Hospices Stepping Up Performance on Visits-in-Last-Days-of-Life Measure

Hospices, in aggregate, are showing improvement on the quality measure for visits in the last days of life.

The number of registered nurse and social worker visits during a patient’s final week is one of the seven quality measures that CMS uses to evaluate providers. In Calendar Year 2021, the share of hospice care days with nurse visits in the last seven days of life rose to 63%, up from 62% year over year, according to the National Hospice and Palliative Care Organization (NHPCO).

While the change is modest, this is the first uptick since the onset of the pandemic, which came with a precipitous drop in these visits. In 2019, for example, the percentage was 66%. Social worker visits in the last days of life also rose to 9% in 2021, up from 7% in 2020.

One major factor is the gradual subsiding of the COVID-19 outbreak.

“We believe that the end of pandemic restrictions and the easing of public fears about the pandemic contributed to increased visits in the last days of life, especially for hospice patients in nursing facilities for whom visits were often significantly limited during COVID-19,” Sarah Simmons, director of quality for NHPCO, told Hospice News in an email.

One factor to note is that this measure captures only nurse and social worker visits and excludes other members of the interdisciplinary team, such as aides, licensed practical nurses, spiritual counselors, bereavement counselors and physicians, and beginning in 2024, mental health counselors and marriage and family therapists, according to Simmons.

Patients may be receiving several visits from these professionals during the last days of life, or multiple visits on the same day, that do not count toward the measure, she said.

The U.S. Centers for Medicare & Medicaid Services (CMS) has developed a financial incentive to foster better performance on the measure, the service-intensity add-on.

CMS introduced SIA in 2016. It allows hospices to bill on an hourly basis for registered nurse and social worker visits during the last seven days of a patient’s life, in addition to the standard per diem reimbursement. Staff can bill for these services for as many as four hours each day in the last week of life.

SIA utilization has risen incrementally since its inception. More than $200 million SIA payments were distributed in 2021, compared to less than $100 million in 2017, according to the Abt research. In terms of patients, that’s more than a million beneficiaries receiving SIA services in 2021, versus under 850,000 beneficiaries in 2017, the data found.

One method that hospices are using to boost their performance on the measure is predictive analytics designed to identify patients in their final days.

A recent analysis by St. Croix Hospice and Medalogix found that such technology has generated improvements on the metric and contributed to smoother care transitions.

Through the predictive analytics data, hospice patients at St. Croix received an average of roughly 10.3 visits in the last seven days of life between May and November 2023. Quality ratings among these patients and their families reached 90% higher than national averages, the case study found. Additionally, 90% of families reported a willingness to recommend the hospice provider to others.

However, though predictive analytics can help, these systems are not a cure-all, according to Patrick Harrison, senior director of regulatory and compliance for NHPCO.

“Predictive analytics are another helpful tool in enabling providers to plan for and determine the right time to deliver care, particularly in the last week of life,” Harrison told Hospice News in an email. “However, just as with other data-driven tools, it’s important that providers still marry the metrics with their knowledge of each patient’s unique disease trajectory and needs. Predictive analytics offer a piece of the puzzle, not the full picture.”

Additional touchpoints with patients via telehealth is another factor contributing to improvements on the measure, Harrison said.

The greatest barrier to further improvement is the ever-present workforce shortage affecting the health care industry at large and hospices in particular.

“Staffing shortages continue to impact providers’ ability to appropriately triage patients’ care needs,” Harrison said. “One of the immediate challenges hospices face in supporting their staffing structure is almost complete reliance upon Medicare as a payer source to provide resources necessary to both attract and retain a skilled and robust workforce. Hospices are uniquely impacted and must compete for a limited pipeline of workers with limited resources.”