Terri Maxwell, PhD, APRN

Care at the end of life should address all of the important elements that play a critical role in ensuring a positive end-of-life experience for patients and families. Therefore, quality end-of-life care extends beyond managing physical pain to include psychosocial and spiritual needs.

Not all long-term care professionals carry the same understanding of the issues.

Frequently, nurses serve as advocates to support patients and families in making care decisions based upon their goals and values. Ideally, physicians, nurses and other team members work together to create an atmosphere of care and compassion in accordance with patient and family wishes.

Although hospice and palliative care both aim to deliver quality holistic care, there are key differences.  

The dimensions of hospice care

Hospice is the model for quality compassionate care for people facing a life-limiting illness. Hospice clinicians focus on pain and symptoms, and attend to the patient and family’s emotional and spiritual needs. Hospice is offered at a patient’s residence, such as their home or nursing home, or, if needed, in a hospice facility.

Hospice programs utilize an interdisciplinary team (IDT) approach to plan the care needed by patients and their families during the final weeks and months of life. The IDT is comprised of nurses, chaplains, social workers, physicians and medical directors, hospice aides, volunteers, bereavement specialists and other clinicians who develop and implement a plan of care that is formulated to relieve anxiety and suffering during the final months and weeks of a patient’s life. This approach allows the team to address physical, emotional, spiritual and social concerns that arise with advanced illness.

Hospice is available to people with all types of conditions and diseases, and focuses on comfort — not cure. Hospice provides care for the “whole person,” including physical care, counseling, spiritual needs, drugs, equipment and supplies related to the conditions that comprise the terminal prognosis. It also supports family caregivers, including bereavement support for up to a year after the patient’s death.

Financing hospice

Hospice care is reserved for people at the end of life who meet Centers for Medicare & Medicaid Services eligibility requirements and elect a comfort approach to care. The Medicare Hospice Benefit (MHB) requires that two physicians certify that a patient has less than six months to live if the disease follows its usual course. However, if a patient is still alive after six months, he or she can continue to receive hospice services if he or she meets eligibility requirements and demonstrates signs of progressive decline.

When a patient elects hospice, they sign off their Medicare Part A (hospital insurance) and enroll in hospice under the MHB. From that point on, hospice covers all services and care related to the terminal diagnosis and related conditions through Medicare, Medicaid and most commercial insurance.

The hospice IDT, together with the patient’s attending physician, is responsible for determining the plan of care. Under terms of the Medicare Hospice Benefit, the hospice agency is responsible for the plan of care and may not bill the patient for services. All costs related to conditions that affect the terminal prognosis are paid from a per diem rate that the hospice agency receives from Medicare. This per diem rate includes all drugs and equipment, nursing, social service, chaplain visits and other services deemed appropriate by the hospice agency. Care and medications not related to the terminal illness or related conditions continue to be paid for through original Medicare.

Distinctions of palliative care

The biggest differences between hospice and palliative care revolve around where the patient is in their illness related to prognosis, their goals/wishes regarding curative treatment, and how palliative care is financed.

Palliative care focuses on relief from physical suffering and caregiver burdens for individuals who are living with a chronic disease that may or may not be terminal, addressing their physical, mental, social and spiritual well-being. Atul Gawande recently defined palliative care “as the field devoted to providing people with serious life-limiting illness with expert care that serves their goals for quality of life, not just quantity of life.”

Similar to hospice, palliative care utilizes an interdisciplinary approach with highly trained professionals, including physicians, nurse practitioners, nurses, social workers, chaplains, and other disciplines.

Palliative care can be offered to people of any age, without restriction as to disease or prognosis. It may be appropriate for anyone with a serious, advanced illness, whether he or she is expected to recover fully, live with chronic illness for an extended time, or experience disease progression. Unlike hospice, patients receiving palliative care may continue to receive aggressive treatments, including life-prolonging therapies.

Conditions appropriate for palliative care include cancer, congestive heart failure, end stage renal or liver disease, chronic obstructive pulmonary disease, and dementia, among others.  While palliative care is often appropriate earlier in the disease trajectory, referrals to palliative care clinicians are often not made until late in the disease process.

Palliative care focuses on relieving symptoms, such as pain, shortness of breath, fatigue, constipation, nausea, loss of appetite, difficulty sleeping and depression. Palliative care providers also support patients in carrying on with daily life so that they can tolerate medical treatments. In addition, patients receive support that empowers them to have more control over their care by improving communication so that they can better understand their choices for treatment. Helping patients and their caregivers coordinate care across care settings is a hallmark of palliative care.

Financing palliative care

Unfortunately, palliative care programs struggle financially because there is no reimbursement code specifically for palliative services and Medicare does not reimburse for interdisciplinary care management. Hospital-based palliative care is paid by the health system with some fee-for-service (FFS) billing for physician services. Medicare Part B covers physician and nurse practitioner (NP) fees for outpatient care delivered in the community or in clinics. Therefore, most community-based palliative care programs utilize NPs and physicians for home visits. 

Other disciplines, such as nurses and social workers cannot bill Medicare for palliative home visits. Palliative care is also paid for through flexible bundled payments under Medicare Advantage, Managed Medicaid, ACOs and other commercial payers.

While Medicare doesn’t have a palliative care benefit, CMS has authorized demonstration projects that are testing different ways of meeting the needs of seriously ill patients. The Medicare Care Choices Model allows patients to receive hospice-like support services while concurrently being treated for their illness.

Demonstrated value

Costs for palliative care teams and programs are offset by fewer trips to emergency departments and lower hospitalization and rehospitalization rates. In addition, patients and families rate the value of palliative care services highly. This explains why 80% of hospitals with 50 beds or more have established palliative care teams and some are starting to consider outpatient palliative care programs. In addition, health plans and payers, including Accountable Care Organizations (ACOs), Integrated Delivery networks (IDNs) and other types of provider-driven managed care organizations, are beginning to offer community-based palliative care programs to their patients/members to extend the benefits of palliative care into the home.

Palliative care programs and advance care planning that include earlier conversations about patient and family goals of care are consistently demonstrating their value in helping patients live their final days in accordance with their wishes. Data shows that in communities that provide greater access to palliative care programs, patients are less likely to die in the hospital.

Furthermore, findings show that patients experience fewer admissions to the intensive care unit in the last six months of life and are less likely to die in an ICU

Today, palliative care is becoming recognized as option at any stage of advanced illness, not simply reserved for care at the end-stage of life. Its use should be driven by patient need, not disease prognosis.  Hospice care remains the gold standard for end-of-life care. Together, hospice and palliative care offer compassionate care when it is needed most.

Terri Maxwell, Ph.D., MSN, is the Chief Clinical Officer at Turn-Key Health.