Hospice has been a popular target on the mergers-and-acquisitions front, but the industry faces a demographic challenge when it comes to minority patients.
The sector is plagued by very low utilization rates for minority patients, and the numbers appear only to be getting worse.
About 87% of hospice patients are white, according to the most recent demographics data from the National Hospice and Palliative Care Organization (NHPCO). That’s up from 2014, when roughly 76% of hospice patients were white.
Two leading hospice and home health care providers are working to reverse that trend and, in turn, expand into a drastically underserved portion of the population. The Visiting Nurse Service of New York (VNSNY) and Miami-based Vitas Healthcare have both launched separate, innovative initiatives at the local and national levels—and they appear to be working to address the racial disparity in hospice care.
Both providers agree the use of hospice among minorities is far too low, eyeing the misconceptions and cultural barriers that currently prevent higher penetration rates.
“…We are keenly aware of the high level of underutilization of hospice services among communities of color and ethnic minorities,” Diane Deese, vice president of community affairs for Vitas, told Home Health Care News via email. “Misconceptions about hospice within these underserved populations keep them from accessing appropriate end-of-life care.”
Vitas—a subsidiary of Chemed Corporation (NYSE: CHE)—is the largest end-of-life care provider in the United States, with almost 11,500 employees throughout 44 hospice locations in 14 states and Washington D.C. It also provides care in residential settings, hospitals, nursing homes and assisted living communities.
Not-for-profit VNSNY provides home- and community-based services and has about 13,200 employees. In 2017, it provided care to about 135,000 total individuals in New York, more than 6,000 of whom were hospice and palliative care patients.
“Across the board, when we’re talking about people of color, the utilization rate is way down,” Michelle Drayton, VNSNY’s director of hospice and palliative care outreach for Manhattan and the Bronx, told HHCN. “There are cultural barriers and systemic barriers that contribute to that number.”
Project HOPE
In 2015, VNSNY launched an ambitious community program—”Project HOPE,” for hospice outreach, patient and provider engagement—aimed at improving hospice utilization rates among minorities living in New York’s Harlem neighborhood.
As part of its mission, Project HOPE, overseen by a dedicated VNSNY liaison, focuses on educating the public about what hospice really is. For example, a common misperception about hospice is the notion that it’s exclusively offered at a facility, Drayton said. That misperception can cause anybody to shy away from hospice, but it can be especially restrictive in Harlem, where people often have strong attachments to their historic community.
“There is legitimate fear,” Drayton said. “People don’t know that about 60% of hospice is provided in the home.”
To ease those misperceptions, VNSNY coordinates with religious leaders, policymakers and other “community influencers” who interact with resident on a daily basis, she said.
In addition to targeting prospective patients, Project HOPE also works with physicians and hospital C-suite officials directly, helping them see hospice as a service that can have a positive impact on a patient’s care plan, rather than a last-resort measure.
Shorter length of stay
Besides the low utilization rates among minorities, past research has also suggested minority groups, when they are offered hospice, are presented with it too late, resulting in shorter stays than white patients.
“We went into [Harlem Hospital Center], worked with physicians and discovered that there was this absence of having that hospice-as-an-option discussion with patients,” Drayton said. “There was much more of a focus on what they can do to keep patients alive instead of thinking, ‘Ok, this patient is terminally ill. We need to be presenting hospice as an option.’”
Since launching Project HOPE, referral numbers show a rise in diverse hospice patients. In 2014, the year before Project Hope launched, VNSNY had only five referrals to its hospice program from Harlem Hospital Center. That total jumped to more than 50 referrals—and 25 admissions—in the first quarter of 2018 alone.
For VNSNY, the overriding reason behind the disparity in hospice utilization rates is simply lack of awareness among African-Americans and other minority groups, she said.
“Project Hope is about having better relations at the community level, but also about having better relations at the hospital level and the provider level to address why there is such low admission rates [among minorities],” Drayton said. “Part of it is addressing myths, stereotypes and misperceptions about what hospice is and when it’s appropriate to access.”
VNSNY is a not-for-profit organization, but the lessons it has learned more Project HOPE can apply to other hospice and palliative care providers in the industry. Partnering with community influencers, improving data collection efforts and solidifying a local hospital presence are all strategies can improve diversity, according to Drayton.
“For those hospices where it does make sense and their market share is diverse, it’s something that they really need to be looking at,” she said. “Not only from a business point of view, but [hospice] is a patient’s right, so from an advocacy point of view.”
Gaining trust
Vitas launched a similar outreach program in 2003 in its Access Initiative, spearheaded by a team of community liaisons who go directly into minority communities and educate residents about the benefits of hospice. Their work includes visiting senior centers, churches, classrooms, assisted living communities, hospitals and various local events to raise awareness and dispel inaccurate views of hospice.
To earn the trust of residents, those community liaisons are typically members of the communities where they serve.
From 2010 to 2017, admissions of non-white hospice patients increased by 26%, according to Vitas. In 2017, 34% of all Vitas admissions were non-white patients.
Ramping up outreach may have far-ranting economic benefits, as hospice care has been linked to lower health care spending overall. Medications and equipment related to terminal diagnosis are covered with no out-of-pocket costs for the patient through Medicare’s hospice benefit.
“Appropriate hospice utilization is an effective use of resources for acute care providers and payers,” Joel Wherley, executive vice president and chief operating officer of Vitas, told HHCN via email. “This includes reducing readmissions, mortality rates and use of intensive services through use of hospice and palliative care options over continued aggressive treatments.”
Written by Robert Holly
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