Three-quarters of individuals in the United States die from chronic illnesses,40 often after suffering both physically and psychologically for months or years.41 Recent evidence19-22 establishes the importance to patients and families coping with serious illness of receiving services across multiple domains that address the patient's physical, psychosocial and spiritual well-being, as well as the caregiver's well-being. However, the health care system has often failed to meet the needs of patients suffering from advanced illness and their families, who frequently experience inadequate pain and symptom management, 42-46 significant caregiver burden and stress,47,46 and overall dissatisfaction with care. Hospice was developed to address the multidimensional needs of patients suffering from serious illness and their families that were not being met by the traditional medical system. Hospice consists of services that focus on the physical, emotional, social, and spiritual needs of patients and their families including medical services, pain and symptom management, spiritual counseling, social services, and bereavement counseling. Services are palliative, rather than curative, and the majority of hospice care is provided in the patient's home.18 The population enrolled with hospice is rapidly diversifying as greater understanding of its benefits, particulariy for older adults with chronic illnesses, becomes wide-spread. Almost two-thirds of individuals enrolled with hospice are age 75 years or older.18 Individuals with a terminal diagnosis of cancer comprise 46% of all individuals enrolled with hospice, followed by those with end-stage heart disease (12%) and dementia (10%).18 The Tax Equity and Fiscal Responsibility Act of 1982 authorized Medicare to reimburse for hospice care under the Medicare Hospice Benefit (Table 1). In order for individuals to be eligible for hospice they must have a life expectancy of 6 months or less if the disease follows its usual course and must be willing to relinquish Medicare reimbursed services focused on life prolongation or cure. In order for hospices to receive reimbursement for hospice care they must be certified by Medicare.50 Medicare is the primary payor of hospice and approximately 94% 18 of hospices are Medicare certified. Certification requires satisfying several """"""""conditions of participation 50 related to the availability of hospice services and the types of personnel that must be employed by the hospice. Reimbursement for hospice under Medicare is on a per diem basis according to four categories depending on the intensity of care delivered: routine home care, continuous home care (i.e., home care provided during periods of patient crisis), respite care (i.e., inpatient care for a short period to relieve the caregiver) and general inpatient care (i.e., inpatient care for patients unable to remain at home).51 More than 95% of hospice care reimbursed by Medicare is for routine home care.35

National Institute of Health (NIH)
National Institute of Nursing Research (NINR)
Research Transition Award (R00)
Project #
Application #
Study Section
Special Emphasis Panel (NSS)
Program Officer
Aziz, Noreen M
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
Icahn School of Medicine at Mount Sinai
Internal Medicine/Medicine
Schools of Medicine
New York
United States
Zip Code
Kelley, Amy S; Deb, Partha; Du, Qingling et al. (2013) Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay. Health Aff (Millwood) 32:552-61
Aldridge Carlson, Melissa D; Barry, Colleen L; Cherlin, Emily J et al. (2012) Hospices' enrollment policies may contribute to underuse of hospice care in the United States. Health Aff (Millwood) 31:2690-8
Legler, Aron; Bradley, Elizabeth H; Carlson, Melissa D A (2011) The effect of comorbidity burden on health care utilization for patients with cancer using hospice. J Palliat Med 14:751-6
Carlson, Melissa D A; Lim, Betty; Meier, Diane E (2011) Strategies and innovative models for delivering palliative care in nursing homes. J Am Med Dir Assoc 12:91-8
Carlson, Melissa D A; Barry, Colleen; Schlesinger, Mark et al. (2011) Quality of palliative care at US hospices: results of a national survey. Med Care 49:803-9
Goldstein, Nathan; Carlson, Melissa; Livote, Elayne et al. (2010) Brief communication: Management of implantable cardioverter-defibrillators in hospice: A nationwide survey. Ann Intern Med 152:296-9
Carlson, Melissa D A; Bradley, Elizabeth H; Du, Qingling et al. (2010) Geographic access to hospice in the United States. J Palliat Med 13:1331-8
Schulman-Green, Dena; Cherlin, Emily J; McCorkle, Ruth et al. (2010) Benefits and challenges in use of a standardized symptom assessment instrument in hospice. J Palliat Med 13:155-9
Carlson, Melissa D A; Herrin, Jeph; Du, Qingling et al. (2010) Impact of hospice disenrollment on health care use and medicare expenditures for patients with cancer. J Clin Oncol 28:4371-5