||There is evidence available from clinical organizations and panels, as well as from individual studies, supporting the measure's basis that clinician visits to patients at the end of life are associated with improved outcomes for both the patients and their caregivers.
The last week of life is typically the period in the terminal illness trajectory with the highest symptom burden. Particularly during the last few days before death, patients experience many physical and emotional symptoms, necessitating close care and attention from the integrated hospice team and drawing increasingly on hospice team resources (de la Cruz 2014, Dellon 2010, Kehl 2013). Highly specific physical signs associated with death were identified within 3 days of death (Hui et al., 2014).
Hospice responsiveness during times of patient and caregiver need is an important aspect of care for hospice patients (Ellington 2016). Although Medicare-certified hospices do not have any mandated minimum number of required visits for patients in routine home care (RHC), the most common level of hospice care, at the end of life, hospices should be equipped to meet the higher symptom and caregiving burdens of patients and their caregivers during this critical period (Teno 2016). Clinician visits to patients at the end of life are associated with decreased risk of hospitalization and emergency room visits in the last 2 weeks of the patients' life, decreased likelihood of a hospital-related disenrollment, as well as decreased odds of dying in the hospital (Sewo 2010, Phongtankuel 2018, Almaawiy 2014). In addition, clinician visits to patients at the end of life is also associated with decreased distress for caregivers and higher satisfaction with home care (Pivodic 2016).
Visits by staff who can assess symptoms and make changes to the plans of care as well as work with the patient and the primary caregiver to provide the appropriate palliation and emotional support (nurses, social workers, and physicians) are important to the quality of care hospices deliver, as noted by the NQF's preferred practices on the recognition and management of the actively dying patient (Teno 2016). During the development of the Family Evaluation of Hospice Care survey, families voiced the importance of visits by these staff in the last days of life (Teno 2016).
de la Cruz, M., et al. (2015). Delirium, agitation, and symptom distress within the final seven days of life among cancer patients receiving hospice care. Palliative & Supportive Care, 13(2): 211-216. doi: 10.1017/S1478951513001144
Dellon, E. P., et al. (2010). Family caregiver perspectives on symptoms and treatments for patients dying from complications of cystic fibrosis. Journal of Pain & Symptom Management, 40(6): 829-837. doi: 10.1016/j.jpainsymman.2010.03.024
Kehl, K. A., et al. (2013). A systematic review of the prevalence of signs of impending death and symptoms in the last 2 weeks of life. American Journal of Hospice & Palliative Care, 30(6): 601-616. doi: 10.1177/1049909112468222
Hui D et al. (2014). Clinical Signs of Impending Death in Cancer Patients. The Oncologist. 19(6):681-687. doi:10.1634/theoncologist.2013-0457.
Ellington, L., et al. (2016). Interdisciplinary Team Care and Hospice Team Provider Visit Patterns during the Last Week of Life. Journal of Palliative Medicine, 19(5), 482-487. doi: 10.1089/jpm.2015.0198
Teno, J. M., et al. (2016). Examining Variation in Hospice Visits by Professional Staff in the Last 2 Days of Life. JAMA Internal Medicine, 176(3): 364-370. doi: 10.1001/jamainternmed.2015.7479
Seow, H., Barbera, L., Howell, D., & Dy, S. M. (2010). Using more end-of-life homecare services is associated with using fewer acute care services: A population-based cohort study. Medical Care, 48(2): 118 124. doi: 10.1097/MLR.0b013e3181c162ef
||This measure addresses a high priority area by assessing hospice staff visits to patients and caregivers during the final days of life when patients and caregivers typically experience higher symptom and caregiving burdens, and therefore a higher need for care. Collecting information about hospice staff visits for measuring quality of care will encourage hospices to visit patients and caregivers and provide services that will address their care needs and improve quality of life during the patients' last days of life. We conducted testing using 100% of Medicare hospice users discharged to death in FY2018 (n=1.1 million beneficiaries) for previously developed Measures 1&2 and the new measure, RN or MSW visits each day in the last three days of life, allowing for one missed day. There 3,594 hospices with reportable data for Measure 1, 3,579 hospices with reportable data for Measure 2, and 3,569 hospices with reportable data for the newly specified measure.
The previously developed Measures 1 & 2 had mean scores of 89.3% and 72.9% (medians 14.9% and 16.6%, respectively); IQRs 86.5%-98.7% and 64.8% and 84.6%. Validity was assessed by calculating the correlation between the measure scores and the hospice's percentage of caregivers who would recommend the hospice; the Pearson correlation coefficients were 0.2166 and -0.0984 for Measures 1 & 2, respectively. We assessed reliability using split-half reliability analysis and the intraclass correlation coefficients were 0.861 and 0.817 for Measures 1 & 2, respective.
For the new measure, the mean measure score across hospices was 64.8% (median 70.2%; IQR 53.0%-80.9%. Validity was again assessed by calculating the correlation between the measure score and the hospice's percentage of caregivers who would recommend the hospice; there was high evidence of validation with a (Pearson's) correlation of 0.2418. We also again assessed reliability using split-half reliability analysis and there was also high evidence; the intraclass correlation coefficient on this test was 0.893, indicating high evidence for reliability (the minimum threshold of acceptability is often given as 0.80).