By Joseph Shega, MD
For a person living with advanced illness, repeated hospitalizations often signal more than a change in medical condition: needs may have evolved, priorities shifted or more support is needed.
Yet conversations about hospital readmissions frequently focus on metrics, penalties and utilization. Equally important is whether the care plan still reflects the patient and family’s priorities. For caregivers, those moments bring difficult questions: What happens next? How will symptoms be managed? What support will be available at home? Those questions deserve a place in every conversation about reducing readmissions and length of stay.
Since the Hospital Readmission Reduction Program started in 2012, health systems have faced financial penalties for patients readmitted within 30 days for heart failure, pneumonia, COPD and other conditions.
While readmissions are often seen in terms of quality and cost, they can also signal that a patient’s needs, goals or support system are changing.
For patients nearing the end of life, recognizing those signals creates an opportunity to revisit goals of care, evaluate available support and consider whether the current care plan reflects the priorities of the patient and family.
Less frequently discussed is the prevalence of readmissions among patients with advanced illness and the role of hospice and other supportive services in helping care plans with patient goals and needs.
The Data Behind the Readmission Numbers
In a 2015 analysis of Medicare claims, patients enrolled in hospice were readmitted to the hospital within 30 days at a rate of 2.2 percent, compared with 18.8 percent among those not enrolled. Research published in Health Affairs found an association between hospice enrollment and lower rates of inpatient death, ICU utilization and hospital readmissions. In that analysis, hospice enrollment was associated with approximately 60% fewer inpatient deaths, 80% fewer ICU admissions and nearly 90% fewer hospital readmissions, with the greatest differences among patients with longer hospice stays.
One Patient’s Path
I think of a patient I discussed recently: a woman in her mid-70s with advanced heart failure, admitted to the hospital three times in six months. Each stay was followed by a skilled nursing stay, then home health, then another crisis. Home health is a strong restorative benefit, but it is not built for a patient whose course is declining rather than improving. When she finally chose hospice, her team managed her symptoms at home instead of sending her back to the hospital. She lived roughly five more months, mostly at home, before she died.
Quality of Life, Not Length of Life
None of this means hospice extends or shortens life. What changes is where and how patients spend the time they have. A study from University of Iowa found 84 percent of patients who died in the hospital had been admitted at least once in the prior six months, yet only 23 percent had a documented conversation about hospice before death.
For patients living with advanced illness, repeated hospitalizations should prompt us to ask whether the care plan still reflects their needs and priorities:
• What matters most to the patient?
• What worries the family?
• What support will they need at home?
When hospice is appropriate and consistent with the patient’s wishes, it offers care focused on comfort, symptom management and caregiver support helping families make informed decisions.
Starting conversations early, coordinating care and preparing caregivers for symptom changes can help reduce hospital visits and give patients and families confidence in the care ahead.
Getting the Timing Right
For clinicians, the practical takeaway is timing. Hospital readmission is a useful trigger for a palliative consult. The same is true for a home health patient who continues to decline despite therapy. Those moments call for revisiting goals of care before the next admission.
Earlier hospice access doesn’t mean withdrawing treatment: heart failure therapy and defibrillators can continue when they serve a patient’s goals.
As health systems navigate an aging population and growing accountability for outcomes, readmissions, and total cost of care, hospice deserves to be understood as a quality strategy, not a benefit reserved for the final days of life. That reframing — more than any single intervention — is worth carrying into the next conversation about a patient who keeps coming back.
Learn more about how hospice supports patients with advanced illness and refer patients to VITAS by calling (800) 938-7827 or visiting VITAS.com/Refer, available anytime 24/7/365. Download the VITAS mobile app for seamless, one-touch referrals by patient facesheet.
Dr. Joseph Shega is executive vice president and chief medical officer at VITAS® Healthcare.
