woman in hospice bed

While the Centers for Medicare & Medicaid Services (CMS) has published the final hospice rule for fiscal year 2023, the agency’s hospice work is just beginning in one area: equity.

Recently, CMS posted a call for nominations for a Technical Expert Panel for hospice health and home health equity, according to LeadingAge, which advocated for the TEP following the release of the hospice proposed rule. The TEP will provide input on a proposed health equity structural composite measure for both hospice and home health settings. Potential panel participants include hospice and home health providers, patient advocates, and quality improvement and health equity experts.

“Our members are really engaged on this issue,” noted Katy Barnett, director of home care and hospice operations and policy for LeadingAge. “We have a couple of members who have made concrete measures to reach underrepresented cultures.”

Among the issues the TEP will explore is the feasibility around CMS’ three proposed structural composite measure domains: 1. How hospices engage in their communities; 2. Hospices’ education and training plans and resources for board members, staff and volunteers; and 3. What hospices are doing in their hiring processes to recruit people who reflect their communities.

LeadingAge in its comments to CMS offered critiques of the domains. Among these, it suggested creating meaningful ways for hospices to work with their communities, determining evidence-based quality of training and training resources, and considering ways to gauge inclusive workplaces beyond hiring practices. The goal is that the panel will convene after August to discuss these issues. Subsequently, providers expect a structural composite measure to appear in the 2024 or FY 2025 proposed rule.

Hospice bias

One issue driving the industry’s interest in equity is the knowledge that most users of hospice are white. But the nuances of equity go far beyond users’ skin color, Barnett explained. For example, the panel also will look at such issues as end-of-life experiences for different cultures. Some cultures actually don’t believe in dying at home, the gold standard for other cultures, she noted. 

“Different cultures have different experiences with that end-of-life process that are not necessarily captured in what hospice provides,” she said.

Equity and infection control

There are also equity issues in home health that may not immediately come to mind. These include expectations surrounding infection control. As an example, in some cultures, taking off your shoes before entering a home is mandatory, but such norms may challenge conventional healthcare cleaning protocols.

“Health equity takes a lot of different forms,” Barnett explained. “That is one of the wonky things the panel will have to get down in the weeds about. Our members are really interested in serving their communities and making sure there is access for their communities.”

One of the hopes is that the structural measures turn into outcomes-based measures, Barnett said. These would be based on “research defining where the gaps are in health equity and help hospices close those gaps.”

Structural measures “are good, but they are not great,” she added. “The gold standard is outcomes-based measures.”