Retrospective On Dialysis and Hospice Care Program: Benefits of and Barriers to Concurrent Care

December 21, 2020

Patients on dialysis require quality end-of life care, yet only 25% of dialysis patients opt for hospice care, despite the comfort it would give them. The reason is clear: The Medicare Hospice Benefit that covers hospice services requires beneficiaries to revoke all life-prolonging care. Because of the predictably short prognosis after treatment cease, many patients are unable to make the difficult decision to discontinue dialysis treatment. Additionally, patients who do choose hospice care do not experience the full benefits, because they may only receive a few days to weeks of treatment. 

In a new perspective published in the Clinical Journal of the American Society of Nephrology, Jane O. Schell, MD, medical director of the UPMC Renal Supportive Care Clinic, describes her partnership with a large nonprofit hospice organization in Western Pennsylvania to develop a concurrent, open access model of care for dialysis patients receiving hospice care. 

The concurrent model promotes timelier hospice services for patients undergoing dialysis, so that patients can experience the full benefits of hospice care. Through this program, patients on dialysis can transition to hospice and receive dialysis treatment as a comfort-focused treatment.  Each participant was allowed up to ten palliative dialysis treatments at a contracted rate; these treatments were often shortened and decreased to twice or once a week based on the patient’s goals and clinical condition. Many opted for only one to a few dialysis treatments, and a significant number requested none. For these patients, it seems that the concurrent care program acted as a psychologic bridge that helped them make a difficult decision about their care goals. The program has also found that the concurrent care model improves end-of-life outcomes. 

The Centers of Medicare and Medicare Services (CMS) has recently announced a benefit enhancement for concurrent dialysis for Medicare beneficiaries who elect the Medicare Hospice Benefit with the Kidney Care Choices model. This policy change will waive the requirement for dialysis patients to give up their right to life-prolonging care to receive hospice benefits. Although this represents a significant step forward, it does not address another challenge for hospices: the cost of dialysis care. 

At a base rate of $250 per session, dialysis treatments are beyond the financial means of most hospices based upon flat per diem rates offered by Medicare to cover all expenses related to the terminal disease. Only hospices with a daily census of more than 500 patients can afford to absorb the cost of dialysis (representing less than 1% of national hospices). 

At UPMC, the concurrent dialysis and hospice care program continues with the goal of implementation on a broader scale. With more data, we hope the Center for Medicare and Medicaid Innovation will respond with further expansion of the waiver to allow concurrent dialysis and hospice services. 

References

1. Schell JO, Johnson DS. Challenges with Providing Hospice Care for Patients Undergoing Long-Term Dialysis. Clin J Am Soc Nephrol. 2020 Oct 9:CJN.10710720. doi: 10.2215/CJN.10710720. Epub ahead of print. PMID: 33037019.

More About Jane O. Schell 

Dr. Schell joined the University of Pittsburgh and UPMC in 2012 as a clinician-educator within the Renal-Electrolyte Division and Section of Palliative Care and Medical Ethics. Focused on improving the experience of patients living with kidney disease, Dr. Schell has pursued this interest through educational curricula development and clinical care. She has developed the UPMC Renal Supportive Care Clinic for kidney disease patients with palliative care needs

Dr. Schell’s academic and educational work centers on communication and provider-patient relationship. Dr. Schell has received funding through the American Society of Nephrology to develop and evaluate curriculum for nephrology fellows within palliative care. She has developed an annual communication training for nephrology fellows called NephroTalk that teaches skills in dialysis decision-making and end of life. This training has been adapted and taught for national audiences as well as practicing nephrologists. She is currently evaluating the concurrent hospice dialysis program through a pilot grant from the Palliative Care Research Cooperative.