Abstract
A
The premise of this article is to identify the cause of hospitalization when associated with disenrollment from hospice. Disenrollment is an imprecise term in this circumstance since there are many reasons a patient may no longer enroll in hospice. The article does not specify whether patients in their study population revoked their hospice benefits or were discharged by the hospice. Under the Medicare benefit, a patient has the right to revoke at any time and for any reason. A hospice has the right to discharge a patient for three reasons, spelled out in regulations. A patient may move out of the hospice's service area, a patient may no longer be terminally ill, or the patient may be discharged for cause. A hospice must have a contract with a hospital or skilled nursing facility to provide General Inpatient (GIP) level of care. It is possible that some of the hospitals in the study were unwilling to provide a contract to the hospice for GIP care, therefore requiring the hospice to discharge the patient in order for inpatient care to be provided in that hospital. However, if the reader does not have this information, it is difficult to interpret or generalize the findings.
This article is not readily generalizable to a broader population for two additional reasons. First, the study evaluated the caregiver perspective of only patients who were disenrolled from hospice after hospitalization, without comparison to patients who required hospitalization but remained in hospice. In fact, it is not known whether the studied hospice cares for any patients in the hospital while keeping them enrolled in hospice. Per Centers for Medicare and Medicaid Services Conditions of Participation, the hospice plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including interventions to manage pain and symptoms, and inpatient care must be available for pain control, symptom management, and respite purposes. It is therefore expected that acute inpatient care will, at times, be a part of the hospice plan of care (although it should be noted that this type of care can be provided in a variety of settings, including hospital, nursing home, or hospice inpatient). While the hospice community generally aims to keep people out of an inpatient setting due to the burden of hospitalization, this preference is patient-specific. Like all palliative interventions, each case should be considered independently. If we perpetuate the idea that people with a terminal condition should never be hospitalized, we may unnecessarily remove hospitalization from the potential options for palliation, although it is sometimes the best way to deliver goal-appropriate care. We need our literature to reflect this so that payment mechanisms will support this uncommon but important need. If the hospice in question discharged all patients who received acute inpatient care, they may not have fulfilled their duty to provide comprehensive symptom management. We cannot be sure of this without data on how many of their patients received GIP level care in an acute care facility who were not disenrolled, information the investigators could not provide.
Second, the perspectives elicited by caregivers cannot be appropriately interpreted because case information is not provided to validate their concerns. For instance, it is not known whether patients actually required or received the interventions they sought in hospital or what interventions were attempted at home before hospitalization. Were there truly interventions available in hospital that could not have been done at home or was this a problem with caregiver education or medication availability? The example of the seizing patient is not uncommon in hospice and should prompt anticipatory guidance from hospice staff to educate family on the expectation of a seizure and how to handle it. Without information about what the patient needed to control the seizure, the example leads the reader to question whether the hospice provided standard of care and most importantly, whether their care is comparable to other hospice organizations. It is only with this information that we can make the determination about whether hospitalization was necessary and if the data and experience the authors present are generalizable to other hospice patients.
If readers wish to apply this study to their practice, or if the authors should choose to expand their study, I would encourage inclusion of the following in the analysis:
Of the patients who were hospitalized and disenrolled from hospice,
• Did they receive an intervention aimed at palliation of symptoms related to their terminal diagnosis? Was hospitalization needed as part of the plan of care for palliation?
• Was the caregiver adequately educated and supported for symptom management at home? Were on-call nurses and medications available? Was there a symptom management kit available in the home with instructions on how to use it?
• Was GIP offered in a free-standing facility or contracted facility? Was this concept introduced before the crisis, so caregivers and patients were aware of this option?
• Was there a conversation with the patient/family upon admission to hospice about their choice of inpatient care facility, should the need arise? Were inpatient options clearly explained including the ramifications of selecting a facility with whom the hospital does not contract?
• Did the hospitalization meet the needs/expectations of the caregivers and patients or did they have unrealistic expectations that may have been addressed preemptively?
• Did patient or caregiver call hospice before calling 911? Does the hospice have relationships with emergency medical services that ensure goal-concordant care of their patients?
• Were patients' caregivers asked about their preferred location of death? Were they informed of alternatives to home death and the process entailed?
In addition, consideration should be given to:
• How many patients were hospitalized but not disenrolled? There are some procedures and types of care that may, rarely, necessitate hospitalization for comprehensive comfort care. Many of those services can be provided through a GIP contract, while keeping the patient enrolled and avoiding burdensome transitions between settings of care.
In the end, the question is how do we provide the most goal-concordant care with the resources we have? With additional, detailed, comprehensive projects on topics like this one, we can improve our ability to do just that.