How Hospice, Behavioral Health May Cross Paths

Hospice and behavioral health care could increasingly intersect in coming years as demand for specialized care grows.

In some respects, the two sectors are already inextricably linked, given the holistic nature of hospice care, including attention to patients’ psychosocial and spiritual needs as well as bereavement support for families. But the prevalence of mental health conditions and related concerns like isolation and substance abuse mean that hospice and behavioral health providers may need to find more ways to integrate their services.

In addition to the psychological toll of serious and terminal illnesses, an estimated 5.6 million to 8 million older adults in the United States have one or more mental health conditions. They represent 14% to 20% of the nation’s overall senior population, the National Academy of Sciences (NAS) recently reported. The most prevalent and increasingly common conditions among aging populations are dementia-related behavioral and psychiatric symptoms and depressive disorders, NAS researchers found.

“Many people living with serious medical illnesses also suffer from comorbid behavioral health issues,” the Center to Advance Palliative Care (CAPC) indicated in a 2020 report. “Patients may be receiving some kind of behavioral health support, but even when available these interventions are time-limited or poorly aligned amidst myriad scenarios. Patients at the interface of behavioral health and serious illness care almost always require additional social services that go beyond the immediate clinical realm.”

As complex medical and psychosocial needs proliferate among patients, providing comprehensive and goal-concordant care will likely require hospices to address behavioral health comorbidities or partner more closely with providers in that field.

Behavioral health integration not only represents an additional ladder of support for patients, but also a business opportunity for providers to maintain a foothold in two sectors primed for substantial growth.

The hospice market is expected to nearly double in the next decade, reaching $64.7 billion in 2030 from $34.5 billion in 2022, a report from ResearchandMarkets estimated. For behavioral health, projections run as high as $105.14 billion by 2029, a rise from $76.44 billion in 2021, according to Fortune Business Insights.

And already, a rising number of providers are ramping up efforts to bring these two essential services closer together through collaborations, partnerships, mergers and acquisitions.

Last year, VNA Health Group enhanced its dementia care training programs for social work and nursing staff, with an emphasis on its home health patients. This included education on how to identify cognitive impairment and, when appropriate, connect patients with community resources or other providers.

VNA Health also has plans to possibly add psychiatric advanced practice nurses into their clinical teams, though this initiative is in its early stages.

“I cannot pinpoint exactly how people will do it, but I do expect more attention and program- and service-line development in mental and behavioral health within the home health and hospice sectors,” VNA Health Group President and CEO Steven Landers told Hospice News. “Basically, there are gaps in need, and that both presents an opportunity for entrepreneurship and social entrepreneurship. I think that’s going to be a continuing area of focus.”

Another recent example came in December, when Arizona-based Hospice of the Valley launched a community education program to help inform health care providers about dementia care support and patients’ changing needs as they age. Offered at the hospice’s Dementia Care and Education Campus, the program aims to reach more than 3,000 health providers within the next year with the goal of enhancing care for patients suffering with cognitive impairment.

“I know how helpless physicians and nurse practitioners can feel when confronted with patients struggling with dementia. Not only problems related to diagnosis and treatment, but also the myriad challenges that arise in the social realm,” Hospice of the Valley Executive Medical Director Ned Stolzberg told local news. “Awareness of even the basic tools to address some of this will greatly empower our medical community.”

Also last year, Elara Caring and Oak Street Health (NYSE: OSH) each developed integrated care models designed to better address behavioral health needs among seniors. Texas-based Elara Caring offers hospice, palliative and personal care in addition to behavioral and home health. Chicago-based Oak Street Health consists of a network of value-based primary care facilities that serve upwards of 145,000 Medicare beneficiaries across 21 states.

Integrating care models could help save money downstream, according to Katherine Suberlak, vice president of clinical services at Oak Street Health. Mental illness directly impacts a patient’s ability to engage in health care, come to appointments, and take their medications, Suberlak previously told Hospice News sister site Behavioral Health Business.

