While many nursing home patients who would qualify for hospice care never get it, a Pennsylvania provider is shoring up its efforts around end-of-life care with a new 16-bed hospice unit.

This week, Masonic Village in rural Elizabethtown, PA, welcomed 11 patients to its Evergreen unit that opened Monday. 

Vincent Mor, PhD, a professor of health services, policy and practice at Brown University, said in-facility hospices remain rare in skilled nursing settings, despite Medicare and Medicaid coverage. Typically, nursing homes have contracts with local hospices who “rent” beds which are then staffed by external hospice employees to manage patients’ symptoms.

Nursing homes may provide aides, just as they do when nursing home residents elect to receive hospice from a local provider.  

“But, having a dedicated inpatient unit located in a nursing home that offers short stays for symptom management or to allow people to die outside the hospital the same way a community-based hospice inpatient unit would is unusual,” Mor told McKnight’s Long-Term Care News. “It makes most sense in a rural setting that has a direct relation with the local hospital so that the hospital can refer patients who can’t go home, or are clearly dying but don’t need acute care any longer.”

Pandemic repositioning

Matthew Mayo, Masonic Villages Assistant Executive Director and Health Care Center Administrator, told McKnight’s the non-profit had long discussed adding a designated hospice unit but had no space in its 453-bed skilled nursing facility building.

That changed with the pandemic, and when census dropped, administrators made the change. Mayo said the original plan was for 12 beds but after crunching numbers with a goal to at least break even, 16 made the most sense.

The non-profit has been providing hospice services for 13 years across its campus and in nursing homes, retirement communities and skilled facilities in neighboring counties, and Masonic Village Hospice staff provided training. Staff for Evergreen had to re-interview for the new roles, said Mayo.

Mayo admits his situation is unique. Donors paid for all furnishings — in addition to a bed, each room has a pull-out couch, two TVs, and an electric recliner — a $200,000 bill. Most of the labor to convert the space to 16 private rooms, a chapel, a library, office space, and a children’s playroom, was provided in-house.

“It’s not just for the residents, it’s also taking care of the families,” Mayo said. “The future is to make sure our residents have a great experience and families feel they’re well taken care of. Do we take care of our families? Do we take care of our staff?”

Hospice access remains limited

Mor has long researched hospice access and nearly 20 years ago he co-authored a paper arguing “that government concerns regarding possible abuse of the hospice benefit in nursing homes, as well as suggestion that the payment for the benefit in nursing homes may be excessive, has perhaps slowed the adoption of hospice services into the nursing home setting.”

A 2019 LeadingAge study found such services remained highly “underused.”

Studies conducted before federal regulators proposed a reduction in hospice payments for patients who live in nursing home found that as many as 24% of nursing home residents who die in nursing homes qualify for hospice services, but only 6% were enrolled

A more recent study by the Regenstrief Institute’s Kathleen Unroe found that 33% of Indiana nursing home decedents received hospice care, the same as the national average at the time, even though nursing home hospice patients were older and more likely to have dementia.

On Wednesday, Mor said adding a hospice and palliative care unit remains a significant investment, and the regulatory review is extensive. Stays require justifications each day after three days since the expectation is that patients will die quickly.

“Indeed, many stays of those transferred directly from the hospital are alive for less than a day, meaning all the administrative costs of a stay are not amortized over a longer stay since they are paid per day,” he said.

Other providers, however, have recognized that hospice services can pay off in patient care, community reputation and reimbursement when done right.

Andrew Salmon, chief future officer at Massachusetts-based Salmon Health & Retirement, said on a McKnight’s webinar Wednesday that identifying and transitioning the appropriate patients to hospice rolls can lessen the impact end-of-life patients may otherwise have on skilled nursing quality metrics.

“It’s good for the patient because there’s less pain and less suffering, and it’s also better for the building,” in terms of care planning and resource sharing, Salmon noted.

Senior editor Kimberly Marselas contributed