National Hospice And Palliative Care Organization Research Articles

State of the Service: Pediatric Palliative and Hospice Community-Based Service Coverage in the United States.

Background: The pediatric literature describes reliance on community-based organizations for home-based palliative and hospice care for children. Objective: To quantify and describe the inclusion of children in services, staffing, and care scope offered by community-based hospice organizations in the United States. Design and Subjects: This study utilized an online survey distributed to organizational members of the National Hospice and Palliative Care Organization (NHPCO) in the United States. Results: A total of 481 hospice organizations from 50 states, Washington DC, and Puerto Rico responded. Twenty percent do not provide services for children. Nonmetro geographies are less likely to provide services for children. Pediatric services provided include home-based pediatric hospice (57%), home-based palliative care (31%), inpatient pediatric hospice (23%), and inpatient pediatric palliative care (14%). Hospice annual pediatric census is an average of 16.5 children, while palliative care annual census is an average of 36. Less than half (48%) of responding agencies have a team that is dedicated to only pediatric care. Medicaid and the Children's Health Insurance Program are the most common forms of reimbursement, with 13% depicting "no reimbursement" for provision of care for children and many relying on philanthropy coverage. Lack of trained personnel, discomfort, and competing priorities were depicted as the most common barriers. Conclusions: Children remain underrepresented in the extension of care offered through community-based hospice organizations in the United States particularly in nonmetro settings. Further research into strong training, staffing, and reimbursement models is warranted.

Analysis of hospice duration and metrics in cancer patients in rural Appalachia.

e24006 Background: Several factors influence the duration of hospice care/average length of stay (ALOS) for cancer patients choosing hospice, including patient and family acceptance of hospice, availability of services, demographics, provider preferences, advances in treatment options, and type of cancer. Cancer diagnoses account for 30.1 % of Medicare hospice beneficiaries. Based on the national hospice and palliative care organization (NHPCO) summary released in 2019 the median length of stay on hospice for cancer patients is 19 days. The purpose of this study is to analyze the length of stay on hospice, and other metrics in a rural Appalachian community given the paucity of published data. Methods: A retrospective chart review (IRB approved) of all adult patients enrolled in three different hospice agencies (total 106) over two years (2016 and 2017) in a rural community in Southern Appalachia. We looked at the interval from metastatic diagnosis to hospice admission, interval from last oncological treatment to hospice admission and length of stay on hospice. Results: Medianinterval from metastatic diagnosis to hospice admission was 143 days (range 6-2948 days). The median interval from the last oncological treatment to hospice admission was 35 days (interquartile range 15-83 days). The median length of stay on hospice was 24 days (interquartile range 7.5 to 52.5 days). ALOS for patients with prostate, colorectal, breast and lung cancer were 77.33, 103.8 (skewed by a single patient-741 days, minus outlier-33 days), 38.9, 31.70 days, respectively. Conclusions: Few studies in the past have focused on the length of stay on hospice and even fewer have analyzed metrics as noted in our study. The median duration of hospice care in this community (24 days) was modestly better than the national data (19 days). This study provides unique data on median interval from the last treatment to hospice admission (35 days) is longer than the time on hospice (24 days). We infer socio cultural barriers to hospice acceptance in the Appalachian community and a need for education. It may be invaluable to assess if similar barriers to acceptance of hospice are a factor in other communities and would be worthy of further study and research.

Coding and Billing Jeopardy—Play with the Experts (FR477)

•Identify the importance and rules for capturing reimbursement from three sites of community-based palliative care eligible for reimbursement.•Delineate Evaluation and Management and Time-Based service codes, including the benefits and consequences of each, including the appropriate use of Advance Care Planning codes.•State billing and coding resources. Payment for services with precise billing and coding systems is essential for revenue for palliative care programs in the community. An organization’s billing and coding system sets the foundation for reimbursement from Medicare, Medicaid, and private insurance—and ultimately the budget. Accuracy and quality of billing documentation and submission is essential, as well as monitoring code changes. Through an interactive and engaging process, this session will provide a review of the potential patient encounters eligible for billing as well as accurately capturing the delivery of services. An interdisciplinary palliative care panel—a coding expert, a palliative physician, and a palliative nurse practitioner—will provide discuss billing and coding essentials from across the spectrum. Using a game format, the session will move through a face paced look at common quandaries, pitfalls, and myths about billing and coding. Participants will learn the importance of documentation supporting codes, the benefits and consequences of Evaluation and Management and Time-Based codes, and the appropriate use of Advance Care Planning codes. Resources from the Center for Medicare and Medicaid Services (CMS), Medicare Learning Network (MLN), Center to Advance Palliative Care (CAPC), Hospice and Palliative Nurses Association (HPNA), American Academy of Hospice and Palliative Medicine (AAHPM) and National Hospice and Palliative Care Organization (NHPCO) will be highlighted. The hour will conclude with an interactive Q & A session, and useful "take home" materials.

