Hospices have contended with two agents of industry-wide change at the start of 2021: access to value-based payment models and a global pandemic. As hospices sought ways to balance the human touch with technology, they’ve refocused efforts around advance care planning, a key element of those value-based models. Those services are one more area in which hospices have leveraged technology to advance their goals with limited access to patients.
The pandemic has accelerated a digital shift in the hospice industry, with COVID-19 growing technological innovations in hospice and building bridges between providers and patients alike. It has also spurred many families to consider their goals and wishes for end-of-life or when confronted with a serious illness, leading to greater interest in advance care planning.
Nevertheless, hospices have wrangled with barriers in existing public policy and public perception that limit growth of advance care planning services. Participation in value-based programs can help hospices take a more active role in advance care planning, with more providers ramping up these services.
“We’ve noticed interest and demand for advanced care planning has absolutely gone up — and that’s across all stakeholders — for patients and their families, the physicians, the hospital systems, the health plans,” said Stephen Bekanich, M.D. chief medical officer and cofounder of Iris Healthcare, an advance care planning company based in Austin, Texas. “The way we’re able to share advanced directives has taken off even in the last year or two. Integration can be a heavy lift and can be expensive, but you have to have that bridge built, because you want these documents right there at the point-of-care.”
Hospice providers have leveraged different types of technology to facilitate goals of care conversations with patients and families from a safe distance. Temporary suspension of some regulations by the U.S. Centers for Medicare & Medicaid Services (CMS) during the public health emergency have helped fueled the recent telehealth boom. Despite unknowns regarding the future of telehealth rules, providers expect that telehealth will not be going away when the pandemic fades.
Advance care planning has branched out into a virtual setting with increased use of video and phone conferencing, and technology systems capable of securely sharing documentation, enabling hospice providers to fill in gaps in care delivery.
Patients have been receptive to the implementation of telehealth. Approximately 80% of family caregivers stated they would give a hospice higher ratings if the provider had real-time communication capabilities via computer, tablet and smartphone, but fewer than half (44%) do not use a digital platform, according to a Net Health study from February.
“The patient’s voice should be the loudest one in the room. That should be put on the pedestal. If you aren’t in the room to hear the words or see their body language, there’s so much richness in that communication you’re missing out on” said Bekanich. “Recording these conversations can be very powerful and brings a great deal of peace of mind to everybody involved in the situation.”
Hospices have used telehealth to augment, rather than replace, in-person services. The high-touch experience of sensitive conversations and care at the end of life can’t be substituted, according to Susan Ponder-Stansel, president and CEO of hospice and palliative care provider Alivia Care, who spoke at a recent webinar from The Petrie-Flom Center for Health Law Policy and the Coalition to Transform Advanced Care (C-TAC). Alivia Care also provides advance care management, private duty nursing services, personal care and PACE programs, with plans to provide home health care on the horizon.
“Technology does bring some benefits. We also found that there’s no substitute for human presence as a patient nears the end of life,” said Ponder Stansel. “What’s good about technology is efficiency, more access and more patient control into that high-touch experience that is hospice care. Those kinds of lessons we’ve learned can apply to any of the services that we offer.”
Advance care planning discussions are currently reimbursable through Medicare and traditionally taking place in physician offices or other primary care settings. However, many hospices are taking a primary care role within emerging payment models.
Diversifying services is among the many ways hospices can demonstrate their value proposition to payers as value-based payment models take effect. Value-based payment programs such as Medicare Advantage and direct contracting include a range of new paths for providers to broach, with advance care planning among the reimbursable services. Broadening the scope of care and services and tracking patient care data will be essential next steps for hospices participating in these demonstrations.
A value-based world can allow hospices to drive advance care planning conversations sooner and potentially reach a wider base of patients. Technology is increasingly seen as a way to get in front of patients and their families to engage in goals of care discussions in a more proactive, upstream fashion. Yet, these changes don’t eliminate the need for necessary transformation in the larger health care system, according to Ponder Stansel.
“Technology isn’t a silver bullet. It’s another thing we can integrate into practice to improve the care that we deliver to patients with serious and advanced illness,” said Ponder Stansel. “[Technology] won’t address that fundamental systemic issue, which is a commitment to improving the care that people receive. Right now, we have a very fragmented system that’s very frightening, isolating and lonely for those who have to navigate it. There hasn’t really been a will to make the kind of disruptive changes that need to happen to allow that continuum of care to be created outside of the hospice benefit and further upstream in a patient’s illness.”
Value-based care brings both challenges and incentives. They tend to be risk-based reimbursement systems that offer increased opportunities to collaborate with other providers to identify patients in need of advance care planning.
Video calls, cloud-based operating systems and predictive analytics are some of the technologies making waves in the hospice space. Speech recognition software has allowed for verbal authorization and recording of advance care directives and other documentation.
According to Bekanich, removing the requirement to do advance care planning in person allows hospices to explore a hybrid approach of technology and in-person discussions in a more approachable way for patients and their families.
“The more complex your patient’s situation — that doesn’t just mean your medical issues that could mean family dynamics or other things happening in your life that are non-medical — then that full-service approach [using technology] is probably going to be more beneficial and can certainly result in a higher yield of completed documents,” Bekanich told Hospice News. “We have hybrid models that can start with the technology, and then call somebody in to help and show them how to have the [advance care planning] discussions.”