Factors driving live discharge from hospice: Provider perspectives

• Published in: Journal of pain and symptom management 2017-06, Vol.53 (6), p.1050-1056
• Main Authors: Dolin, Rachel, BA, Hanson, Laura C., MD, MPH, Rosenblum, Sarah, BS, Stearns, Sally, PhD, Holmes, Mark, PhD, Silberman, Pam, JD, DrPH
• Format: Article
• Language: English
• Subjects: Anesthesia & Perioperative Care; end-of-life care; Fear & phobias; Hospice care; Hospice Care - economics; Hospice Care - methods; Hospices - economics; Hospices - methods; Hospitalization; Humans; Inappropriateness; Interviews as Topic; Medicaid; Medical prognosis; Medicare; Medicare - economics; Pain Medicine; Patient Discharge - economics; Patients; Qualitative Research; Quality of care; United States
• ISSN: 0885-3924; 1873-6513
• DOI: 10.1016/j.jpainsymman.2017.02.004

Context The proportion of patients disenrolling from hospice prior to death has increased over the decade with significant variations across hospice types and regions. Such trends have raised concerns about live disenrollment’s effect on care quality. Live disenrollment may be driven by factors other than patient preference and may create discontinuities in care, disrupting ongoing patient-provider relationships. Researchers have not explored when and how providers make this decision with patients. Objective The objective of this study was to ascertain provider perspectives on key drivers of live discharge from the Medicare hospice program. Methods We conducted semi-structured telephone interviews with 18 individuals representing 14 hospice providers across the country. Transcriptions were coded and analyzed using a template analysis approach. Results Analysis generated four themes: 1) difficulty estimating patient prognosis, 2) fear of CMS audits, 3) rising market competition, and 4) challenges with inpatient contracting. Participants emphasized challenges underlying each decision to discharge patients alive, stressing there often exists a grey line between “appropriate” and “inappropriate” discharges. Discussions also focused on scenarios in which financial motivations drive enrollment and disenrollment practices. Conclusion This study provides significant contributions to existing knowledge about hospice enrollment and disenrollment patterns. Results suggest that live discharge patterns are often susceptible to market and regulatory forces, which may have contributed to the rising national rate.