Joanne Ford knows all too well the challenges hospice faces in senior living.
“One of the barriers for people making referrals to hospice from assisted living facilities is (AL operators say), ‘We don’t want people to see hospice in our building — please don’t wear your name tag here,’” says Ford, vice president of the AL division of Tidewell Hospice out of Sarasota, Florida. Tidewell delivers hospice services to residents in 174 AL facilities, with an overall average daily census of more than 1,100.
“We actually have corporate entities that tell their folks, ‘Don’t refer to hospice. We don’t want that image in this building,’” Ford says. She spoke with Senior Housing News for a recent deep-dive report exploring the pressing need for senior living providers to formulate hospice strategies, and the significant benefits they could see from doing so.
That trepidation is fading. Utilization of hospice — a spate of end-of-life services for the terminally ill geared toward a person’s physical and spiritual wellbeing — is rising in the U.S., particularly in assisted living. As more senior living operators explore hospice, what they are finding is a barrage of trends, statistics and use cases that highlight the unique value hospice has within senior living.
Here are five of the biggest.
1. Hospice utilization trends are rising — both overall and in AL
Since the start of the decade, hospice utilization has boomed. National Hospice and Palliative Care Organization (NHPCO) data shows that the percentage of Medicare decedents receiving one or more days of hospice care rose from about 44% in 2012 to 48% in 2017.
Zoom out to 2011 as the starting point and 2019 as the endpoint and we see greater growth. A HealthPivots analysis of Medicare Standard Analytic Files shows a 35% increase in average daily census in hospice from 2011 to 2019, jumping from about 234,000 patients to about 317,000 patients.
The change is even more stark when broken down into care settings. Hospice patients in hospitals have dropped by 20% in that time, while hospice patients in assisted living have doubled, from nearly 32,000 patients in 2011 to nearly 64,000 in 2019.
This rise can be attributed to two main factors. The first is the increase in the 65+ population, which in turn is boosting the AL population. The second is the increased comfort level consumers have with hospice as a care stage, which comes in part from AL operators educating families and residents about the benefits of hospice, and doing so early in a person’s illness.
“I think operators are getting savvier with the importance of hospice in senior living,” says Loren Shook, founder, president and CEO of Irvine, California-based Silverado, a memory care leader that owns 11 hospices. “There is a greater awareness to the importance.”
2. Hospice in senior living remains underutilized, offering room for growth
In a boon to operators considering finding ways to bring hospice to their residents, utilization has grown at a faster rate than the senior population over a similar timeline. The hospice population grew 35% from 2011 to 2019, while the 65+ population in the U.S. grew 30% from 2010 to 2018, per U.S. Census data.
While not all hospice patients are over 65, most are. And with the 65+ population projected to eclipse the under 18 population in 2035, even a plateauing of hospice participation within that population will still leave massive raw numbers.
Yet those numbers have a long way to go yet in senior living, leaving the immediate possibility for growth. According to a 2019 study from United States Department of Health and Human Services, about 68% of residential care communities, including assisted living, offered hospice in 2016, compared to nearly 81% of nursing homes.
“I think (the rise of hospice in AL) is just a recognition of the benefits of hospice,” says David Macke, Director of Reimbursement Services for VonLehman CPA & Advisory Firm. “People in assisted living are probably more sophisticated than (other care providers) in promoting it.”
3. Hospice length of stay is significantly higher in AL than any other setting
Arguably the most compelling statistic around the hospice opportunity in assisted living is length of stay (LOS). As the national comfort level around hospice increases, and the rate of chronic illness among seniors also increases, the number of assisted living residents who opt for hospice care will rise as well.
As this happens, these seniors and their families will face a choice. They can leave their AL community and enter hospice care in another setting, or they can remain in their AL home and receive hospice there.
The ever-growing desire among seniors to age in place means that many will prefer to receive hospice in their senior living community. Senior living operators that facilitate that care will have the inside track to keeping their residents in their communities for much longer than would otherwise be possible.
