Bridge prehospice programs and their effectiveness

Bridge/Prehospice Program: Do Hospice Bridge Programs Increase Quality of Life for Terminal Patients by Encouraging Earlier Access to Palliative Resources?

The work of Levy, Bemski, and Kutner (2008) entitled "Are Hospices Establishing Pre-Hospice/Palliative Care Programs?" reports that outpatient palliative care programs (OPCPs), sometimes known as prehospice or 'bridge programs' allow for patients to receive comfort care in their home, nursing home, or assisted living facility even if they are not eligible for or are not ready to choose to enroll in hospice care." (p.1)It is reported that the OPCPs in terms of their "prevalence and sustainability…remains uncertain because these programs are, in general, not supported by health care insurance in the United States." (Levy, Bemski, and Kutner, 2008) Reported by Levy, Bemski, and Kutner (2008) is a survey that was comprised by an 18-question Web-based survey "created based on input from a team of palliative care/hospice clinical and researcher physicians and nurses affiliated with PoPCRN." (Levy, Bemski, and Kutner, 2008, p.1)

The hospital programs were asked if an OPCP existed within their hospice and if it did what the characteristics of the OPCP were. Then the hospice characteristics were obtained "via 2005 hospice claims data obtained from the Centers for Medicare & Medicaid Services and hospices without OPCPs were compared to those with OPCPs. The report states that 42 of 177 hospice agencies contacted responded to the survey with a response rate of 24%. Findings include the following:

24 or 57% had an OPCP;

Agencies with an OPCP had a significantly higher mean number of patients annually and total days of care annually and care for a higher percentage of patients with noncancer diagnoses that did not have an OPCP;

50% were in the process of developing one;

67% indicated that their OPCP is not profitable;

58% stated that they continued providing OPCP services because the program is "an important service to the community."

85% of hospice agencies reported that fewer than 25% of patients remained in the OPCP until death.( Levy, Bemski, and Kutner, 2008, p.1)

Other findings include that 50% of the patients enrolled in their OPCP eventually enrolled in a hospice program." (Levy, Bemski, and Kutner, 2008, p.1) In addition, 86% did not report an increase in an overall length of hospice service for patients who were referred to the hospice program from the OPCP compared to non-OPCP patients." (Levy, Bemski, and Kutner, 2008; p.1) It is also reported that 35% of hospice agencies stated that "overall length of hospice services was longer after starting the OPCP." (Levy, Bemski, and Kutner, 2008; p.1) This study is reported to create more questions than it actually answers and that more research is needed in relation to OPCPs.

The work of Carlson, et al. (2010) entitled "Impact of Hospital Disenrollment on Healthcare Use and Medical Expenditures for Patients with Cancer" reports a study through use of "Surveillance, Epidemiology, and End-Results Medicare data for hospice users who died as a result of cancer between 1998 and 2002 to compare rates of hospitalization, emergency department, and intensive care unit admission and hospital death for hospital disenrollees and those who remained with hospice until death." (Carlson, et al., 2010, p.1) The study additionally reports comparing "per-day and total Medicare expenditures across the two groups." (Carlson, et al., 2010) Results of the study state that patients with cancer who disenrolled from hospice "were more likely to be hospitalized, more likely to be admitted to the emergency department or intensive care unit, and more likely to die in the hospital." (Carlson, et al., 2010, p.1) Patients who disenrolled from hospice died a median of 24 days following disenrollment, suggest that the reason for hospice disenrollment was not improved health." (Carlson, et al., 2010, p.1) It is reported that the "distribution of Medicare expenditures for individuals with a primary diagnosis of cancer who enrolled with hospice was substantially skewed to the right. The 5% of individuals with the highest Medicare expenditures accounted for 40$ of total Medicare expenditures during the study period. The mean total Medicare expenditure per individual with $9,196, the median expenditure was $3,508 and the 95th percentile expenditure was $35,479." (Carlson, et al., 2010, p.1) The study concludes that oncologists "should view hospice disenrollment by their patients as a marker for patient complexity and be aware of the increased probability that such patients will be hospitalized, perhaps multiple times, and often in their last few weeks of life." (Carlson, et al., 2010, p.1) Recommended are strategies for supporting patients who have disenrolled from hospice. A more targeted approach to decreasing Medicare expenditures for hospice users may be to better understand the processes of care and patient and family decision making related to hospice disenrollment and to develop strategies to better manage the patient's care and support the family following hospice disenrollment." (Carlson, et al., 2010, p.1)

The work of Casarett and Quill (2010) reports that hospice programs "provide a unique set of benefits for dying patients and their families." Examples include that hospice patients receive medications related to their hospice diagnosis, durable medical equipment, home health aide services and care from an interdisciplinary team." (Casarett and Quill, 2010, p.1) In addition, families receive emotional and spiritual support and bereavement counseling for at least a yare after the patient's death." (Casarett and Quill, 2010, p.1) While hospice provides high quality care and high levels of satisfaction due to "improved pain assessment and management, improved bereavement outcomes, better overall satisfaction nd lower mortality rates among family members who received hospice care" hospice is noted to make provision of care for "only one-third of all dying patients in this country and patients who enroll generally only do so very late in the course of illness." (Casarett and Quill, 2010, p.1)