“It’s very helpful to our care teams to have the added specialty there,” Sublerlak said. “And then lastly, we see the outcomes, that it impacts our total cost of care when we include behavioral health as a service to our patients. It’s the right thing for the patient, clinically.”

Other hospices have gone as far as acquiring behavioral health businesses.

Case in point, Maine-based Androscoggin Home Health Care + Hospice last year acquired behavioral health and home care company Care & Comfort for an undisclosed sum, fueled by a demonstrated need for those services in their home state.

Androscoggin’s new business line opens up a range of potential referral partners, as well as an attractive Medicaid reimbursement structure. The company stands to receive Medicaid payments via medical homes and behavioral health homes, which are designed to lower costs and improve care quality for patients with chronic and complex health needs.

“The behavioral home model for reimbursement is very appealing to us,” Androscoggin CEO Ken Albert told Hospice News at the time of the deal. “We are clearly looking to expand into [licensed clinical social workers and licensed clinical professional counselors] and other behavioral health services as a means of being a partner to our other referral sources for a full-range of home based services, including behavioral health. It’s going to depend on whether or not we can leverage that cohort of that population and behavioral health across all of our other service lines from a revenue perspective, delivery infrastructure, and how can we decrease the overall costs in all of the service lines at a shared services level.”

The providers making these investments are working to address a vast unmet need among seniors and the general population. Less than half (46.2%) of adults nationwide with a mental illness received care or treatment in 2020, according to data from the National Alliance on Mental Illness (NAMI).

Serious mental health and substance abuse conditions are also associated with higher rates of hospitalization, nursing home and facility-based placement, as well as other types of high-cost emergency and health service utilization, according to NAS researchers.

These conditions also put a burden on family caregivers, just as many medical ailments do. The United States has an estimated 8.4 million caregivers of adults with mental or emotional health issues who spend an average of 32 hours weekly providing unpaid care, NAMI reported.

Despite the potential benefits in terms of patient quality of life, reduced high-acuity utilization and the business opportunity for providers, closer integration won’t be easy.

An obvious challenge is the ubiquitous labor shortages in health care, which persist in behavioral health as well as hospice. Roughly 158 million Americans live in designated mental health professional shortage areas, according to data from the U.S. Health Resources & Services Administration (HRSA).

Both sectors are also plagued by widespread social stigma and limited understanding of the nature of the services they provide, including among clinicians who are in a position to make referrals.

Other barriers pertain to funding for provider reimbursement and further research into patient needs and best practices, according to Cameron Muir, M.D., chief innovation officer for the National Partnership for Healthcare and Hospice Innovation (NPHI). Muir also serves as chief innovation officer for Capital Caring Health headquartered in Virginia and chief medical officer for Hospice of the Piedmont.

Bereavement care, for example, may be the least defined aspect of hospice care within Medicare rules, which say little more than that providers must have an “organized program” furnished by qualified professionals that reflect the families’ needs.

Hospices also lack quality measures associated with bereavement care. None appear in the Hospice Item Set or Hospice Care Index.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey does include a question related to emotional support families received from the hospice team in the weeks after their family member died. But regulations require hospices to send out the surveys within two months of the patients’ death, meaning that many responses may not reflect the full scope of the required 13-month bereavement period.

Though new quality assessment methodologies are in development, it remains to be seen if they will address bereavement care. The U.S. Centers for Medicare & Medicaid Services (CMS) is currently testing the forthcoming Hospice Outcomes & Patient Evaluation (HOPE) quality measurement tool, which is not yet available for public viewing.

These barriers have long-plagued hospices seeking to further integrate behavioral health care, Muir previously told Hospice News.

“You have a challenging recognition that it is really important to provide behavioral mental health for hospice family members in addition to the patient, but a complete disregard for how that’s supposed to be sustained economically with a regulation that’s effectively unfunded,” Muir said. “The research funding is a complete disconnect from the everyday experience of hospice and palliative care providers. This is such a big issue.”

However, other avenues of behavioral and mental health services are “grossly underfunded both on the research side and on the reimbursement side,” Muir told Hospice News.