A Quality Improvement Approach to System-Wide Physician Referral Patterns for Hospice Care (QI803)

•Recognize that referral for hospice care is a behavior amenable to behavioral feedback.•Physicians change their behavior when given their personal performance for hospice referral. Hospital-based hospice programs generally have short lengths of service in home hospice care—much shorter than free-standing hospice programs Improve Hospice Length of Service by giving physicians feedback on their performance. The OhioHealth Clinical Guidance Council, comprised of physician subcommittees by specialty, sets standards of care for purposes of improving quality and decreasing cost by facilitating decrease in variation for 3500 physicians serving the system across 40 counties in central Ohio. The, median length of stay of patients referred by all OhioHealth physicians was obtained for 2015. For the oncology, cardiovascular, neurosciences, primary care and hospitalist clinical guidance councils, a letter from the Chair was sent to each physician noting gap between the council's opinion about optimal length of stay, the length of stay reported by the National Hospice and Palliative Care Organization (NHPCO), and the median length of stay of all patients referred by OhioHealth physician members of that clinical guidance council. A chart graphing the median length of stay by member, indicating the name of the member to which the letter was directed, was mailed to each physician. One year later, for calendar year 2016, the measurement of median length of stay by physician was repeated. For all physicians in 2015, the median length of stay in targeted specialties was 15 days, in those not targeted (control), 16 days. In 2016, the median length of stay for all physicians in targeted specialties was 25 days. In those not targeted (control) it was 10 days. The national median length of stay in hospice care is 17 days. The median length of stay for all OhioHealth Hospice patients was 10 days at the time this project was conducted. A simple QI approach yielded a 250% improvement in hospice median length of stay between intervention and control to a level above the national median.

A quality improvement approach to oncologist referrals for hospice care.

45 Background: Cancer patients frequently experience short lengths of service in home hospice care. Methods: The Oncology Clinical Guidance Council, composed of medical, surgical, gynecological and radiation oncologists sets standards of care for the OhioHealth system serving central Ohio. The Council was polled for consensus on how long a cancer patient should be enrolled in hospice care. Then, median length of stay of patients referred by 18 medical oncologists from their offices to OhioHealth hospice for calendar year 2014 were obtained. A letter from the Chairs of the Oncology Clinical Guidancee Council was sent to each medical oncologist noting the council's opinion about optimal length of stay, the length of stay reported by the National Hospice and Palliative Care Organization (NHPCO), and the median length of stay of all patients referred by OhioHealth oncologists. A chart graphing the median length of stay by oncologist, indicating the name of the oncologist to which the letter was directed, was mailed to each oncologist. One year later, for calendar year 2015, the measurement of median length of stay by oncologist was repeated. Results: 64% of the Oncology Clinical Guidance Council members polled think the median length-of-service for hospice care for cancer patients should be 90 days (3 months) and 20% think it should be 45 days (6 weeks). The NHPCO national median is 43 days. At baseline, the median length of stay for 176 cancer patients referred in calendar 2014 was 19.7 days. The median length of stay for 133 patients referred in the first 10 months of 2015 was 39.6 days. Conclusions: A simple quality improvement approach to improving hospice length of service by oncologists yielded a doubling to reach the national median in one year.

Personally Meaningful Rituals: A Way to Increase Compassion and Decrease Burnout among Hospice Staff and Volunteers.

Rituals can increase a sense of connectedness, meaning, and support, especially after the death of those for whom we care. Hospice staff may benefit from the use of personal rituals as they cope with the frequent deaths of their patients, ultimately aiming to provide compassionate care while minimizing burnout. This study investigated the role of personally meaningful rituals in increasing compassion and decreasing burnout among hospice staff and volunteers. An online survey was completed by members of the National Hospice and Palliative Care Organization (NHPCO) which inquired about personal ritual practices, and included the Professional Quality of Life (ProQOL) scale to measure current levels of Compassion Satisfaction, Burnout, and Secondary Traumatic Stress. Three hundred ninety hospice staff and volunteers from across 38 states completed the online survey. The majority of participants were Caucasian and female, with an average of nine years of experience in hospice and palliative care. The majority of hospice staff and volunteers used personally meaningful rituals after the death of their patients to help them cope (71%). Those who used rituals demonstrated significantly higher Compassion Satisfaction and significantly lower Burnout as measured by the ProQOL, with professional support, social support, and age playing significant roles as well. Rituals may be an important way to increase compassion and decrease burnout among hospice staff and volunteers. Organizations may benefit from providing training and support for personalized rituals among team members, especially new staff who may be at greater risk for burnout.

