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J Palliat Med. 2014 Feb;17(2):135-40. doi: 10.1089/jpm.2013.0109. Epub 2013 Dec 10.

All hospice patients are not equal: development of a visit-based acuity index.

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1 Hospice and Community Care , Lancaster, Pennsylvania.



Although hospices need to be able to anticipate patient acuity, there are currently no published models that predict the frequency of visits that a new hospice patient is likely to receive.


To identify patient characteristics that are associated with the frequency of health care provider visits in the first 8 days of hospice care.


An electronic health record (EHR)-based retrospective cohort study was conducted in seven hospice programs in the United States. Participants were 35,232 patients who were admitted between October 1, 2008 and May 31, 2011 and received hospice care at home on the day of enrollment. The main outcome measure was the average number of visits per day by nurses, social workers, chaplains, and home health aides in the first 8 days of home hospice care (day of admission plus up to 7 subsequent days).


In a mixed effects regression model, 14 independent predictors of visit frequency were identified. For instance, several demographic characteristics were associated with more frequent visits, as were lower Palliative Performance Scale (PPS) scores (<40: 1.78 visits/day, 95% confidence interval [CI] 1.74-1.82 versus 40-60: 1.65 visits/day, 95% CI 1.61-1.69 versus >60: 1.41 visits/day, 95% CI 1.36-1.47; p<0.001), the presence of pain (pain: 1.77 visits/day; 95% CI 1.72-1.82 versus no pain: 1.44 visits/day, 95% CI .39-1.59; p<0.001). Patients admitted to home hospice from a hospital also received more frequent visits compared with other patients (hospital: 1.73 visits/day, 95% CI 1.67-1.79 versus home: 1.42 visits/day, 95% CI 1.40-1.44; p<0.001).


An acuity index based on these variables could help hospices to better anticipate patient needs and staff workload, and could be used to guide strategic planning as hospices take part in accountable care organizations (ACOs).

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