Capstone Project on "Government Regulations and Hospice"

Capstone Project 20 pages (6236 words) Sources: 1+

[EXCERPT] . . . .

74 of the final rule.

Additionally the rules allow two hospices to collaborate to provide services to each other either core services or specialized services.

Impact of rules on Hospice services

The impact of these new regulations is bound to increase the pressure on hospice centers to bring their services up to par. However, according to a study, the changing policies, and the deregulation of the health services sector has made the offering of health services a commodity offering in competitive market where hospices compete with each other. (Ward & Gordon, 2006-2007, p. 3) This study indicates that pushing the hospices to participate in the competitive environment will encourage the care centers to leave their ideals of helping patients at large and encourage them instead to participate in heavy commercial competition. This might mean that the hospice functions on increasing cost efficiencies and on cutting down on quality time with the patients that will negatively impact the clients who are receiving end of life care. (Ward & Gordon, 2006-2007, p. 5)

Additionally, in accordance with some of the amendments that were proposed to the federal register for hospices participating in Medicare programs, there will be increased pressure on these centers to increase their quality, and this will incur an added cost, that might be difficult for the hospices to meet. Moreover, in light of the fact that services were better provided in larger hospices that has economies of scale, the improvement in quality would further increase costs. However the rules did provide a clause where two hospices could collaborate on provision of services, which in fact would encourage collaboration, and might help in improving the range of services that each hospice could offer. On the other hand, the same services would be more difficult to keep a track of as two hospices would be serving one patient and responsibility might not be as easily assignable as in the case of one hospice working for one patient. (Centers for Medicare & Medicaid Services, 2008)

Other changes that include the fact that a hospice can also offer its services to in-patient facilities for patients who are terminally ill might create challenges for patients and their families, where they may be in a conundrum as to which treatment to follow in case of conflict. This is the reason why the laws also ensure that the nursing facilities and hospice program consider the stage at which the patient is, and the needs that he has, confer upon these aspects with each other, and then introduce hospice care to the patient. But again, this too has a downside where Medicare patients will not be able to take advantage of curative services if they opt for hospice care, and might need to pay out of their pockets for the curative or hospice treatments. Even though there is a clause which allows that the patient may opt out of hospice care if he wants to take advantage of curative care and this in turn will create complications where curative and palliative care might need to be integrated. (Centers for Medicare & Medicaid Services, 2008)

Other affects that government regulations have had on hospice arrangements also include the fact that bereavement services that the hospice offers will have to be both before and after the death of the patient for the family, as bereavement counseling is a necessary part of hospice programs. (Centers for Medicare & Medicaid Services, 2008, p. 32090) In all the changes that are wrought in the amendments the fact is that hospice centers will now have to proactively monitor their services and will need to evaluate and improve their services in terms of quality of care.

Recommendations

Keeping in view the rules and regulations that govern hospice care, some recommendations that might help in improving the quality of services provided include:

Encouraging hospice and inpatient integrated services as patients might require a bit of both. Hospitals may diagnose the cases that need palliative or hospice care and refer to an integrated hospice care program

To make hospice care more effective, the state should encourage consolidation of services by several smaller free standing hospices which can achieve economies of scale through their collaboration.

Even though regulations provide to waive off the availability of 24-hour services in physical therapy, occupational therapy, speech-language pathology, and dietary counseling, the hospice should have some activities that are 24-hour, and this includes physical therapy.

Hospice staff is stressed as they are faced with the constant factor of death, and for this, the state should have inclusions in law that mandate holidays and breaks for these staff members so that they are able to serve their patients better.

Hospice centers should have a standard quality manual that is applicable to centers that provide the same services out of the five broad categories, as leaving the quality improvement program up to the fancies of each hospice center is not going to give the push desired for proactive strategy making.

One study that has implications for the policy-making authority as it finds that a large local hospice program was the only factor that was consistent in hospices being able to offer more intensive treatments such as chemotherapy and radiation, as these tended to support economies of scale. (Lorenz, Asch, Rosenfeld, Liu, & Ettner, 2004) The paper also indicates the need to have the Medicare policy-makers to consider the capacity of care that the hospice can provide in order to give better services to patients. It also realized the need to integrate end-of life care with other services.

Conclusion

The paper explored the institution of the hospice as it was revived by the work of Cecily Saunders, who understood the concept of total pain, and worked on it extensively, even so as to include strong doses of opiates, which she found to help in avoiding cases of euthanasia as well. Moreover, studies conducted by independent researchers also concluded that instead of getting addicted to opiates and using those more frequently, the use decreased as patients went further on in the hospice care program. (Meldrum & Clark, 2000)

Studies have indicated that the median duration of people availing hospice care is 30 days, which indicates that hospice merely makes living last days of life easier, where there is a lesser rate of hospitalization in the last 30 days of life for those who have enrolled in hospice care centers. (Christakis & Escarce, 1996) Some of the problems that Christakis & Escarce, identify in their paper are to do with the regulations, whereby, a patient relinquishes his right to receive medical treatment to prolong his life, if he or she signs up for hospice care. This seems to be a demotivating factor for hospice care staff, as they understand that the merely have to make the patient comfortable, and not take any chances or treatments that might otherwise be able to save the patient's life. Another key point that the study makes is that there is an issue in determining whether a patient really has the probability of living six months or less.

Additionally, a striking conclusion that the study drew was that there was a substantial variation according to the type of hospice provider. The study indicates that patients enrolled in large, for profit hospice facilities have a higher chance of survival than for the ones that do not operate for profit. But the fact remains, that there are constraints in these findings, as the study too is limited in scope and in the generalizability of the conclusions that it has drawn where only the patients in hospice programs were studied, and that Medicare patients were a predominant part of the group implying that all of them were above 65, and if they were young, they had disabilities.

But despite these factors, it has to be borne in mind that hospice centers were created with the purpose of alleviating pain, and this mission has to be given precedence in whatever rules and regulations that are being passed by the authorities.

Current regulations do impact the working of the hospices, and might increase costs to some extent; and as it has also been proved that commercial aspects of patients, such as their ability to pay higher are not considered by hospices granting admission (Lorenz, Asch, Rosenfeld, Liu, & Ettner, 2004), there is a need to make sure that hospices don't start resorting to admitting only wealthy patients and caregivers, if competition among hospices is encouraged. Having said this, the current amendments in rules allow for better collaboration, which is hoped to be a move towards better provision of services for all hospice patients.

In all, studies have proved that hospice care helps the overall well-being… READ MORE

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