Pilot program provides a treatment bridge to hospice

February 1, 2019


Battling chronic obstructive pulmonary disease, a Medicare patient at Hospice of Siouxland and Siouxland Palliative Care in Sioux City, Iowa, needed several months to sort through his end-of-life health care options. Finally, in December, the ailing patient chose a full hospice program.

Prior to making that decision, the ailing man had participated in a federal pilot program for patients who have been diagnosed with certain terminal illnesses — including COPD — and want to receive curative treatment for their illness in addition to a scaled-down hospice benefit.

The federal government launched the Medicare Care Choices Model program in January 2016 to examine an alternative to the wrenching decision Medicare patients and their families too often face at the end of life. Medicare requires a patient to halt curative treatment in order to receive hospice benefits.

Previous research has found that patients saw improved quality of life, higher satisfaction with their health care services and fewer hospitalizations when hospice services were combined with treatment for terminal conditions, according to a September 2018 report prepared for the Centers for Medicare and Medicaid Services by Abt Associates of Rockville, Md.

"Ultimately, the success of this model could alter the current delivery of care for terminally ill Medicare beneficiaries, and improve the quality of their end-of-life care," the report's authors wrote in their evaluation of the Care Choices program.

The pilot program is aimed at hospice-benefit eligible Medicare beneficiaries who have been diagnosed with one of four terminal illnesses. In addition to COPD, those include advanced cancer, congestive heart failure and AIDS. In addition, eligibility requires a prognosis of six months or less to live if the disease runs its course.

Pilot program
Patients enrolled in Care Choices continue to see the physician who is providing curative care, and that ongoing care continues to be reimbursed through Medicare Parts A, B and D. Meantime, Care Choices provides additional supportive services — similar to services that Medicare's full hospice benefit provides as part of routine home care — including nursing, social work, hospice aide services, volunteer services, access to a chaplain, bereavement counseling, and nutritional support.

Initially, 141 hospices participated or pledged to participate in the program. In addition to Hospice of Siouxland, which is part of Trinity Health, other ministry member participants included: SSM Health at Home in Madison, Wis., and Lake Saint Louis, Mo.; Catholic Hospice of Miami Lakes, Fla., part of Catholic Health Services; Lourdes Home Care and Hospice in Paducah, Ky., a member of Bon Secours Mercy Health; Mount Carmel Hospice and Palliative Care in Columbus, Ohio, part of Trinity Health; Mercy Hospital Jefferson in Festus, Mo., part of the Mercy system; Providence Hospice in Hood River, Ore., and Providence Hospice of Seattle, both members of Providence St. Joseph Health.

By the end of the first year, the number of participating providers dipped to 105, according to the September 2018 Abt Associates report. Among the reasons for the decline were concerns about the Care Choices eligibility criteria, reporting requirements and the adequacy of the $400 payment per beneficiary each month for the modified hospice services, according to the Abt Associates report. (The payment amounts to a fraction of the traditional Medicare hospice benefit.)


Some eligibility requirements were relaxed, beginning in April 2016. For example, the program originally required a beneficiary to have had three office visits in the previous year with the same provider, and those visits had to be related to their terminal illness. In January 2017, the requirement was changed to three office visits with any provider for any reason.

Siouxland's experience
With the program now entering its fourth year, there were 18 people enrolled in Care Choices at Hospice of Siouxland and Siouxland Palliative Care in January. To date, Siouxland has enrolled 65 people in the demonstration program. Siouxland's director, Ann Myers, said it has taken time to educate staff and the community about the program's aim.

"It was real slow going at first," Myers said.

Tammy Thomas-Mahaney, team manager for palliative care and the Care Choices program at Siouxland, said it helped that their organization had been offering community-based palliative care for more than a decade.


Physicians often refer patients to Siouxland's palliative care program. Siouxland staff screens the referral to determine whether the patient is best suited for traditional palliative care, hospice care or the Care Choices program, said Thomas-Mahaney.

If the Medicare patient comes in with one of the eligible diagnoses and that patient's prognosis fits the criteria, then hospital records are pulled to further determine eligibility.

Sobering decisions
One of the Siouxland's palliative care staff will talk to the patient about his or her goals of care and the patient's options, which may include Care Choices. These face-to-face visits can last 90 minutes to more than two hours.

"People are really scared," Thomas-Mahaney said. "They have seen multiple people. They've seen their regular doctor. They've maybe seen a couple of specialists and no one is coordinating their care. I think the relief comes when there's one person who can kind of help them sort through that."

Siouxland's nurse working with the Care Choices program has accompanied patients to cancer center and primary care physician appointments with her patients, Thomas-Mahaney said. Part of the Care Choices program involves educating and supporting caregivers and family.

In the case of the patient with COPD who chose traditional hospice in January, Siouxland's social worker met with the man's wife a couple of times a month about her questions and concerns, while the nurse talked to the patient about his symptoms, Thomas-Mahaney said.

La Rocco

Ultimately, Myers stressed, the choice for hospice care and/or curative care is entirely up to the patient.

"Really the goal was to see if we could move people earlier to the hospice benefit," said Thomas-Mahaney, "because we know that one of the huge issues with hospice care is they're getting people way too late."

SSM experience
SSM Health at Home Wisconsin is beginning its second year of the Care Choices program. Nurse Practitioner Tammy La Rocco, the program's homecare clinical manager, said four people have enrolled to date.

The Care Choices program provides an effective bridge to the hospice benefit, La Rocco said. In that sense, the program has provided an added layer of support for those patients — all of whom ultimately chose hospice, either at SSM Health at Home or elsewhere.

"They are not quite in the hospice mind-set," she said of the Care Choices enrollees. "They are not yet on board with the hospice philosophy of no more treatment, no more anything. Just comfort. It is definitely a program where you have many, many more options as far as continuing treatment."

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