled up within 12 hours! They now have six spots to house people with extreme medical and social needs, with all six spots staying full all the time. According to Robert, "You've got to have the ability to have social workers and people in the program that can talk to the patients and help them see that this is an opportunity for them."

The results they're seeing should come as no surprise. "When someone who hasn't had housing and clothing and regular meals gets some structure in their life and is willing to accept this help," Robert says, "the outcomes have been fantastic! We've got folks that are springboarding from this respite, where they've had housing and meals and some job assistance programs to help get them into outpatient behavioral health and substance abuse programs."

The goal is a "medium" stay in respite – 90 to 120 days – but they are not putting time limits on the program. Robert gives an example of a case that shows the importance of no time limit. 

"We had a person with diabetes and a new amputation that was basically going to be discharged from the hospital to the street. This person took a respite bed, and they've been in that bed for over 120 days. They would have been back in the ED and inpatient multiple times during those four months without this support." Robert noted the level of medical care needed in this case, plus a safe and stable environment to regularly take those medications and have regular meals, which have combined to help maintain glycemic control and give needed social support. 

Robert emphasizes that Rhode Island has a wonderful and supportive Medicaid leadership, and they have acknowledged that without food, shelter, or clothing – the basics – it is very difficult to be healthy. This philosophical support helps garner the financial support from the Medicaid payers that Prospect Medical needs to make this program a reality.

While finances are not the primary motivation for assessing and addressing social risks, the process of paying for these programs and services becomes easier to swallow when an organization actively participates in the accountability of the medical premium dollars (aka – risk). The VBC revenue that comes because of the investment in improving health and well-being and improving lives usually more than offsets the expense of providing those services. 

Assess and address – by all means and through great creativity.