Saturday, December 31, 2011

"Corporatizing" Hospice- More Heart Needed

Across the health care system, the quest for efficiency is tightening processes into numerically competitive strategies.  Each behavior has to generate a profit.  Does hospice have to follow suit?

Is hospice becoming too corporate?

I wonder because I think of the changes over the years that I've seen in hospice procedures.  As a family physician, I usually have a patient or two in hospice care at their homes, with me as their "attending" physician.  My small business mentality has to merge with some aspects of the big business mentality of our two larger hospices in the Dayton, OH area.  The personal nature of Family Medicine gets me used to relating to the patient and their family in the context of their life and work.  The relationship-based nature of the specialty makes it more meaningful for both patient and doctor.

Large hospice corporations, whether for profit or not-for profit, have more functions and people per unit of time to consider, making their management less able to personalize with patients in the same way.  They often have wonderful front line professionals (about whom I've posted to this blog before) to interact with patients, but sometimes hamstring them with bureaucracy.  They are not used to dealing with individual physicians who aren't tightly connected to their system of policies and protocols.  I've found this to be true repeatedly for the last eight to ten years.

On weekends, there have been surprising obstructions to patient care generated by the use of regional call centers to triage information about patients.  I suspect that the business people of hospice noticed a cost savings with this decision.  People, though, don't benefit by the efficiency.  Especially dying people and their families.

I remember a weekend call to our office phone system that allows a recorded message and pages the doctor on call.  A hospice nurse was at my patient's home and left a message that she needed an order for more morphine.  The number she left was a call system for hospices located in another state.  It took four more calls (and an hour) for me to connect with the nurse who was no longer with my patient.

Another of the large hospices has a similar regional call center on weekends now and the same type situation happens.  The physician who isn't a hospice medical director may have to call the patient's home and speak with family members to find a number for the weekend hospice person (I did).  The number may be the regional call center in another state (like Illinois).  The non health care professional at the center may then connect the physician with Cincinnati where a hospice nurse manager can provide the phone number for the hospice nurse who is covering my patient for the weekend (she did for me).  The local weekend hospice nurse may answer her cell phone or be occupied and have a voice mail system record my message and phone number.  We either talk about my patient right away or later when she calls back (which is always very soon for both our large hospices).

Ordering the "Comfort Pack" which includes morphine (Roxanol), lorazapam (Ativan), atropine and other medications to help with patient comfort toward the end of life is another sometimes cumbersome undertaking with the corporate minded hospices.  I remember giving admitting orders, including the Comfort Pack, on a Friday evening for one of my patients who also had a medical condition which would be helped by the morphine if it flared up.  It did flare up two days later, so I gave the order to use the morphine in the comfort pack to relieve the symptoms.  "It won't arrive for another couple days," I was told, since the hospice orders it from a center in another state.  I was stunned, and disappointed.  Four phone calls later in the local  private health care system (and to the family) had the morphine available for use.

Do we have to "corporatize" hospice to this extent?  Can these big corporations fix the weekend hassles?

Suggestion:  Put nurses in charge of the hospice.  CEO's should all be nurses.  They have a heart for patient care.  They are especially sensitive to end of life issues for individuals (patients) and families.

Dying people are not widgets.  Death is not efficient.  It is natural, though, and should not be over-medicalized.  It is not seen by the dying and their families as a business opportunity.  It should not be corporatized.  Can we upgrade hospice leadership and management to realign with the heart of the hospice movement?  Please.


  1. Thank you for your voice of reason. I hope that it is heard.

  2. You bring up some great points on the problems of applying the economy of scale to health care. While I cannot excuse the delays in these cases, it is a problem that most hospice staff realize impacts patient care. I think it is important to realize that hospice (and the rest of the health care system) do need to work hard on increasing efficiency. There is a lot of waste, but as you correctly point out, we can not do that to the point that the quality of care is impacted. Call centers and getting medications from an out of state pharamcy are not morally good or bad, but the execution of these tools of efficiency needs to be done well to ensure good patient care and flexibility.

    If this happens again or any other similar challenge, I would encourage you to ask to speak to the medical director on call to and express your concerns directly. If I got a call like that from a referring doctor, you can bet there would be changes.

    Thanks for the post.

  3. Susan Wallace, MSWJanuary 5, 2012 at 5:07 PM

    Thanks for this post. As a hospice quality improvement professional, I can tell you that after hours and weekend responsiveness is an area that many hospices monitor because it can be so challenging, and because it's an area that can make or break a hospice experience for a patient and their family.

    I echo Christian's encouragement to dialogue with the hospices. It is the only way that improvements can be made.

    Thanks for this post. It's nice to read the family physician's perspective.

  4. I think there are many simple, available and commonsense workarounds for the problem you described. In the region where I work, there are "corporate" hospices - but the nurses that work for them, at least the good ones, are acutely aware of that fact. So if they need to get a hold of a covering doctor on the weekend or after hours, they will leave a direct number or their personal cell phone to call back, thus avoiding the dreaded automated response systems. These same nurses are familiar with the surrounding health care systems, so they know how to find you to pick up that morphine script, whether its at your office, the local hospital, or pharmacy. Again, we are faced with a large bureaucratic system that is difficult to change, it takes creative and commonsense solutions to get the job done.