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.