New market for special end-of-life care that is inpatient

For most people, hospice is a collection of services - and an attitude - that helps the terminally ill die comfortably at home.

But as the number of patients entering hospice grows and as the drugs and technology used to ease pain become more sophisticated, some hospice providers say they're seeing more patients who need more care than their families can provide at home.

That need, combined with the availability of some empty hospital buildings, has led to the creation, since November, of three new inpatient hospice units in this area.

The Visiting Nurse Association of Greater Philadelphia is the newest entrant into this market, with a 14-bed hospice unit in the former MCP Hospital in East Falls that it expects to open this month. Its unit, called Hospice of Philadelphia, is for patients with pain, agitation, seizures, or other symptoms that can't be managed at home.

In April, Abington Memorial Hospital opened a 19-bed unit in the former Warminster Hospital that provides symptom management plus residential care, a less-intensive level of care for people with simpler medical needs.

The University of Pennsylvania Health System's 12-bed inpatient unit opened in November in the former Graduate Hospital in South Philadelphia.

The new local units promise large, quiet rooms, relatively homelike furnishings, and a welcoming environment for families.

Heather Wilson, a principal with Weatherbee Resources, a hospice consulting firm, started seeing growth in freestanding inpatient hospice units about five years ago. Aging baby boomers want more alternatives, she said. "Most people want to die in their homes," she said, "but sometimes, it's just not reasonable."

The number of inpatient hospice beds in the five-county Philadelphia region has grown from 53 five years ago to 122, not including the new Visiting Nurse unit, the Pennsylvania Department of Health said.

Most hospice patients still die at home, but the percentage who die in an inpatient hospice unit grew from 14 in 2003 to 19.2 in 2007, according to the National Hospice and Palliative Care Organization (NHPCO). The symptom-management units are meant for short stays, and not all patients who go there die there.

Medicare began covering hospice services in 1982, with the idea that hospice was both a better and cheaper way to die than the all-out medical assault many encounter in hospitals. That year, only 25,000 people received hospice services, NHPCO says. In 2007, 1.4 million people were in hospice.

Patients qualify if they are likely to die within six months and if they agree to switch from treatments aimed at curing disease to those meant to ease symptoms, called palliative care. People can receive hospice services such as nursing care or bereavement counseling in a variety of settings, including homes, nursing homes, and hospitals.

John Kimberly, a Wharton School health-care expert, says the increase in hospice use stems from the aging of the population and greater acceptance of hospice by patients and by doctors. "There's a growing awareness on the part of physicians that losing a patient doesn't mean they've failed," he said.

Hospice experts think health reform may lead to even faster growth as the nation turns to palliative care as a way to rein in the cost of end-of-life treatment. Baby boomers will "bankrupt Medicare if they don't do something about end-of-life care," said Lynn O'Brien, a nurse who is director of hospice for Abington hospital.

Hospice providers receive a daily fee from insurers that is based on the amount of care a patient needs. Routine hospice care, which is what most people get in their homes or nursing homes, brings a local hospice $156 a day, according to the Centers for Medicare & Medicaid Services. The rate for inpatient care - the type aimed at managing symptoms like severe pain or seizures - is $669. Less medically complicated patients who stay in a residential hospice pay out of pocket for room and board. At Abington's new unit, those patients pay $300 a day.

Joseph Straton, medical director of Penn's hospice program, said he hoped that, some day, his program, which offers only inpatient symptom management, would have space for people who needed residential service. "Telling somebody they're dying is easy," he said, "compared to telling somebody they can no longer stay here."

Penn and Abington had hospice care in their hospitals, but the new units free up most of those beds for better-paying patients and allow hospice workers to give a different kind of care, officials said. "Hospitals are not well-designed for people who are dying and for families who are taking care of patients who are dying," Straton said.

The Visiting Nurse Association previously contracted with hospitals for inpatient space. (All hospices are required to make provision for this kind of care.) Having its own unit gives it more control over the quality and cost of care, said Jane Feinman, a nurse and senior vice president for hospice.

"We didn't really think of it from a financial perspective as much as we did from a quality-of-care perspective," Feinman said. Hospice is supposed to create a homelike environment. "I don't know how you can do that in a hospital setting."

She said it's hard for hospital nurses to turn off the aggressive, life-saving approach required for most of their work. "It's different if someone chooses to work in hospice and they really believe in the philosophy."

Palliative medicine and hospice were once a sideline for doctors, Straton said. As more physicians have specialized in alleviating pain, care has grown more sophisticated. In an inpatient setting, patients can start intravenous or epidural pain-killers that work better than those that can be given at home, he added. While hospice has always meant "high-touch, low-tech" care, the new techniques are changing it to "high-touch and high-tech and whatever the patient needs," he said.

Abington expected more people to use residential hospice, given the number of elderly people in Montgomery County. But so far, most of its patients have come for symptom management. Most have been senior citizens, although the hospice directors said younger patients with children at home may be more likely to seek inpatient care. They don't want their kids to think of home as the place where a parent died. Plus, O'Brien said, "it's very hard for young people to die in front of their children."

Gail Inderweis, president and executive director of Keystone Hospice, an 11-year-old residential hospice housed in a Wyndmoor mansion, is skeptical of the "hospice frenzy" she thinks is leading to too many hospice beds. And she's not a fan of more-aggressive medical involvement in death. "As doctors make careers in palliative care, we are seeing death be more institutionalized."

But directors of the new hospice units said they believed the region needed the new beds. "Our patients," said the Visiting Nurse's Feinman, "go back and forth to the hospital more than we'd like."