Palliative Care and Patient Autonomy: Moving Beyond Prohibitions Against Hastening Death.

The National Hospice and Palliative Care Organization (NHPCO) upholds policies prohibiting practices that deliberately hasten death. We find these policies overly restrictive and unreasonable. We argue that under specified circumstances it is both reasonable and morally sound to allow for treatments that may deliberately hasten death; these treatments should be part of the NHPCO guidelines. Broadening such policies would be more consistent with the gold standard of bioethical principles, ie, respecting the autonomy of competent adults.

219 The Recognition of Hospice-Eligible Patients in the Emergency Department: A Missed Opportunity

219 The Recognition of Hospice-Eligible Patients in the Emergency Department: A Missed Opportunity

Testing a Model of Caregiver Satisfaction with Hospice Care in the Cancer Population (S762)

•Identify factors that place a caregiver at risk for dissatisfaction with hospice care and potential negative health outcomes.•Discuss the complex nature of caregiver satisfaction and critique one model of caregiver satisfaction. Caregiver satisfaction with hospice care is a quality measure for hospice organizations and predicts caregiver and patient health, mortality, and resource use. Contributing factors to caregiver satisfaction are poorly understood and tested models of caregiver satisfaction in the literature are scarce. To fill this gap, our aim was to develop and test a model of caregiver satisfaction with hospice care in the cancer population. This retrospective cohort study used national data collected by the National Hospice and Palliative Care Organization (NHPCO) using the Family Evaluation of Hospice Care (FEHC) survey in 2011. We utilized a random sample of 1000 cancer caregivers (70,782 available). Our initial theoretical model posited a relationship between demand (measured by reported patient symptoms) and satisfaction, modified by internal and external caregiver resources. Structural equation modeling was used to test the model and adjustments made to improve model fit. The final model fit the data well (LR=189.08, df=78; RMSEA=0.04; CFI=0.91; SRMR=0.03). Caregiver satisfaction was predicted by demand—higher perception of demand (more patient symptoms) reduces caregiver satisfaction. Patient age, caregiver race, education, relationship to the patient, and length of hospice stay modify this relationship directly—black, non-spousal, and more highly educated caregivers are less satisfied, along with caregivers of younger patients and those with shorter lengths of stay. Patient and caregiver age, caregiver sex, and length of stay influence this relationship by altering caregiver perception of demand. Younger caregiver and patient age, female caregivers, and longer length of stay increases caregiver demand, decreasing satisfaction. Note that length of stay works both for and against satisfaction. Caregiver satisfaction is a complex perception that depends on caregiver and patient characteristics, as well as hospice care received.

Testing a model of caregiver satisfaction with hospice care in the cancer population.

107 Background: Caregiver satisfaction with hospice care is a quality measure for hospice organizations and predicts caregiver and patient health, mortality and resource use. Yet contributing factors to caregiver satisfaction are poorly understood and there are no tested models of caregiver satisfaction in the literature to date. To fill this gap, our aim was to develop and test a model of caregiver satisfaction with hospice care in the cancer population. Methods: This was a retrospective cohort study of national data collected by the National Hospice and Palliative Care Organization (NHPCO) using the Family Evaluation of Hospice Care (FEHC) survey in 2011. We utilized a random sample of 1000 cancer caregivers (70,782 available). An initial theoretical model was developed which posited a relationship between demand (as measured by reported patient symptoms) and satisfaction, modified by caregiver internal and external resources. Structural equation modeling was used to test the model and adjustments made to improve model fit. Results: The final model fit the data well (LR=189.08, df=78; RMSEA=0.04; CFI=0.91; SRMR=0.03). Caregiver satisfaction was predicted by demand – higher perception of demand (more patient symptoms) reduces caregiver satisfaction. Patient age, caregiver race, education, relationship to the patient and length of hospice stay modify this relationship directly – black, non-spousal and more highly educated caregivers are less satisfied, along with caregivers of younger patients and those with shorter lengths of stay. Patient and caregiver age, caregiver sex and length of stay influence this relationship by altering caregiver perception of demand. Younger caregiver and patient age, being a female caregiver and longer length of stay increases caregiver demand, decreasing satisfaction. Note that length of stay works both for and against satisfaction. Conclusions: Caregiver satisfaction is a complex perception that depends on caregiver and patient characteristics, as well as hospice care received. Hospice care providers should consider screening caregiver-patient dyads for “high-risk” characteristics and providing additional supportive measures.

