After completing her internal medicine residency, she couldn’t find a hospice-related position, but she had learned to appreciate the pace and complexity of hospital medicine. After doing locum tenens (temporary assignments), she landed in the hospitalist position at UTHCT. The 100-bed facility began as a tuberculosis hospital housed in a former U.S. Army base in 1949, and in 1977 it became part of the University of Texas health system.
Today Dr. Praszek heads a three-person hospital medicine department, with another physician and a physician’s assistant and the backup of 10 clinic physicians for after-hours coverage. Her job combines both clinical and administrative responsibilities, including risk assessments, protocol development, and the ethics committee. Roughly 10% of her time is devoted to patients on the hospice unit.
The family room at UTHCT.
Providing Necessary Care
Hospice is an approach to the care of patients with life-limiting illnesses and their families, emphasizing the relief of pain and other symptoms, maximizing quality of life and support for the emotional and spiritual issues that come up at this time of life. Under the Medicare Hospice Benefit (introduced in 1983) Medicare-certified hospice programs are responsible for providing essentially all of the care needed to manage their enrolled patients, who have a life expectancy of six months or less. Medicare pays the hospice a daily packaged rate for its services—all-inclusive except for attending or consulting physicians, who are able to bill separately. Although the hospice benefit is primarily intended as a service in the patient’s home or other place of residence, such as a nursing home, often terminally ill patients require inpatient care for short periods to bring their medical symptoms under control.
To fill this need, hospice programs can open their own freestanding inpatient facilities, as Hospice of East Texas did with its 28-bed HomePlace, or else contract with a hospital for inpatient beds, as the hospice did with UTHCT. Those involved in planning the hospice unit at UTHCT emphasize that at the rate Medicare pays for inpatient hospice care ($562.69 per day, regionally adjusted), neither partner is likely to derive a profit from it. Instead the unit reflects a true commitment by both to meeting the needs of terminally ill patients in the hospital.
“This hospice unit was the right thing to do,” says UTHCT’s Chief Medical Officer Steven Brown, MD. “It’s an opportunity to educate our medical staff about end-of-life care, introduce the concept of hospice into the hospital, and improve utilization,” by changing the focus of treatment for those who choose the hospice approach.
The unit also provides an opportunity to concentrate palliative care training for nurses on the floor, which includes neuro-restorative and tuberculosis beds as well as non-dedicated hospice beds. Many patients are simultaneously referred to the unit and to Hospice of East Texas, while others may receive hospice care at home at the time of their placement on the unit.
Bring Inpatient Care Closer to Families
Marjorie Ream, CEO of Hospice of East Texas, explains that the origins of the hospice unit at UTHCT are in response to her agency’s family satisfaction surveys. Some families in the northeastern corner of the agency’s 13-county service area said they drove too far to visit loved ones at its HomePlace inpatient facility.
“We looked at our mission statement and started to explore how to make inpatient care available closer to the folks we serve,” says Ream. “I started a dialogue with Dr. Kirk Calhoun, the hospital’s president.”
Coincidentally, Dr. Calhoun had attended a hospital conference where he learned about a collaboration between a public charity hospital and a hospice in Atlanta that had received recognition from the American Hospital Association.