About one in eight dying patients receiving Medicare-funded hospice care were not visited by hospice staff in the last two days of life, a study has found. Patients who were black, in nursing homes, and who died on a Sunday were less likely to be visited, the authors noted.

The findings were published today in JAMA Internal Medicine.

The last days of life can be extraordinarily difficult for patients and their families, said lead author Dr. Joan M. Teno, a UW Medicine palliative-care specialist and University of Washington professor. The vast majority of patients suffer pain and symptoms such as extreme shortness of breath.

“It is critical that dying hospice patients receive the needed professional visits in the last days of life to ensure that death is as comfortable as possible and the family receives the support they need to take care of their loved one,” Teno said.

Until this year, Medicare paid hospice-care organizations on a per-diem basis, regardless of whether staff visited the patient.  

Teno

Brian Donohue

(Click to enlarge.) Dr. Joan Teno is a palliative-care specialist and UW professor of medicine, gerontology and geriatrics.

picture of Dr. Joan Teno

Although Medicare required the programs to provide the highest standard of care for the dying person and assistance to family members serving as the primary caregivers, it did not mandate a minimum number of visits by hospice staff.

Teno and colleagues analyzed Medicare payment records from fiscal year 2014, focusing on whether patients received a hospice visit in the last two days of life from a nurse, social worker, nurse practitioner or physician. They focused on the 3,448 U.S. hospice programs that had cared for at least 30 patients who died in the study period.

Of the 661,557 patients who died while receiving routine hospice services, 81,476 (12.3 percent) received no hospice visits in their last two days of life, researchers found. These lapses emerged across more than 8 percent of the programs, and were more prevalent among smaller hospice units and those based in nursing homes. Of the 3,448 hospice programs studied, only 21 provided visits to all of their patients receiving routine healthcare services during the last two days of life.

Black patients (15.2 percent) were less likely to be visited than white patients (12 percent). Those in a nursing facility (16.5 percent) were nearly twice as likely to have no visits as those not in a nursing home (10.6 percent). Patients who died on a Sunday were three times less likely to receive a visit in the final two days as those who died on Tuesday.

The findings may explain why, among people surveyed about quality of end-of-life care, black families are more likely to say their loved one’s pain-control needs were not met and that they did not receive adequate training to care for the dying relative, Teno said.

The Sunday-related finding suggests that many hospice programs are understaffed, Teno said. “There’s no biological reason to explain why there was such a large difference in hospice visits to patients dying on Sunday.”

The percentage of patients receiving visits also varied greatly by geographical area, the researchers found. Alaska had the highest proportion of patients who did not receive a visit in their last two days (19.7 percent), followed closely by Washington (19.6 percent), and New Jersey and Rhode Island (both 19.2 percent). Wisconsin had the lowest proportion of patients not visited in the last two days of life: 3.8 percent. 

“This lack of visits in these hospice programs raise an important concern,” said co-investigator Dr. Mike Plotzke of Abt Associates in Cambridge, Massachusetts. “ In response, the Center for Medicare and Medicaid Services has implemented a service-intensity payment adjustment that pays hospice programs for visits … to ensure that hospice patients receive the right care at the right time by the right professional who can make changes to the plans of care to ensure the comfort of the dying person.” 

The study was conducted under contract HHSM-500-2005-000181 from the Center for Medicare and Medicaid services, Department of Health and Human Services.

Media contact:
UW Medicine, for Dr. Joan Teno: Brian Donohue, 206.226.2437