That’s because hospice patients receive more days of care in assisted living than any other care setting. According to a July 2017 report from the Journal of the American Geriatrics Society (JAGS), the average hospice patient in AL receives 112 days of care, compared to the overall average of 70 days. Twenty percent of hospice patients in assisted living remained in hospice care for more than 180 days, which is the six-month mark afforded by the Medicare hospice benefit.
That total eclipses any other setting, such as 13% in nursing homes and 6.6% for hospice patients living at home. Looking at just the percentage of hospice patients exceeding 60 days of care, only 21% of patients living at home and only 29% of patients in nursing homes meet that mark.
In assisted living, that figure is 42%.
“There are studies that show that patients who have been on hospice do live longer lives with better quality of life,” says Kristy Krumwiede, a registered nurse at Lutheran Senior Services. “Our patients do live longer, and that’s even with diagnoses of cancer. Due to the additional support, they are less depressed and they do have a meaning to live.”
4. Hospice and palliative care reduce hospitalizations
A person enters hospice when they are terminally ill, with hospice serving to improve the quality of their remaining time alive. But hospice is a sort of self-fulfilling prophecy in the sense that its ability to improve the quality of life is so great that it even extends the patient’s life.
A 2007 study published in the Journal of Pain and Symptom Management and funded by NHPCO analyzed 4,493 patients from the Medicare beneficiary population for 1998 to 2002, and found that the hospice patients therein had a mean survival of 29 days longer than the non-hospice patients.
Senior living operators have seen these benefits too. Hospice eliminates what can be intrusive procedures while increasing a person’s access to caregivers, CNAs and other aides that provide support both physical and spiritual.
Lastly, because these patients are now in hospice and are no longer receiving curative care, their hospital admissions drop, which helps the patient and helps the senior living operator that increasingly is working with health systems and payers to manage population health.
“We knew the importance of not having to transfer end-of-life to a higher level of care, which was normal in the industry and is normal today,” Shook says. “(It is also) a lot of trauma on the family. We didn’t want that to happen and we didn’t think that needed to happen.”
5. Dementia overlap between AL residents, hospice patients
Looking at the dramatic difference in LOS for hospice patients in AL compared to other settings, the question arises: Why? Why are patients remaining in hospice so much longer in AL than these other settings?
There are a few explanations. Because seniors in AL are in a health care setting, they are more likely to be educated about hospice earlier in their lives. They also benefit from the coordinated care and other health-related capabilities of their AL facilities.
But perhaps more significantly, the typical long-stay hospice patient correlates with the typical AL resident in terms of diagnosis.
The people who stay in hospice the longest are those whose primary terminal diagnosis is dementia. And the hospice patients for whom dementia diagnoses are highest are those living in AL.
That diagnosis prevalence tracks with the overall dementia population in AL. A 2018 New York Times story noted that 40% of AL residents have dementia, while a 2014 study showed that as many as 70% of AL residents had some form of cognitive impairment.
Regardless, the rise in dementia has contributed to the rise in AL population, a trend that aligns with the hospice data in the JAGS report. That study shows that for hospice patients, cancer is the most common primary terminal diagnosis — that is, the disease that puts them into hospice — at 33%. Next up is dementia at 21% and then cardiovascular disease at 11%.
But those numbers change based on the care setting. Cancer is the primary terminal diagnosis for close to 53% of hospice patients living at home, with dementia at 9%. In nursing homes, cancer is 17% with dementia at 30%, and those rates continue in those directions in AL, where cancer is just 11%.
The highest terminal diagnosis for hospice patients in assisted living is dementia, at 35.6%.
And when it comes to hospice, dementia patients will likely always have a longer LOS than cancer patients. One major reason is that when a person enters hospice, they must rescind their other Medicare benefits related to the diagnosis and end all curative care.
As a result, cancer patients tend to enter hospice much later than those with other diagnoses. Conversely, dementia is a much more elusive disease to treat, which removes some of the concern from doctors that they are “giving up” when they push hospice for one of their patients.
This article draws from the new report, “Why Senior Housing Should Embrace Hospice.”
Click here to access the complete report, which digs deep into these five trends, reveals the three benefits senior housing operators miss out on if they don’t facilitate their residents’ hospice and fully explores the evolving world that is increasingly bringing hospice into senior housing.