Is hospice on the down swing?

[Nash3222]

Been a hospice nurse for over 8 years, have done it all. HC, INPT, admissions.

1. seems like hospice's were popping up on every street corner for a while there.

2. Where i work , Census is down and has been slowing moving in that direction for over a year.

Stats show that the WW 2 generation is almost all gone and stats predict that the next big wave of hospice patients wont hit until the now baby boomers start to get up in age, that will be in another 10- 20 years or so.

My question is how is your hospice doing? How is your census? Have you noticed census fluctuating more and in the downward direction?

I want to move to another state and stay in hospice, my concerns are the job prospects for hospice over the next 10 years or so.

what do you think?

[Libby1987]

All are valid points, if more people understood what hospice is all about, they would use the service. But the uninformed think along the lines of hospice : " stops all meds, does not feed them, over medicates them, then they die".

We really do provide a much needed service.

As a career HH nurse I was mortified to have my dad die in the hospital. He went in on a Tues with sepsis and couldn't be transferred home. He was gone in the morning. His hospice admission appt was scheduled for Friday. He wasn't receiving any cancer tx (CLL) but Mom and Dad just struggled with the idea of hospice. They almost made it but 3 days too late. I've seen it play out in HH a number of times and have been a Hospice pusher for years. If I can just get you guys in the door as an informational visit they'll accept admission almost everytime.

[Nash3222]

Libbey, Sorry to hear about your Father.

Yep and Yep, I always stress to people that it is better to come on hospice sooner rather than later. My mother was on our hospice, she did not want to come on , "why do i need hospice" she had advanced cancer with mets. She lasted about 3 months on the program, very symptomatic in the end, but we had the meds needed in the house and I got her calmed down for a peaceful transition.

As Hospice nurses we see it, we know what is needed, but many are just scared of the word hospice.

[Red Kryptonite]

Hospice does not provide 24 hour care.

This isn't true for all. The one I work for has its own inpatient units, used for short term stays for symptom management. However, once the patient is no longer "GIP-able" the families have the option to private pay for their loved one to stay with us, and our rate is less than most other facilities. We also have a private duty program where families can pay for anything from a 2 hour tuck in visit, to several-hour blocks during work, to 24 hour care from a CNA or nurse. Of course these services are only available to those who can pay for them.....which I really hate but we have to get paid somehow and we do provide charity care (in a unit) in cases of real need.

I realize my hospice is one of very few, or maybe the only one, doing such things. Especially the private duty was started in response to years of requests and as a revenue-generator for our struggling nonprofit. The inpatient private pay really doesn't make any money, I'm not sure we even break even on it.

Also, while I know continuous care reimbursed by Medicare has become nearly non-existent, I think there are still a few ways to justify it, but it's gotten much, much harder.

[Red Kryptonite]

He wasn't receiving any cancer tx (CLL) but Mom and Dad just struggled with the idea of hospice. They almost made it but 3 days too late.

Sorry.

Just because we're involved in the field doesn't necessarily mean our families become more easily able to accept mortality. I too find it sad how many people come in last minute, when we could have done so much to improve their quality of life for months.

[Nash3222]

Red Kryptonite

Yes we have INPT where I work as well and the whole medicare thing is changing hospice care--not for the better I fear. We really don't have CHC any more, just recently eliminated that.

What you said about your hospice's private duty program, that is a good idea!! There is a huge need for that, any idea what is charged for that?

Thanks

[RN_SummerSeas, MSN, APRN, NP]

There can be 24 hour care in hospice, it depends on many things. I worked in a SNF as a staff nurse and a hospice nurse. Where I live there are so many SNF's and sadly there are few I would put a loved one in. I am sure it has to do with staffing, pay, reimbursement etc. but still that is just me. I care for plenty of people who die at home, it depends on your views of it. As a society Americans are far different from other countries, I have worked with so many people from other countries where dying at home is normal, generations of families living together and caring for one another is normal. For many other societies/countries/etc. sending older adults away to a home is inconceivable. For some it is unsafe to be at home, for some unrealistic, and others yet not possible and there are people who don't want to be home for whatever personal reason. I enjoy caring for my patients in their homes, teaching their loved ones or personal CG about hospice care.

