In today’s home-based health care landscape, the intersection of home health care and hospice presents challenges—but also offers opportunities to evolve to best support patients. The agency I work for provides home-based care in more than 70 communities in New Hampshire, which has the second-oldest population in the country behind Maine. As our population ages and the preference for receiving care at home increases, we have recognized that opportunities for collaboration between home health and hospice service—improving communication between patients, their loved ones and their providers around health care, mortality and quality of life—becomes essential.
Communication Is Key
When it comes to helping patients and their loved ones make decisions regarding end-of-life care, prognostication can be a significant roadblock. To be eligible for hospice, a doctor (often in conjunction with a hospice medical director) must certify that a person has a terminal illness with a prognosis of six months or less to live if the disease runs its expected course. Unfortunately, overestimating life expectancy can delay referrals for patients who would benefit from the transition to more appropriate hospice care.
In recent years, we have seen an increasing number of patients who qualify for and would benefit from hospice remaining on home health services. This concerning trend means patients may potentially be receiving suboptimal care relative to their
clinical needs.
A lack of communication between patients and their loved ones around end-of-life wishes can also delay hospice. While a patient may be ready to “move on,” their loved ones may be reluctant to confront the inevitable. In addition, patients receiving home health care services, especially if they have been receiving care for an extended period, can be reluctant to transition to hospice because they are comfortable with their homecare nurses and other care team members.
Removing Barriers to Meeting Patients Where They Are
According to the National Alliance for Care at Home’s 2023 report, “Value of Hospice in Medicare,” longer hospice stays improve patient and family satisfaction and provide more time for comprehensive care planning and support. Financially, longer lengths of stay also stabilize hospice provider operations, as shorter stays tend to be more resource-intensive with less time for cost balancing.
Our agency encourages people to initiate these difficult conversations with loved ones and others and to develop advance directives long before the need arises so that when the time comes, people close to them will understand their end-of-life wishes.
Over the past year, our agency has begun to cross-train home health nurses in hospice protocols and care practices. This program has proven to be a win-win for patients and the agency. For patients, knowing that the nurse and other providers they have grown to trust will continue to care for them provides a sense of comfort and lessens anxiety about transitioning to hospice, which in turn has resulted in earlier hospice admissions.
To meet patients where they are, health care organizations must foster a culture that normalizes and encourages discussion around death and dying. This includes supporting providers with training in empathetic communication and encouraging advance care planning as a routine part of patient care.
By acknowledging and addressing our tendencies to under-prognosticate, cross-training homecare nurses and hospice nurses, and initiating earlier conversations around mortality, we can ensure that more patients receive the type of care they genuinely want and need at the right time in the right place.