Improving Barriers to Hospice Referrals for Older Adults in the Primary Care Setting

Many primary care providers (PCP) are reluctant to refer older adult patients (>65 years old) for hospice services even though these services have shown to improve end-of-life care. This reluctance in referring is a problem because many older adults who would potentially qualify for hospice services are not being referred and, as a result, are not benefitting from hospice services, or only receiving services for a portion of the time for which they would qualify. The end result is underutilization of hospice services, which undermines delivery of high quality care to older adult patients. The PCP is key in facilitating this change. The purpose of this project was to determine barriers to hospice referral in the primary care setting (e.g. knowledge gaps, lack of resources, poor patient education, etc.) to increase appropriate/timely utilization of these service therefore improving end-of-life experience for both patient that qualify and their caregivers. The objectives of this project were to 1) assess both hospice providers' and PCPs' perceptions of what barriers exist for primary care providers in referring older adults to hospice, particularly PCP knowledge deficits surrounding hospice referral; 2) develop a learning module regarding hospice and its services that addresses the barriers identified by both hospice providers and PCPs; 3) improve PCPs' knowledge of hospice and its services; and 4) disseminate findings at student poster presentation and prepare a submission for a professional conference. Research suggests that potential barriers to making hospice referrals include knowledge deficits in regards to hospice, communication issues with patients and families, and inter-familial issues between patients and their families. In addition, it has been recommended that provider education be enhanced, with increased focus on effective communication regarding disease trajectories, goals of care, advanced directives, and end-of-life care. It is suspected that these barriers continue to go unaddressed for practicing PCPs, and continue to reinforce underutilization of hospice services. As part of the implementation and evaluation process, a questionnaire was developed to assess referral barriers, and was delivered to both PCPs (n=10) and hospice providers (n=9). Based on the survey findings, which found lack of education regarding hospice and unfamiliarity with the hospice referral process among top barriers, an educational module was developed and sent to the original PCP participants. Those completing the educational module were then asked to answer a questionnaire assessing their knowledge of hospice. After delivery of the educational module, questionnaire data showed a 25% improvement in hospice knowledge scores (p<0.05). An abstract of these findings was submitted to the 2017 Snowbird CME Conference in Utah for poster presentation. While beyond the scope of this project, the long-term goal is to increase appropriate and timely utilization of hospice referrals in all PCP settings. In summary, hospice is a vital resource that has potential for positively affecting older adults in need of its services. Determining barriers to appropriate and timely hospice referral making in the primary care setting is necessary to improving end-of-life care. Development and dissemination of educational modules based on provider-perceived barriers may help to close knowledge gaps and remove barriers to making hospice referrals for this population.