OASIS Alert

Don't avoid the difficult hospice conversation.

Improve outcomes--and provide better patient care--by focusing on your agency's hospice referral process.

Home health agencies will need to concentrate on improving unplanned hospitalizations. The Centers for Medicare & Medicaid Services has selected improving this quality measure as a national focus for HHAs beginning in Aug. 2005 (see related story, later in this issue).

Heads up: Home health patients with a life expectancy of less than six months may be one important factor in unplanned hospitalizations. These patients showed unscheduled hospitalization rates of more than 30 percent, according to data collected by Seattle-based Outcome Concept Systems for the first quarter of 2005.

In contrast, hospice patients--who must have a similar six months or less life expectancy to be eligible for the Medicare hospice benefit--were unexpectedly hospitalized only about 6 percent of the time, reported OCS' Melinda Moore speaking on Oct. 24 at the National Association for Home Care & Hospice's 24th annual meeting in Seattle.

For the first quarter of 2005, Moore looked at three OASIS questions--M0280, M0270 and M0260--all of which address the clinician's assessment of either the patient's prognosis or life expectancy.

11 Percent of Home Health Patients May Qualify for Hospice

M0280 (Life expectancy) is one OASIS question HHAs could use to screen for patients for whom hospice care might be the best option. The national average for home health patients showed 11 percent with a life expectancy of six months or less--"1" on M0280, Moore reported. For patients whose primary diagnosis was a neoplasm, 34 percent scored "1".

In other relevant questions, OCS' analysis of M0270 (Rehabilitative prognosis) showed that, nationally, 25 percent of patients had a "0" or guarded prognosis, and 51 percent of those with a neoplasm primary diagnosis scored "0". Nationally, 10 percent of patients scored "0"--poor--on M0260 (Overall prognosis), while 37 percent of patients with a primary diagnosis of neoplasm had a poor prognosis on M0260, Moore said.

Patients with a short life expectancy and poor or guarded prognosis used more skilled nursing and aide services and less therapy service, Moore noted. Patients with a primary diagnosis of neoplasm had an average case mix weight three tenths of a point lower than the general patient average and also were more likely to be suffering from intractable pain and memory loss than other home health patients, Moore explained.

What to do: Although referring some of these patients to hospice might be one way to improve your acute care hospitalization outcome, that would just be a side benefit. The most important reason you should make these referrals is to provide better patient care.  

Home health agencies generally serve some patients who would be better served by hospice, OASIS data demonstrates.

Example 1: For M0420 (Frequency of pain interfering with activity), home health patients with life expectancy of six months or less showed improvement in this item only 54 percent of the time, OCS data showed. Hospice patients, on the other hand, showed 89 percent improvement in pain within 72 hours, Moore reported.

Example 2: Home health patients with life expectancy of six months or less showed a 51 percent improvement in dyspnea--M0490--while hospice patients had a 61 percent improvement in dyspnea, OCS data showed.

Remind Physicians Alzheimer's Disease is a Terminal Illness

If you don't match the services available to the ones the patient needs, you're doing the patient a disservice. Hospices have strengths in pain management, dyspnea management and keeping patients at home that may be important to some patients currently under home health care, Moore pointed out. At the same time, proper placement of terminally ill patients may have a positive effect on your outcomes.

Often, clinicians and physicians have difficulty initiating the conversation about hospice, even though the patient qualifies, experts say. Inviting a hospice staff member to discuss appropriate referrals at a staff meeting or case conference can stimulate clinicians to think about this issue. If patients need more information, hospices can schedule a consultation to explain services, experts advise.

When to refer: Home health agencies can train staff to better recognize when a patient may be an appropriate hospice referral by discussing indications for referrals for patients with various diagnoses, says Lin Simon with the National Hospice & Palliative Care Association. Start with one general question: "Would you be surprised if this patient died within six months?" she suggests. Other characteristics can be specific to a diagnosis.

Example: If your patient has advanced Alzheimer's Disease (AD), watch for progression to the stage where he doesn't recognize family and friends, has unintentional weight loss, doesn't speak intelligibly, can't walk and has bowel and bladder incontinence. These signs correlate with a less than six months life expectancy, Simon explains.

In addition, more than half of patients with pneumonia or hip fractures who also have AD die within six months, she notes. These patients may benefit from hospice's expertise in pain management. And their families will get the more intensive counseling they need at this point, she adds.

Tip: Many physicians don't look at Alzheimer's as a terminal disease and may not think about making a hospice referral unless you suggest it, Simon warns.

Note: For more information about indications that patients may qualify for hospice, go to intermediary Cahaba GBA's Web site at www.iamedicare.com/Provider/policy/L13653.htm.