Construction and Performance of the Hospice Care Index Claims-Based Quality Measure

As part of the Medicare Hospice Benefit (MHB), hospices submit claims containing information that allows policy makers to assess hospice quality, help policy makers improve the MHB, and increase patients’ experiences of care. We examine ten different hospice quality indicators related to the provision of services and patterns of live discharge. We calculated indicators using 100% Medicare fee-for-service (FFS) claims from October 1, 2018 through September 30, 2019. A hospice’s total score among all ten indicators is referred to as their Hospice Care Index (HCI), with a possible high score of 10. We examined all hospices with at least 20 discharges. After exclusion, we examined 4,155 hospices representing 1,562,003 beneficiaries. Most hospices earn a high HCI score: over 85% of hospices had scores of eight or more. At the same time, there were some lower scoring hospices: one in ten hospices scored seven on the index, and the remaining 4.9% scored six or lower. We find that on average hospices with higher HCI scores have better Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospice ratings. Among hospices with a score of ten, 85.1% of caregivers reported they would definitely recommend the hospice vs. 82.9% of caregivers of patients receiving treatment from hospices with a score of seven or less. Using the HCI, the Centers for Medicare and Medicaid Services and hospice patient caregivers can assess hospices across a broad set of indicators. Policymakers and hospices should monitor these ten indicators to understand their performance relative to peers.

Fingertip pulse oximetry prevented premature declaration of death

ObjectiveWe describe a case of persisting readings from a fingertip pulse oximeter (FPO) in an elderly cachectic woman with pancreatic cancer, who fulfilled all classical criteria of death.MethodsIt is an instructive example of a home hospice patient who died during the physician’s intervention. Although all classical signs of death had been confirmed several times, a portable FPO continued to indicate satisfactory saturation and pulse readings for the following 30 min.ResultsOur case report confirms that the classical criteria of death might sometimes be faulty. The application of a portable FPO prevented a premature declaration of death.ConclusionIn exceptional cases, even the most careful physical examination may erroneously indicate that a person is dead. A residual cardiac output and gas exchange may be preserved and revealed by FPO readings. In doubtful situations, FPO can provide additional information and prevent a premature declaration of death.

Use of Sitters for Patient Safety in a Veteran Population

Patient safety including falls risk, is a high priority and an increasing challenge for all health care facilities. Safety risk factors include both physical factors and psychological factors. One common strategy to increase safety has been the use of “sitters.”. Studies on functions and outcomes are conflicting some have reported no differences in falls, decreases in falls and restraints, and increases in falls. A total survey sample of 22 “sitters” and 56 registered nurses conducted at a large midwestern VA facility to assess perceptions of sitters. Groups were similar in ages (41-50 years) with sitters having slightly more experience (11-20 years) versus nurses (6-10 years). Safety conditions most likely to be identified with sitter usage were delirium, elopement, and being a hospice patient. Sitters were more likely to identify falls risk, sitters 63% of time versus RN perception 30.9% (Chi Square=7.0, df=l, p=.008); dementia 59% vs 13% (Chi square=17.15, df=1, p=.001); and weakness 66.7% vs 18.2% (Chi square=16.54, df=1, p=.001). Sitters were more likely to have training in delirium 55% vs nurses, 34% (Chi sq=2.557, df=1 p=.11). Nurses identified that the use of sitters were very likely to prevent falls 29.8%, calm patients 25.2%, maintain lines 25.2%, prevent elopement 30.5% and redirect patients 29.7%. Nurses identified the following available safety strategies: alarms (67.2%), adjusting assignment (47.2%), music therapy (5.4%), use of restraints (<2%), pet therapy (<2%), and video monitoring (<1%). Implementation of safety programs must address availability of multiple strategies including: matching sitter competencies with patient populations served.

Peritoneal-cutaneous fistula successfully treated at home: A case report and literature review

We present the first case of peritoneal-cutaneous fistula (PCF) within ovarian carcinoma neoplastic infiltrates located inside a large abdominal hernia in a home hospice patient with massive ascites. It is an instructive case featuring a rapid diagnosis and efficient treatment of the PCF at home. As the patient refused hospitalization, she had successful paracentesis performed at home. Subsequent hydrocolloid dressing application, diuretics, and oral protein supplementation were recommended. Our intervention led to PCF closure, improved quality of life, and deepened the trust between the patient and the home hospice team. Our case demonstrates that in some instances, PCF may be efficiently treated at home, which may require paracentesis, appropriate dressings, and identification of all factors affecting healing. It also provides further support for the safety of paracentesis in home settings.

“I want to go home”: How location at death influences caregiver well-being in bereavement

ObjectivesGoal concordant or congruent care involves having expressed wishes upheld. Yet, the preferred location for end-of-life care may be unaddressed. Caregiver–patient congruence between preferred and actual locations of care may influence the quality of life in bereavement. The study aimed to explore how the congruence between caregiver–patient preferred and actual locations of death influenced well-being in bereavement.MethodsMixed methods were employed. In-depth in-person interviews were conducted with 108 bereaved caregivers of a hospice patient about 4 months after the death. An interview guide was used to collect quantitative and qualitative data: demographics, decision-making, Core Bereavement Items (CBI), Health Related Quality of Life, and perspectives on the end-of-life experiences. Data were analyzed with a convergent mixed methods one-phase process.ResultsPatient preference–actual location congruence occurred for 53%; caregiver preference–actual location congruence occurred for 74%; caregiver–patient preference and location of death occurred for 48%. Participants who reported some type of incongruence demonstrated higher levels of distress, including more days of being physically and emotionally unwell and more intense bereavement symptoms. The Acute Separation subscale and CBI total scores demonstrated significant differences for participants who experienced incongruence compared with those who did not. Preference location congruence themes emerged: (1) caregiver–patient location congruence, (2) caregiver–patient location incongruence, and (3) location informed bereavement.ConclusionsCongruence between a dying person's preferred and actual locations at death has been considered good care. There has been little focus on the reciprocity between caregiver–patient wishes. Discussing preferences about the place of end-stage care may not make location congruence possible, but it can foster shared understanding and support for caregivers’ sense of coherence and well-being in bereavement.