Exploring Hospice Live Discharges in the Carolinas

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High and variable rates of patients leaving hospice before death have increasingly caught the attention of health services researchers. Found to be associated with poorer patient outcomes and higher medical expenditures, these so-called live discharges may reflect poor quality care or that the Medicare hospice benefit is not being used as intended. This dissertation uses quantitative and qualitative methods to investigate factors relating to live discharges from three novel perspectives. There is substantial state variation in live discharge rates, yet despite the influence of local factors on health care utilization, research has not explored variation in live discharge rates at the county level. My first study assesses the relationship between county-level characteristics and live discharge rates in North and South Carolina’s 146 counties using fractional logistic regression analysis. I find that greater hospice market competition and the presence of a hospital in the county with inpatient palliative care were associated with a lower live discharge rate. I also find that an increase in the proportion of the county population living in poverty was associated with a higher rate of live discharge. Lastly, counties in South Carolina (which lacks hospice certificate of need (CON) legislation) had a significantly higher rate of live discharge than counties in North Carolina (which has hospice CON legislation). My second study examined the relationship between characteristics of 168 hospice providers and live discharge rates in North and South Carolina. Using fractional logistic regression analysis, I found that being located in counties with lower hospice market competition was associated with a lower live discharge rate. Having a greater proportion of patients who had state buy-in, who had a primary hospice diagnosis of cancer, who were white, and who were older was associated with lower live discharge rate. Additionally, I found that having a higher proportion of patients in assisted living facilities was associated with a higher rate of live discharge. Being a for-profit hospice provider was also associated with a higher live discharge rate. Finally, I found that providing general inpatient level of hospice care was associated with a lower rate of live discharge. The hospice admission is typically a patient’s introduction to hospice. Often conducted during a period of heightened emotions and stress, this interaction offers an opportunity for hospice staff to assess patient and caregiver readiness for and understanding of hospice services, ensure support throughout the patient’s disease course, and prepare patients and caregivers for the reality of managing a terminal illness most often in the home setting. Through 35 semi-structured interviews, this third study explored hospice admission staff and bereaved caregiver perspectives of the hospice admission process. Our findings indicate three overarching areas where the transition to hospice might be improved: referring provider issues, hospital discharge process, and the first touch of hospice. Staff interviews also provided insight into how the Covid-19 pandemic had altered the conducting of hospice admissions. Optimizing the hospice admission process may be one avenue for reducing future live discharges. These studies contribute to our understanding of variation in live discharge rates across geographic regions and between hospice providers. Additionally, our interviews with hospice staff and caregivers offer important perspectives on the hospice admission process and areas for improving the transition to hospice. Findings from these three papers may inform policy and practice changes to improve end-of-life care outcomes and potentially reduce unnecessary disenrollment from hospice.






Cross, Sarah Harrington (2021). Exploring Hospice Live Discharges in the Carolinas. Dissertation, Duke University. Retrieved from https://hdl.handle.net/10161/23122.


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