August 26, 2019

Taking a Hard Look at Hospice Care in the United States

Partners Population Health Perspectives blog aims to share the opinions and ideas of our leadership team on health care topics related to population health management. In this post, Chuck Pu, MD, Medical Director for Care Transition & Continuum, shares his thoughts on the state of hospice care in the United States and what Partners HealthCare is doing to improve it.

The Department of Health and Human Services (HHS) recently released two reports which showed that from 2012-2016 a disturbing 87% of the 4,563 U.S. hospices participating in Medicare had at least one deficiency in the quality of care they provided to their patients. In one specific survey year (2016), most hospices that had a deficiency had multiple deficiencies in that same year as well as deficiencies in other years. Perhaps most unsettling was the finding that nearly 20% of hospices were found to have a deficiency that reached condition-level “serious” which meant that the hospice’s capacity to furnish adequate care was either significantly limited or to a point where the patient’s health and safety were jeopardized.

As a physician leader focused on improving end-of-life care, the issue of hospice quality first hit my radar when I observed a high degree of variation in hospice care quality for my own patients enrolled into hospice. A quote from a 2017 Time Magazine article, “Hospices promise peace at the end of life – but many don’t deliver,” made a deep impression on me and sowed the seeds to help spearhead an effort to improve hospice care for our patients. While HHS’s recent report saddened me, it did not surprise me. In fact, I found great validation for the work Partners HealthCare has undertaken over the past two years.

For anyone committed to advancing meaningful value-based care, trying to improve appropriate, timely, high-quality end-of-life care (of which hospice care is a key component) has become an increasingly recognized strategic priority. In our efforts at Partners, we learned that hospices were in their infancy when compared to other health sectors such as the nursing home or home health industries when it came to quality reporting and regulatory oversight.

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So, taking a step back, where does this leave us? Firstly, I would like to note the innumerable excellent end-of-life care cases delivered through high-caliber, professional, compassionate, mission-driven hospice agencies on a daily basis. My family and I personally experienced this wonderful care, delivered over five weeks to my dear uncle at the end of his 96 years of life. He passed away in peace, in his own home, surrounded by the most important people in his life.

Secondly, delivering a top-notch hospice care experience does not fall solely on hospice agencies. Large health care delivery organizations such as Partners often do not own a hospice agency large enough to meet the hospice care needs of its population and must depend on outside hospices to deliver that care. Providers at Partners, such as myself, make the referrals and must own an important role in improving hospice care. For example, when we compare ourselves to other health care delivery systems across the country, Partners is on the low-end of hospice use for our patients in their last six months of life. And when we do enroll our patients into hospice, the time many of them spend on hospice is very short (5 – 10 days).

Although the ideal duration of hospice care remains unclear, studies have shown that there are not only cost benefits around the 30-day mark, but also significantly better perceptions of care by patients and families the longer the stay (around three months). This means we as providers should continue our journey towards increasing appropriate, more timely hospice referrals through earlier goals of care discussions so that patients and their families are not in crisis during the transition to hospice.

Bottom-line, we humbly recognize that no one organization has all the answers, can provide all the solutions, or can do it all. Improving end-of-life care must be a deeply collaborative, cross-organizational, bi-directional effort.

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To help address these challenges, Partners has built a set of three strategic initiatives to improve not only acute end-of-life care episodes, but for longer term planning and palliative care for patients with chronic, life-threatening issues in the last few years of their life (what we refer to as “Serious Illness Care”). The first piece includes a broad based effort to train 100% of our medical providers on effective goals of care conversations about patients’ preferences and make this information easily accessible to clinicians enterprise wide through our single electronic health record.

As a second piece of our strategy, we’ve built our own high-touch home-based palliative care program for frail, significantly home-bound patients with advanced, complex illnesses who may not yet be eligible to enroll in hospice due to a more prolonged prognosis, or who are not ready for hospice, despite qualifying through Medicare for assistance.

The creation of the Partners Hospice Collaborative Network anchors the third piece of our current palliative care strategy. Launched in November 2018, the Partners Hospice Collaborative Network is a group of 18 preferred hospices brought together to help build a collaborative ecosystem that will confidently bring high-value hospice care to our patients at the end life. These hospices were elected through an innovative Request for Proposal (RFP) application developed by a team of convened experts from across Partners and scored in a blinded manner based on quality measures. The RFP application was designed specifically to close the gap we believed existed between the very limited, currently available public hospice quality data and what we believed to be a more accurate picture of high-quality hospice care.

I come back again to those two Health and Human Services reports—which I challenge us all to receive as clear wake-up call.  Although these reports will likely signal a change to the hospice industry in regulatory body oversight and public perception, hospices still have ample opportunity to shape the direction of this narrative moving forward.

Will the response be one of defensiveness, rationalization, finger-pointing, inaction, denial, short-term self-preservation? If so, I caution hospices to look at the path the nursing home industry took decades ago, ending up as one of the most heavily regulated industries around. It’s a sad story of an opportunity lost decades ago.

Or, will the response be one of deep self-reflection, mature accountability, professionalism, and a self-initiated commitment towards proactive, aspirational quality improvement both as an industry and starting with your own agency? At Partners, we are proud to stand together with hospices in the latter group, who have already started this journey to re-write the narrative.


Dr. Charles “Chuck” Pu is a board-certified Geriatrician and Internist with over 20 years of clinical experience and administrative leadership roles in numerous post-acute care settings including SNF, LTAC, and IRF. Currently an Associate Attending Physician within the Massachusetts General Hospital’s Division of Palliative Care and Geriatric Medicine, Dr. Pu was hired as MGH’s first ‘SNFist’ back in 1998. He currently serves as a Medical Director at Partners Population Health and oversees a strategic portfolio of Post-Acute, SNF, Palliative/Hospice and Advanced Home-Based Medical Care Initiatives. He also serves as core faculty of the MGH Geriatrics Fellowship Program and is an Assistant Professor at the Harvard Medical School. Nationally he has served on numerous post-acute care technical advisory panels and is currently serving as a member of the CMS Healthcare Transformation Taskforce – Advanced Payor-Provider Partnerships Workgroup.

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