Legal Briefing: Voluntarily Stopping Eating and Drinking

This issue's "Legal Briefing" column covers recent legal developments involving voluntarily stopping eating and drinking (VSED). Over the past decade, clinicians and bioethicists have increasingly recognized VSED as a medically and ethically appropriate means to hasten death. Most recently, in September 2013, the National Hospice and Palliative Care Organization (NHPCO) called on its 2,000 member hospices to develop policies and guidelines addressing VSED. And VSED is getting more attention not only in healthcare communities, but also in the general public. For example, VSED was recently highlighted on the front page of the New York Times and in other national and local media. Nevertheless, despite the growing interest in VSED, there remains little on-point legal authority and only sparse bioethics literature analyzing its legality.This article aims to fill this gap. Specifically, we focus on new legislative, regulatory, and judicial acts that clarify the permissibility of VSED. We categorize these legal developments into the following seven categories: 1. Definition of VSED. 2. Uncertainty Whether Oral Nutrition and Hydration Are Medical Treatment. 3. Uncertainty Regarding Providers' Obligations to Patients Who Choose VSED. 4. Judicial Guidance from Australia. 5. Judicial Guidance from the United Kingdom.

Hospice Practices, Perceived Satisfaction, and Entrepreneurial Opportunities: Strategic Insights across Geographic Settings

Introduction(Dame) Cicely Saunders, founder of the first real hospice, was clearly an entrepreneur (Thompson, 1999: 209).As the U.S. population continues to age, an increasing number of patients and families will be facing end-of-life care. Hospice and palliative care programs are uniquely designed to offer a continuum of care to serve the physical, emotional and spiritual needs of patients and families in the last months of life. According to the National Hospice and Palliative Care Organization (NHPCO), hospice care is a model for quality compassionate care for individuals who are medically defined as terminally ill or facing life-limiting illnesses. Hospice services are directed towards caring versus curing in a variety of settings to include the patient's home, freestanding hospice centers, hospitals, nursing homes, as well as other long-term care facilities (NHPCO, 2010). As a larger proportion of the U.S. population continues to age, clearly the need and demand for hospice services in all settings will continue to accelerate over the next decade. Indeed the magnitude of this challenge is significant and growing, and has important implications for healthcare recipients, providers, and policymakers alike. A fundamental question of interest across various stakeholders is how prospective entrepreneurs and strategists in established organizations can leverage various sources of entrepreneurial opportunities these dynamic changes represent and, innovate to meet the challenge of the changing hospice care landscape (Carr, Topping, Woodard, & Burcham, 2004).This study seeks to inform both members of the hospice community and broader healthcare reform discussions by examining family perceptions of the overall satisfaction with service quality in hospice care in contrasting geographical settings. Prior research suggests there are specific factors that contribute to the patient and family members' perceptions of service quality provided during the hospice episode of care. This study extends that prior work by theoretically developing and empirically testing the central thesis that geographic disparity of services and resources (i.e., urban versus rural) influences family members' perceptions within the delivery areas for hospice services differently in urban versus rural settings. Further, it extends prior work by suggesting that the type of setting in which hospice patients are treated (and ultimately die) may also influence the perceptions of the quality of care provided. It also suggests other factors such as the lapse of time between identifying the need for hospice services and the actual delivery of the hospice services can affect the perceptions of quality care. Finally, it suggests the length of time the patient receives hospice services may also influence the perceptions of care delivered during the hospice episode.Literature ReviewEntrepreneurial OpportunityThe notion ?? entrepreneurial opportunity is at the heart of entrepreneurship theory (Stevenson & Gumpert, 1985). Entrepreneurial opportunity is defined as external environmental conditions suggesting the introduction and sale of new products, services, raw materials, and/or organizing methods at prices in excess of their production costs will be feasible (Casson, 1982; Shane & Venkataraman, 2000). Such conditions change over time, impacted in part by large shifts in attitudes, government policy, economic conditions, and technology (Hills & LaForge, 1992). Environmental conditions also change as a function of the competition. Hitt, Ireland, Camp, and Sexton (2002) observe that a new competitive landscape began to develop in the 1990s, emerged in earnest in the 21st century, and is characterized by substantial and frequently frame-breaking change, a series of temporary, rather than sustainable competitive advantages for individual firms, short product life cycles, and new forms of competition. As a result, they argue an entrepreneurial mindset is required that emphasizes carefully selected and implemented entrepreneurial strategies to compete successfully. …

Anticipatory Grief Among Family Caregivers of Patients With Advanced Cancer, Congestive Heart Failure, and Chronic Obstructive Pulmonary Disease (751)

Method. A survey was developed assessing current medication error reporting practices in hospice. The survey included questions regarding hospice demographics, medication error reports and the reporting process. Additional questions were asked assessing the attitudes of employees regarding medication error reporting. In conjunction with The National Hospice and Palliative Care Organization (NHPCO), approximately 2500 hospice organizations were invited to participate in the survey administered through the online survey tool: SurveyMonkey. Participation was voluntary and surveys were submitted anonymously.

