The National Advisory Committee is a 21-member citizens’ panel of nationally recognized rural health experts that provides recommendations on rural issues to the Secretary of the Department of Health and Human Services. Each year, the committee selects one or more topics upon which to focus.
The policy brief published by the National Advisory Committee in 2013, “Rural Implication of Changes to Medicare Hospice Benefit,” was an important beginning of research on rural and hospice.
The Office of Rural Health Policy continues its interest in hospice and palliative care in rural areas, most notably with a project calling for quantitative and qualitative research. The Rural Health Reform Policy Research Center, a partnership between the University of North Dakota Center for Rural Health and the Walsh Center for Rural Health Analysis at the University of Chicago, was tasked with this important research assignment on rural hospice and palliative care which lead to a policy brief, “Perspectives of Rural Hospice Directors,” published in March 2015.
Methods for the research project included a qualitative study involving phone interviews with rural hospice directors (or key staff) in 47 states, a focus group of rural hospice directors, and a comprehensive literature review.
From the beginning, the National Hospice and Palliative Care Organization worked collaboratively with the researchers to identify rural hospice providers for interviews, identify a focus group for in depth discussions of rural hospice issues, and to review and comment on quantitative findings from the CMS claims data. Additionally, the NHPCO Rural Task Force served as an expert panel providing an overview of operations, environmental conditions, terminology, and overall contextual development for rural hospice issues.
Qualitative Research on Hospice in Rural Areas: Key Findings
The research team identified six primary issues (which are covered in more detail in the report):
Rural hospices struggle financially. Among shared concerns, interviews with study respondents indicated that the “level and adequacy of reimbursement, operational costs that are not factored into the per diem rate, equity with urban hospices, and other factors” were challenges to remaining financially viable.
Perceptions of excessive regulatory requirements creates financial and workforce implications. Those interviewed focused almost entirely on federal regulations, like the “face-to-face” requirement for recertification. The impact of regulatory requirements that take staff time away from direct patient care was cited. Ways the perceived regulatory burden affect staff in terms of morale and burnout were discussed as well.
Rural hospice workforce availability is influenced by a number of contextual conditions that include supply and demand, workplace setting, competition, economics, rural factors (as mentioned below), and compliance. Recruiting and retaining qualified staff members is a challenge for rural providers when urban providers often offer better salaries, benefits, and hours. Issues involving future staffing needs are a concern. Other factors researchers found include heavy workloads, small staff size, the need to wear “multiple-hats,” and limited options for education and training.
The most common theme researchers found involved issues of travel and distance – known as “windshield time” – that present unique workforce, financial, and management implications. Furthermore, the study found the elements in rural environments, while not necessarily unique to rural hospice organizations, do factor adversely in operations. Factors include population changes, volunteer availability, and perceived livability for recruitment purposes. Economic factors such as poverty rates, income levels, and fluctuating economic conditions were also important issues.
Hospice providers cited relationships with other provider organizations as significant. These include such areas as referrals, purchasing, and employment. Competition with other providers raised concerns with perceptions that urban/larger hospice programs had greater resources available. Competition with nursing homes was noted by some respondents. It should be noted that relationships with critical access hospitals were positive.
While not seen as a primary issue – none of the 53 respondents identified it as their highest rated concern – technology issues did generate a number of specific concerns, such as connectivity in rural areas, efficiency, the possible utilization of more technology in direct patient care, financial and added cost implications, and adaptability to new and/or complex technology. For example, access to Internet service was a significant issue which included: no Internet service available, speed constraints, blackouts, dead zones, power outages, and other factors. A typical problem identified was access in a private residence. While the central hospice site may have Internet access, it was difficult to access in many patient homes.
The six foremost issues described in the study are not mutually exclusive as they tend to overlap and influence each other.
This is a complex issue that requires ongoing research that will rely on the findings from these previous projects. The work of the NHPCO Rural Task Force will continue and the organization is committed to helping providers in rural and frontier areas with issues unique to their geographic regions.