It has been interesting coming back as an Administrator for a hospice program after a nearly twenty-year absence. During that time, regulatory oversight and medical science has changed as the hospice movement evolved into the hospice industry.I am fortunate to work for Broward Health, a robust public hospital system that serves a diverse community in Southern Florida. It allows Gold Coast Home Health & Hospice to be part of an environment of high-tech, cutting-edge care to a wide variety of people from many walks of life. The biggest challenge we have faced as a hospice provider is maintaining a connection to the movement’s core philosophy of allowing terminally ill patients a comfortable passing that is as pain-free as possible – this among the many messages being given to the vast majority of patients that benefit from aggressive treatment.
During the last twenty years, advances in medical technology and the rise of the informed consumer with limitless access to the internet has led to the expectation of patients/families and sometimes physicians to continue aggressive treatments when there is little evidence of the medical benefits. The cost/benefit ratio of discussing treatment versus quality of life has been tipped in favor of treat aggressively as long as possible.
As a hospice provider, we have the duty to learn and honor the wishes of our patients, including recognizing their decision as to when to cease aggressive treatment and instead choose hospice care. I have witnessed a change in the public’s perception of when that decision should be made, or even appropriate to discuss. After 30-plus years of hospice care in America it is more of a challenge than ever to have patients elect hospice care earlier in their terminal phase. Instead, hospice length of stay slowly grows shorter as patients delay quality of life decisions in favor of extending longer medically aggressive treatment that holds thin promises of cure or extension of life. This leaves hospice as a crisis intervention program rather than an option for planning quality of life and the most comfortable passing possible.
Another issue confronting some hospice providers is what can be described as the emergence of the hospice industry. Many communities, including those within Broward County, find themselves with both locally founded and managed hospice programs running alongside hospice businesses which generate tens of millions of dollars a year in revenue—thus creating a new competition for market share. Quality of service and reputation of a program is overshadowed by families literally shopping hospice programs for the “best deal” offered in terms of promised hours of service. The integrity and dignity of assisting the patient and family to plan for the quality of the patient’s life becomes lost among the offers and counter offers made by competing programs in order to make their admission quotas.
Much in parallel with the growth of the hospice industry has been the need to grow regulatory oversight to help ensure that public dollars being spent on hospice care are being spent appropriately. Along with this important need comes the burden of the agency to be able to meet the regulations. An increasing number of staff hours need to be devoted to non-patient care activities which add to the burden of overhead costs. This, in an atmosphere of falling reimbursements, is a challenge for programs to maintain their focus on patient-centered care and what the Hospice Movement was founded for in the first place: a deep commitment to serving our patients and their families.
Still, as hospice providers we should reflect back during this month devoted to recognizing hospice care across America on the value that remains in the important work we do each day with our patients, their families and caregivers, and our staff.
