Background: Concurrent care hospice allows veterans to have both disease-modifying therapy, such as chemotherapy, and hospice care. While available nationally since the VA Comprehensive End-of-Life Care Initiative 2009-2012, it has not been implemented uniformly. The palliative care team at the Minneapolis VA began to actively promote concurrent care in July of 2018. Our team includes three physicians, one nurse practitioner, social worker, hospice nurse coordinator, palliative RN, chaplain, and oncology clinical nurse specialist. We hope to share what we have learned as an interdisciplinary team and how we will continue to promote concurrent care going forward.
Results: To date, 38 patients have enrolled in concurrent care hospice through 13 hospice agencies. By chart review, we found that most patients have died (22/38 enrolled). The average length of time to death from the initial enrollment with concurrent care hospice was just over 60 days, while the average for usual hospice cancer patients is about 50 days. Two patients enrolled longer than 6 months are still living. Most patients died at home or a nursing home (19/22) while 2 died in our CLC and 1 at our inpatient hospital.
Discussion: We have identified several barriers to enrollment. Hospices have expressed concern that concurrent care is not consistent with the philosophy of hospice care and may result in withheld Medicare payments. Our hospice coordinator has invested a significant amount of time educating hospices and establishing relationships. Several agencies have declined to enroll these patients and for agencies accepting patients, the review process is more rigorous and time-consuming. Internally, our biggest partners are in oncology. We had the opportunity to present our initial data and rationale for concurrent care at a monthly oncology staff meeting. While many staff saw the benefit of adding hospice support, several physicians expressed concern that hospice patients will not receive proper medical attention for chemotherapy- related side effects. We discussed communication as the best tool to help veterans and hospice agencies understand the needs of concurrent care patients. Going forward, we hope that concurrent care becomes a normal, utilized component of best practice for our veterans.
