Most notable is the hospice's interpretation of the Medicare Hospice Benefit as something fundamentally separate from the menu of hospices services available to patients nearing the end of life.
The Essa Flory Hospice Center, which houses the inpatient and administrative offices of the Hospice of Lancaster County (the Hospice), sits on five acres near Pennsylvania's Route 30. Even before a visitor hears staff muse that "cradle to grave" care is available on the same street, the Hospice's unique location is apparent: the state-of-the-art building is on the same street as a hospital for women and children and a day care center. But its unique setting is not its most pioneering feature. Equally notable is Hospice's interpretation of the Medicare Hospice Benefit as something fundamentally separate from the hospice services available to patients nearing the end of life.
Creating services for the community. The Hospice was built by and for the community. Initially established in 1980 as a home and hospital-based service, home care remains the centerpiece of its work; just 4% of hospice patient days are inpatient. However, recognizing that it was not always possible for very ill patients to remain in the home, the Hospice established Essa Flory Hospice Center.
The inpatient unit reflects the program's philosophy. Its 12 hospice rooms and common areas feel like home. The community donated almost all materials used to build, furnish and decorate the building, whose pioneering design is based on lessons learned during site visits to 24 inpatient facilities nationwide.
Lifting barriers to admission. The Hospice has taken an innovative approach to increasing business while better meeting county residents' needs. All calls are routed to an intake nurse, who frequently arranges an immediate introductory visit to the home or facility. A nurse or social worker conducts the initial assessment, and promptly contacts the patient's physician and other providers, if needed, to avoid delays in the admission process. The success of this approach is reflected in an 86% admission rate for patients for whom initial inquiries are made.
Unlike some programs, which use Medicare hospice benefit eligibility as an admission prerequisite, Hospice staff work with any patient who might benefit from hospice services to determine whether the Medicare benefit is indeed the best option. Although it is the best approach for the vast majority of patients, alternative payment approaches are offered.
The Hospice sets an out-of-pocket payment ceiling based on a patient's household income - but not on assets. Although patients receive an invoice documenting the costs of services received, once the costs have exceeded the ceiling, the patient is no longer accountable for the charges. Joan Harrold, MD, Vice President, Medical Director, explained, "Instead of paying a percentage of fees, patients have a payment ceiling set. This lets patients and families plan for their expenses instead of wondering what the bills could grow to be." Hospice staff note that a number of patients continue to pay their bills even when they are no longer required to do so.
"Weeks or months, not years." Hospice staff consider any patient sick enough to die "in weeks or months, not years" to be appropriate for services, rather than strictly adhering to Medicare's six-month prognosis yardstick. By separating admission and financing processes from the Medicare benefit, the Hospice ensures that more patients who could benefit from hospice services can access them. This approach is clearly working: fully 60% of patients have non-cancer diagnoses. Janet Carroll, MSN, RN, CRNH, Vice President of Clinical Services, noted that staff make clear to patients and families that even if hospice is not the appropriate choice at one time, hospice is always available to help. Carroll added, "This policy has not led to markedly longer lengths of stay, but has led to significantly increased admissions overall."
"We offer care and support to patients and families facing a life expectancy of weeks or months. How they do that-which treatments they pursue-does not change the fact that they can benefit from hospice," said Harrold. Accordingly, patients and families are not excluded if they choose to pursue life-prolonging treatments-chemotherapy, radiation therapy, and other treatments may be included in the plan of care. Harrold said, "Hospice [staff] can then help patients and families get the support they need to manage symptoms, cope with end of life issues, and even make decisions about the benefits and burdens of certain treatments as a condition progresses."
Staffing for patient satisfaction. The Hospice's staffing scheme allows staff to meet patient needs. On the inpatient unit, all evening and night shifts have three RNs and 2 LPNs, who also take 24-hour call and serve as triage staff for home hospice. All nurses are cross-trained to work in either the home or inpatient setting. Two physicians and a full-time social worker also staff the inpatient unit. Four teams of nurses and social workers working within specific geographic areas care for outpatients.
Serving the larger community. The Hospice provides a depth and breadth of community services. A recent month included a teen grief club and retreat; a caregivers support group; volunteer training; and various programs for patients, families, and the general public. Hospice staff keep in touch with area physicians through the Fast Facts Fax service. These "clinical pearls for busy physicians" are regularly distributed to physicians in the service area to inform them about an array of issues, such as introductory hospice visits and the use of opioids.
Looking forward. There are approximately half a million residents in Lancaster County; the Hospice average daily census is 250 patients. Hospice staff realize that despite their high admission rates there is still an unmet need for hospice services. In particular, many more nursing home residents stand to benefit from hospice services. To this end, the Hospice is developing new research and outreach efforts to establish a stronger relationship with area nursing homes. The team is forging new ties to make its presence even more widely known in the community, and to make services more accessible during illness and bereavement, including developing relationships with area funeral homes and various community groups.
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