Benefits and challenges in use of a standardized symptom assessment instrument in hospice.

BACKGROUND: Hospices are now mandated to perform routine quality assessment under the final Medicare Hospice Conditions of Participation, creating an opportunity to explore standardized approaches to monitoring hospice quality. OBJECTIVE: We report hospice staff experiences using a standardized symptom assessment instrument, the Edmonton Symptom Assessment System (ESAS), in a pilot study designed to develop and test quality measures on symptom management. Use of the ESAS illustrates the benefits and challenges arising with standardized symptom assessment for quality monitoring in hospice. METHODS: We interviewed 24 individuals representing 8 hospices involved with the National Association for Home Care & Hospice Quality Assessment Collaborative, which pilot tested the ESAS as a source of standardized data for quality assessment. Transcripts were analyzed using the constant comparative method. RESULTS: Participants reported benefits and challenges with the ESAS. Benefits were that the ESAS was a brief and easy tool that identified areas of concern, engaged patients in symptom assessment, and monitored symptom changes over time. Additionally, the ESAS was viewed as a useful teaching tool for less experienced staff. Challenges included lack of clarity about inclusion rules and frequency of assessments; difficulty interpreting the numeric symptom rating scale, difficulty incorporating patient preferences with symptoms, and a sense that the use of standard assessment instruments was "unnatural." DISCUSSION: Recommendations to promote effective use of ESAS data for quality monitoring of hospice care include standardizing implementation procedures, adding patients' preferences to the ESAS form, and staff education to enhance comfort with the instrument before implementation.

What does the future hold for hospice in the present envirornment?

This has been a monumentalyear for Medicare Hospice Benefit (MHB) providers. Rapid growth in expenditures ($10 billion in 2007) and anticipated doubling of that figure in the next 10 years has drawn more attention, notably from the Centers for Medicare & Medicaid Services (CMS), the Congress, the Medicare Payment Advisory Commission (MedPAC), and Office of Inspector General (OIG). In 2007, about 40 percent of Medicare decedents used hospice compared to about 27 percent in 2000. Between 2004 and 2005, spending on hospice increased by 20 percent as compared to about a nine percent increase for overall Medicare spending. MedPAC estimates that the number of patients receiving hospice care for more than six months has increased from 14 percent in 2000, to 21 percent in 2005. How has the government responded to this growth?