Recently I wrote an article for family members of patients who could benefit from hospice care and/or palliative care, in which I discussed the factors that physicians must consider in referring hospice or palliative care options to their patients. In this article, I will explore the topic in greater depth, discussing the similarities as well as the differences between the two primary options: hospital-based palliative care and traditional hospice-based palliative care.
Hospital-Based Palliative Care
Hospital-based palliative care comes into play following a patient's hospital admission, and prior to discharge. For example, if the physician orders chemotherapy, it could be administered in the hospital—but not by the hospice—as chemotherapy is considered a therapy (and precludes hospice admission). It is important to remember that hospitals are acute facilities that strive to restore patients to optimum function. Very simply, this means that they focus on therapeutic, rehabilitative measures. When that is not a viable option due to a patient's terminal or life-limiting disease, the hospital-based palliative care team can assist the physician in structuring a plan of care that strives to maximize quality of life while managing pain and symptoms. In this situation, the palliative care team might suggest an early hospice referral, as the patient would be leaving the hospital setting. Generally, while the patient's doctor and the hospital-based palliative care team make the referral, the patient and family also participate in the decision, so that the outcome best benefits and supports the patient's desires.
The physician must be confident the hospital-based palliative care team incorporates holistic care at its very base, including ensuring the patient's physical comfort, providing emotional and psychological support, and supporting shared decision-making. In addition, the patient's physicians should also be confident that the hospital-based palliative care team coordinates the care across different care settings and involves the patient and family as appropriate. A candid prognostic dialogue is paramount, as communication bridges the gap between the patient's needs and the physician’s expertise.
What to Expect from Hospital-Based Palliative Care
The physician should expect the following from the hospital-based palliative care team:
- Evidence-based symptom palliation and psychological support
- Shared decision-making that supports both the patient and the family or caregiver
- Dignity and respect regarding the patient's cultural values
- Practical, financial and legal assistance for patients and families
- Coordination of care across the health care setting that helps patients move from one setting to another (e.g., from hospital to home) in a seamless fashion
The hospital-based palliative care team can work closely with the local hospice agency once patients have completed all therapies and have a prognosis of six months or less. I have found that when working with physicians, patients and families who are considering hospice care in the last months, everyone appreciates a coordinated health care approach, which helps guide the patient to navigate the system, providing appropriate care at each stage. A hospice nurse on the hospital-based palliative team can advise as to when the patient would benefit more from hospice services, and advocate for the patient and his or her family regarding those services.
Hospice-Based Palliative Care
Patients who are not hospitalized or are currently undergoing therapy can still access the expertise of the hospice nurse regarding pain and system management. Many hospices provide limited support to patients who are not yet eligible for hospice care or are not emotionally ready for hospice. These are non-reimbursed services that hospices provide as community outreach. Medicare stipulates all curative measures must be exhausted, and all therapies completed, before patients access hospice care benefits. So an early hospice referral from the hospital-based palliative team for these services can establish, and foster, a caring relationship with the case manager and the patient before any hospice care is actually needed. Establishing this relationship and making an early hospice referral helps alleviate fears on the part of the patient and family, and allows for a rapport to develop should the patient access hospice services at a later date.
How to Choose a Quality Hospice Agency
Physicians who determine it is time for a hospice referral due to patient preference and disease trajectory may wonder how to select a competent hospice organization. Not all hospices are created equal: some are very good, and some are truly excellent. But, like choosing a hospital-based palliative care team, there are guidelines for determining high-quality hospice programs. To begin with, the physician can ask:
- Is the hospice accredited or certified through a national organization?
- Are staff members certified in hospice and palliative care medicine?
- Does each team member use a standardized assessment tool?
- Does each patient have one case manager and social worker assigned to them?
- How does the program monitor and improve its quality of care?
Most hospice agencies are Medicare certified, as Medicare is the primary source of reimbursement for patient hospice care. But if the hospice is Joint Commission Certified, it is held to a higher standard and level of accountability. The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) is an independent governing body that oversees hospitals and nursing homes. By voluntarily participating in this outside review and evaluation process, in addition to the mandated (federal) Medicare and state Department of Health annual reporting, a hospice demonstrates a commitment to quality care, continuous improvement and public accountability for the care and service of terminally ill patients and their families. When a hospice agency has this certification, both physician and patient can rest assured they have chosen a truly excellent hospice whose guiding principles focus on delivering competent, compassionate, and coordinated care.
Palliative Care in the Hospital Vs Hospice Care at Home
Hospice care may be provided in any residential living environment, from a patient's private home to a long-term care facility or hospice house. Following is a brief comparison of what each team offers:
| Hospital-Based Palliative Care Team | Hospice Agency Services | | Patients can be at any stage of illness, from months to years | Patients have a prognosis of 6 months or less and a terminal diagnosis | | Services provided in the hospital | Services provided in home, nursing home, assisted living, or hospice house | | Reimbursed through existing channels | Reimbursed per diem under hospice benefit | | Length of stay varies based on identified needs, therapies involved | Length of stay is 2 months on average; all therapies must have been completed | | No bereavement services | 1 year of bereavement counseling | | Does not use volunteers | Uses volunteers for family team members and bereavement support |
The hospital-based palliative care team offers very important services for the patient, but those services vary from hospital to hospital, and not all hospitals have such teams. Hospice services and team members are the same, however, from hospice agency to hospice agency, as mandated by Medicare. Both hospital-based palliative care teams and hospice agencies strive to provide an interdisciplinary approach to care that takes into account the patient's physical, social, psychological and spiritual well-being. Whether a patient receives care from the hospital-based team or the hospice team, both must strive to provide patient and family-centered competent and compassionate care. This allows for a life closure with dignity and respect—hallmarks of all palliative care.