Effective Communication for Controlling Medication Costs in the Hospice Setting


There is a great deal of concern in the hospice industry about the rising costs of medications.  Hospices are increasingly frustrated and looking for solutions that will help them be successful financially while keeping the focus on providing the very best in patient care.  For more than 15 years the forefront of cost reduction was focused around compliance with a formulary, a tool used to direct prescription fill behaviors through optimum selection of drug products.  If the focus on optimum drug selection is the way to control medication costs, the question then becomes why are so many hospices struggling with increased cost and per patient day charges become higher than expected?  One answer may be found in proper staff training and communication regarding the need for adherence in dispensing behavior consistent with the formulary.

Many hospice staff believes that medication cost-reduction training needs to focus around a clinical protocol that is based upon a comprehensive knowledge of prescription products/therapies. This philosophy isn’t necessarily true. The opportunity to facilitate cost reduction begins when the patient is transitioning from curative care to hospice care. When making this transition, the hospice staff must be able, ready, and willing to have informative dialogue with the patient and family about the expectations and outcomes for the parties involved.  This seems simple, but it is the most common error in the fiscal process for hospice.    

Observation of the admission process has revealed that, too often, the admission staff is either unprepared or reluctant to offer what could be considered difficult, yet sound, advice that will help the patient and family understand the changes in medication therapy can be invaluable for everyone involved.  If the staff is trained properly in how to communicate the value of a modified prescription regimen, the process can be a positive interaction for all parties.   By making slight changes to the admission documentation and how these changes are communicated, the hospice value proposition will be promoted making the changes perceived as an end-of-life improvement.  Finally, the changes made at admission must be supported by the field staff charged with the daily care of the patient.  Therefore, the training proposed must be consistent throughout the hospice organization in order for optimum prescription therapy in hospice to succeed.    

Optimizing prescription protocols for hospice patients must include these four stages:

1. Hospice must employ the use of a quality palliative care and admitting diagnosis formulary to ensure the best use of drug products to care for the patient

2. Hospice staff must be trained in the art of Prescription Drug Transition Optimization to minimize the number of drugs taken by the patient so the end of life process is as positive as possible

3. Enrollment paperwork should support the change and provide critical opportunities for acceptance from the patient, family, and the prescriber

4. Nurses, CNAs, social workers, and clergy must practice using simple, caring words to validate the decisions of the experts, validate fears of the patient and encourage the parties to trust the process

Once this process is followed, the hospice can begin to experience a decrease in per patient day prescription costs that offer excellence in patient care, while freeing up financial resources that can be used for a host of alternate services.  A focus on these steps is far more effective in reducing waste and abuse than any discount or contract negotiation.  This simple four step process is an important component of the future of hospice as we all seek to be finically sustainable in a time of increased cost and decreased compensation from Medicare.

A Quality Formulary

A quality palliative care and admitting diagnosis formulary should be available from any hospice PBM.  The PBM should have a team consisting of palliative care practitioners that have reviewed drug products for efficacy without compromising patient care.  This formulary should be divided into categories of the admitting diagnoses to help guide the decision making process for the hospice clinical staff.  Finally, following the formulary will help prevent the hospice from paying for medications that are not its responsibility or that have been deemed no longer appropriate.

Drug Transition Communication

Staff training must include a basic skill set to communicate changes critical to financial success.  These clear and direct conversations should start early in the admission process, when the patient/family is aware of the upcoming changes in their future.  Conversations need to focus on the value of narrowing the number of drug products the patient will take to ensure a good palliative care regimen while alleviating any fear associated with change.  This process is referred to as Prescription Drug Transition Optimization.  Successful hospices employ training guidelines for staff members to follow when introducing the concept of drug transition communication with patients. Scripted language, supported in the admission documents, can be used to minimize the confusion and reiterate the value and reason for the changes.  A clinical team as well as a PBM should be able to help craft the language used to transition the patient to the formulary medications.  An important part of the process is to practice this conversation using role play to allow the admission staff member the practice communicating the changes with confidence and poise.

Supporting Documentation

Validating any message is important especially when the message can be controversial or even perceived as negative.  Admission personnel can drastically improve their success rate of conversions if the admission documentation is properly employed to support the changes.  Once a list of current medications is written on the documentation the admission nurse or staff member should communicate any potential drug selection changes and the use of “therapeutically equivalent medication”. A short dialogue can be employed to make certain the patient/family understands that the use of “therapeutic equivalents” is determined by their palliative health care team consisting of physicians, pharmacists, nurses, and/or other prescribers. This is also an opportune time to discuss elimination of certain medications as they may no longer be effective, in the best interest of the patient, and/or are not considered palliative in nature. The documentation of possible changes should be signed by both hospice staff and the patient/family to confirm the understanding of the possible changes in upcoming care.

Patients or family members adamant about keeping past non-hospice medications in use have the option to pay for that medication out-of-pocket or the hospice may choose to continue that therapy even though it may not be the financial responsibility of the hospice.     

Caring Words of Validation

Changes in medication therapy can be seen as sensitive issues for many patients.  It is the responsibility of the entire hospice staff to know the proper verbiage when the patient questions any changes in medication therapy.  Every hospice staff member who interacts with the patient at any time in the process must be able to offer a calm, caring, and positive validation of any concern that patient may have as well as help reassure the patient that his or her entire palliative clinical staff are there to help optimize his or her end of life care.

In conclusion, controlling costs in medication therapy can be a complicated process.  There is a fine balance between establishing strong cost saving protocols and satisfying the medical, emotional and physical needs of the patient and his or her family members.  It is evident that the best way to care for all parties is to prepare the hospice staff in communicating the value of hospice and end of life care.  Furthermore, the hospice staff must know the best manner to support the decisions made by the clinical staff when evaluating the needs of the patient.  Each hospice should employ all its resources to craft the best service offering to the patient, using insights of their vendors, such as PBMs, medical supply companies and DME providers along with the clinical staff to ensure quality of life.  

Fundamental to success in this endeavor is a strong commitment from top leadership within the hospice along with continual training for staff.  When the “top” of the organization sets the tone, establishes expectations, enforces accountability through objective measures, and drives this initiative, this important change will result in a higher success rate for formulary compliance along with potentially significant cost savings with a stronger financial outcome. Transformative change requires transformational leadership and working together for the benefit of the patient and hospice should be the combined focus of a new generation of hospice and vendor leaders.  Using these processes to continuously improve end of life care should be the shared and ultimate goal.    


- Mark Lewandowski, PH.D., CM&AA and DiGi Graham, D. Ph.