On Tuesday, November 10, over 100 health care workers gathered at the Montpelier Capitol Plaza for a presentation on the use of hospice care in Vermont. A large poster hanging in the room read “In life we plan for everything – college, marriage, children, retirement – but we seldom plan for the end.”
University of Southern Maine researcher and professor of public health Elise J. Bolda presented the results of a six-month qualitative study, beginning in April 2015, which looked at why Vermont has the sixth lowest rate of hospice care in the country for Medicare recipients who died while enrolled in hospice care.
While Vermonters usage of hospice falls below the national average, Bolda said that she does not know what it means—that “it may be a good thing.”
In October 2014, the education arm of the Visiting Nurse Association’s (VNA) End-of-Life Care services commissioned a study with support from the VNAs of Vermont and a grant from the Coverys Foundation to examine hospice utilization in Vermont.
Those conducting the study wondered what the quality of end-of-life care is in Vermont and what residents of Vermont, including those in The Valley, want and need in this domain.
About 1,500 total health care workers and community members were surveyed and interviewed for the study.
The data showed several reasons as to why usage may be low. Many Vermont residents use private caregiving services and the rate of hospital death is high as well. The data implies that hospital deaths are not ideal, as 40 percent of community members surveyed said that their recently deceased friend or family member was not comfortable in the hospital.
The data also illuminated that knowledge of hospice care, as well as communication of that knowledge, may be lacking in both health care settings and among community members. Health care professionals may not always understand who is a good candidate for hospice care or what hospice care entails specifically.
Over 20 percent of those surveyed in Central Vermont view hospice enrollment, as one physician put it, as a service that could cause patients to feel “given up on.” Physicians and patients often have lifelong relationships in Vermont and many physicians reported the desire to keep attempting treatments.
Central Vermont Home Health and Hospice (CVHHH) will work with communities in Central Vermont to understand this perception more. CVHHH bereavement coordinator Ginny Fry and a hospice nurse visited Evergreen Place in Waitsfield this past fall to answer residents’ questions. They will continue this work in the future.
Health care professionals also reported concerns with Medicare rules for hospice enrollment, such as the stipulation that physicians must certify that a patient has a life expectancy of six months or less in order to qualify for hospice care within Medicare.
However, often patients live beyond six months and are re-evaluated by a physician to see if they will continue to meet hospice criteria. Further, many community members do not realize that patients can receive hospice care even if health care professionals do not suggest it.
According to data, a reluctance to discuss end-of-life goals with patients was found among nurses and other nonphysicians. Bolda said that in Vermont it may be that “conversations about end of life are more rare” and that she wants to “bring death to the public discourse.”
A member in the audience asked, “Are Vermonters so confident with providing care that they don’t need hospice?” She likened this possibility to the home birth movement, in which midwives and community members decided to take birth away from institutions and into their own hands. Bolda called this “the independent Vermonter thing” but added, “It’s a piece—but not the whole picture.”
The study is merely a first step in the overall goal of providing better end-of-life care to Vermont residents and Bolda discussed with the audience how the results could be taken forward. Regional committees may be formed to create and implement strategies throughout the state. Most importantly, these committees will work to create stronger partnerships between hospice and palliative care organizations, health professionals, and community members.
The need for community and hospitalist provider education was voiced, as was the overall goal to eliminate confusion about what hospice care entails, and how it is paid for.
The full report of the study can be read here: www.vnacares.org/wp-content/uploads/2015/11/FINAL-VHS-REPORT-pdf-version.pdf.