To answer the question I don't think hospice is on a downward trend, I agree that areas of healthcare go up and down. Where I live there is an extremely large number of seniors and that rate will keep growing. I do not think the majority of WWII aged adults are gone, I often see my pt born between 1915-1930, the ones who are younger are usually ca pt and that is heartbreaking. I think the medical field still needs a great deal of education on hospice and EOL care in general. Many people fear hospice and view it as negative (research studies show) and if that can be dispelled it will make a huge difference.

[CapeCodMermaid, RN]

Anything is available for a price but most of the people I know who are on Hospice at the SNF are there because their families couldn't possibly afford 24 hour care at home.

[RN_SummerSeas, MSN, APRN, NP]

There is a double standard with this, however. Unless one qualifies for Masshealth their bed must be paid for by the family which is also a great cost. I have seen families struggle with the decision of whether to keep a loved one home with caregivers 24/7 or pay out of pocket for a SNF bed. Many times family members will step up to the plate and help provide care, it is a hard choice and either way is very costly. Mass health is not quite as easy to qualify for as one may think, unfortunately. In the end it really is a personal decision where ones EOL care is given, disease process and prognosis as well as affordability.

While most of my pt at my old organization, a for profit hospice, were in SNF's, on Masshealth, without family, and Dx was ES dementia, the new organization is far different as a non-profit and the majority of pt are home, with family, and many have Ca Dx with a short prognosis. It is a very different experience. The few I have seen in SNF's are there because they were not safe to be home and usually have a CHF or COPD Dx, some also combined with dementia.

There are so many variable to each situation, whatever works out best for each family, where ever they call home is where they get care. I personally prefer to provide care in a home or ALF as I have found SNF's very difficult to work with. Whether it is the MD's beliefs and reluctance to use hospice, the minimal staffing causing the inability to provide PRN and scheduled meds frequently at EOL, territorial nurses who would rather cause strife than accept help or any other number of issues that tend to arise in this situation, I am happy to not have to be put in the middle any more. I think hospice in SNF's is going to decrease with CMS regs anyway, in house hospice care/staff may be the way to go, some already have that in place.

It is sad that so few SNF's are well staffed with happy workers, I have seen some, sadly very few. I have worked in a SNF as a staff nurse and it was the most awful experience that I would not wish on my worst enemy! It really takes great leadership, appropriate staffing, caring managers nurturing caring staff to make a SNF really work the way they should. I hope in the future we see more of this as many seniors will have to rely on SNF's, it would be nice to have them be in a place where positivity, creativity and unity thrives.

Anything is available for a price but most of the people I know who are on Hospice at the SNF are there because their families couldn't possibly afford 24 hour care at home.

[toomuchbaloney]

Sometimes there just are not SNF options for families, that is true in AK. Additionally, many SNF facilities are not affordable for many people. Paying for a bed or for hourly care is just not an option for many many American families.

[TammyG]

My hospice saw a downflux in census over the last two years, largely due to the increase in live discharge as required by the additional CMS scrutiny. However, at the same time, hospice is becoming more widely accepted every year, and the number of individuals over 65 will continue to increase every year. In addition, many minority ethnic groups where hospice has been underrepresented (Hispanic, African-American) are becoming more welcoming of hospice. I do think that the start up costs of opening a new hospice are extraordinary, just too much technical compliance and very little profit margin. But I think the health of the field over all is good. In addition, there are several CMS demonstration projects either active or in the works regarding extending and expanding hospice eligibility.

[CapeCodMermaid, RN]

We have contracts with several different hospice providers. It is the family's choice which hospice they use and despite the regulations, there is a difference in the quality of services they provide. Each group interprets the guidelines/regs in a different manner especially when it concerns putting someone on GIP when they are in a facility. My staff is certainly more than capable of providing end of life care, but it's a benefit to the resident and family when we get hospice involved. It shouldn't come down to money but it often does. We usually won't take someone off skilled Med A to put them on hospice unless they have Mass Health as a back up.

[makeitwork, BSN, RN]

So true RK. I do case management and admissions. The biggest complaint we get is that families (or MD's, but, that's another topic) wait too long to get their loved one on service. If a patient/family is on the fence about hospice, I sometimes mention that fact to them. Many then ask friends or relatives that have had hospice in their lives about this and they confirm the need for sooner rather than later.