More research is emerging indicating that patients are receiving hospice care too late. The COO of one large hospice provider believes that data can help combat this trend, but that a larger cultural shift is called for as well, to make end-of-life care more “mainstream.”
Corina Tracy has been on the frontlines of end-of-life care throughout her career, serving in roles such as clinical manager, director of clinical services, executive director, and in executive positions. In 2003, she joined Brentwood, Tennessee-based Compassus, an in-home and facility-based hospice provider with a footprint spanning 30 states. She has served as executive vice president and COO since 2015.
Home Health Care News caught up with Tracy to discuss the timing of hospice admissions, the obstacles to improving end-of-life care, and why Compassus is striving to measure the well-being even of terminally ill patients.
According to current industry standards, when is hospice care administered or introduced to terminally ill patients?
That’s extremely variable. Really, hospice is introduced depending on an individual clinician’s judgment. Sometimes, it’s never introduced. So, there isn’t an algorithm, so to speak… If I go into the doctor’s office and I have high blood pressure, there are evidence-based ways to handle that; there’s a process that, generally, most practitioners will follow. When it comes to [hospice care], it’s just not practiced that way. Some clinicians will bring it up early, talk about goals of care, advanced directives, and some never do.
You’ve spoken about how the biggest barrier to end-of-life care is “being more mainstream.” Can you elaborate more on this?
It’s a bit about what I was talking about with evidence-based medicine … When I say it’s not mainstream, there’s a lot of data that we have that says if [certain] things happen, it means that you have a limited prognosis, and we don’t let the data, the evidence, trigger the conversations.
In my view, when I say it should become more mainstream, it means that as soon as we believe that’s the case—if I’m diagnosed with a disease based on medical statistics where, if it runs its normal course, I have a six-month or less life expectancy—then having a hospice conversation should automatically be what happens next.
You mention that data is not being utilized more in the industry and that there’s a lack of predictive analytics. Is that the reason why hospice is introduced so late for patients?
I think it’s a big reason why, and I think there’s a lot of opportunity. It’s a dilemma … Never do we want to get to a place where we’re removing autonomy from a clinician; that’s where the rubber meets the road. They’re humans; we want humans dealing with humans. I am talking about putting data in a clinician’s hands so they can feel more confident about their decision. … I would never suggest that data would replace the clinical judgment, but it would be a trigger and a reminder to the clinician that those conversations need to happen.
As an organization, we want to be more helpful. Not everybody has the same skillset or will to have end-of-life conversations; but there are a lot of resources for clinicians to have different kinds of conversations.
You mentioned earlier that a conversation around hospice is a “high-risk conversation.” In what ways can providers initiate that conversation?
Many years ago, I met a wonderful palliative care physician, and she’s used the term “medically possible.” I think it’s a great and honest way to approach patients about what’s going on with them and helps hope remain, because this is what’s medically possible, it doesn’t mean that aren’t miracles or things that happen outside of medicine. … There [may be] nothing else medically possible that we can do [but] there are many other things that we can do from an emotional, spiritual support side.
Honestly, at the end of the day, that’s what people want to know. As health care providers, I think we have to remember that we live and breathe this every day and we all speak code. We have so many acronyms and we understand that, but [for the patient] this is so brand new for them. They really need to understand what’s medically possible and what other options are out there. I think [we need to be talking] about it in that way and making sure that there’s some support they’re given and that it’s not expected to be a one-and-done conversation. People will have a lot of questions and if there’s nobody that can answer their questions, I think that’s when fear comes into play.
In what ways can technology like remote monitoring platforms play a role in providing hospice care? How do you achieve this at Compassus?
We really think remote monitoring and technology can play a part.
When people think about telemedicine or remote monitoring now, I think oftentimes they think about vital signs and basic medical intervention. When we think of remote monitoring and the way technology can really help with hospice patients, we think about well-being.
We have this saying that we want to make life wonderful for our hospice patients, not just less horrible. And what that means is when people think of hospice, they think we’re really good at controlling pain. We are, but we’re more than that. People at the end of their life need more than that, and deserve more than that. Controlling pain is what we have to do and should do … Where remote technology comes in is helping monitor almost emotional symptoms and activity that bring people joy.
We’re piloting this idea of capturing and measuring well-being and distress; so, not just symptoms, but how we capture and measure well-being so we can help patients and families be higher on a well-being score. The best way to improve something is to measure it. … We take an inventory with patients and families about things that make them feel happy.
What must the hospice care industry do to address this trend of introducing hospice care so late? What are some solutions?
Definitely, partnering with organizations that have big data and helping figure out the analytics, the triggers. I think that is something that the hospice industry can and should do.
When you have a patient that comes on, we have the end of the story, and when you can take the data that hospice has on length of stay and the symptoms that we’ve seen on admission and work with other organizations that have a lot of data, you can start to see a pathway of when a patient should be referred and what are the triggers and link it to length of stay … Hospice has to be a part of that type of conversation for predictive analytics. We need to collect data, we need to aggregate data from a hospice industry.
We’re a small industry and we kind of hold things tight; that’s one of the things the industry has to do, is be more open about data. … I think the other thing that the industry can do is just be a proponent of sponsoring [goal-centered] types of care, advance planning, advance directives, really be as much of a champion as we can about the things that happen before hospice care.
How can hospice providers play a more active role in the care continuum?
What worries me about health care is the aligning of the incentives. Sometimes, it feels like in some cases, many different providers are taking care of and targeting the same group of patients. So that doesn’t fare well for good partnerships on a continuum. I think using data and sharing data amongst the continuum, I think we all need to do that and do it better so we really can get the right care for the right patient at the right time and help them move along the continuum.
I think the biggest barrier to that is incentives not always being aligned, and sometimes it’s hard to tell what the right care is at the right time, what the best care is for the patient.
Written by Carlo Calma