Annals of Long Term Care

Currently, approximately 1.45 million individuals are receiving hospice care in the United States, but many more could benefit from hospice services. While hospice originated to support individuals caring for terminally ill relatives at home, hospice services under the Medicare hospice benefit (MHB) can also be accessed by individuals residing in nursing homes or assisted living facilities. Although the number of hospices participating in Medicare is rapidly increasing, there is still considerable confusion about hospice as a care option in the long-term care (LTC) skilled nursing setting. With the “baby boomers” reaching retirement age, the number of patients requiring hospice care and nursing home services will likely increase; thus, it is imperative for individuals serving the LTC community to have a solid understanding of the MHB. This article provides a review of hospice care in the nursing home setting, outlining demographic trends in hospice; patient eligibility; clinical guidelines of end-stage disease; services that are covered and not covered by the MHB; regulatory concerns; financial coverage concerns; benefits of hospice in the LTC; impact of hospice on survival rates; and the future of hospice care. (Annals of Long-Term Care: Clinical Care and Aging. 2010;18[12]:32-37.)

In the United States, modern hospice care is guided by the Medicare Hospice Benefit (MHB), which was established in 1983 and pays for 80% of all hospice care, including medical and nursing services, counseling, and bereavement services.¹ The original goal of the MHB was to support families caring for a dying relative at home; however, under certain circumstances, the MHB hospice services can be provided in a nursing home or in an acute care hospital. Referral for hospice care is appropriate when the overall plan of care is directed toward comfort rather than reversing the underlying disease process. An increasing number of older adults are living in assisted living facilities or have other semi-independent living arrangements, and the variations among the mare vast, making challenges to care unique in this patient population. We provide a review of hospice care in the nursing home setting.

Demographic Trends
In 2011, the oldest “baby boomers” will turn 65, and the sheer volume of this generation will likely increase the number of patients requiring access to hospice care. In addition, this generation will likely play a more active role in healthcare decision making than previous generations; thus, the demand for hospice services in the community and the nursing home setting will likely increase.

According to the Hospice Association of America, the total number of hospices participating in Medicare rose from 31 to 3346 between 1984 and 2009, representing a 108-fold increase.² The National Hospice and Palliative Care Organization (NHPCO) estimates that in 2008 approximately 1.45 million people in the United States received hospice services and about 38.5% of all deaths were under the care of a hospice program. ³ Of these hospice deaths, 22% occurred in nursing homes.

The racial and ethnic diversity in patients who use hospice services has not changed significantly in recent years. Of those who received hospice services between 2007 and 2008, about 82% were white. Among black individuals, fewer used hospice in 2008 (7.2%) than in 2007 (9%). Among the multiracial or other race category, there was a slight increase, from 7.8% in 2007 to 9.5% in 2008.³ According to the NHPCO, 4 out of 5 hospice patients are over the age of 65, and more than 33% are 85 years or older.³

Who is Eligible for Hospice under the MHB?
To be eligible for hospice services, the patient must meet the following criteria¹:

• The patient must be entitled to Medicare Part A (hospital payments).