National Hospice and Palliative Care Organization (NHPCO) Position Statement and Commentary on the Use of Palliative Sedation in Imminently Dying Terminally Ill Patients

This paper was written by Timothy W. Kirk, PhD, and Margaret M. Mahon, PhD, RN, FAAN, on behalf of the Palliative Sedation Task Force of the National Hospice and Palliative Care Organization (NHPCO) Ethics Committee. Members of the Palliative Sedation Task Force were Timothy W. Kirk, PhD (Chair), Kathleen Bliss, MSN, RN, CHA, Pamela Dalinis, MA, BSN, RN, Margaret M. Mahon, PhD, RN, FAAN, Martha McCusker, MD, FACP, W. Brian Guthrie, MD, Marian Silverman, PhD, RN, CHPN, and Joseph Wadas, STL. This paper was approved by the NHPCO Ethics Committee in October 2009 and the NHPCO Board of Directors in December 2009. Creation of this manuscript was not supported by external funding. All members of the NHPCO Ethics Committee are volunteer members. Address correspondence to: Timothy W. Kirk, PhD, Department of History and Philosophy, CUNYdYork College, 94-20 Guy R Brewer Blvd., Jamaica, NY 11451, USA. E-mail: timothy.kirk@york.cuny.edu

Hospices' Preparation and Practices for Quality Measurement

Context Hospice and palliative care organizations need to measure and analyze quality of care, in response to national palliative care practice guidelines and new hospice regulatory requirements. Little is known about hospices' readiness to meet this new mandate. Objectives We analyzed data from a national survey of hospices to describe preparation and practices for quality measurement and research and to examine associated organizational characteristics. Methods Web-based survey of hospice staff responsible for quality of care. Results Survey respondents represented 652 National Hospice and Palliative Care Organization (NHPCO) member hospice organizations; 52% were participating in the NHPCO Quality Partners program. Most of these hospices involve clinical providers in decisions to change care practices (69%) and participate in quality improvement projects (64%), but research participation is uncommon (16%). Many hospices collect data about staff certification and training (76%) and use family surveys to measure care quality (70%). A minority of hospices have clinical data in electronic format (13%–29%). Large size, multiple sites, government ownership, and presence of a change leader in the organization were the characteristics associated with greater preparation for quality improvement and research. Conclusion Current organizational activities, data collection rates, and use of electronic data systems may limit hospices' preparation and practices related to quality improvement and research participation; larger size and designation of a change leader are associated with greater capacity. Hospices may need technical assistance and training to provide for meaningful measurement of quality of care.

Providing Hospice Care to Children and Young Adults

Over the past two decades, end-of-life organizations have served an increasing number of children and young adults and expanded services important to terminally ill youth, and yet we know little about these organizations. The purpose of this study was to describe the characteristics of end-of-life care organizations that admitted children and young adults to hospice care. Using data from the 2007 National Hospice and Palliative Care Organization (NHPCO) Survey, we conducted a descriptive analysis of operational, mission, market, and financial characteristics, and explored a sub-analysis by age group. Our analysis revealed that these organizations had similar profit status, ownership, and payer mix when compared to the hospice industry. However, they differed in agency type, referrals, organizational size, geographic location, team member caseload, and revenues. We also found important differences in organizations that provided hospice care by age groups (infants, toddler, school-age children, and adolescents/young adults) in geographic location, region, agency type, accreditation, and team member caseload. These findings have managerial and policy implications.

Social Work Practice in Palliative and End-of-Life Care: A Report from the Summit

ABSTRACT In 2005 a Social Work Summit on End-of-Life and Palliative Care was hosted by the National Association of Social Workers (NASW) with support from the Project on Death in America (PDIA) and National Hospice and Palliative Care Organization (NHPCO). Building on the work of a first summit held in 2002, work groups focused on practice, research, policy, and education with “State of the Field” presentations used as a point of convergence for setting priorities and developing action plans. This article describes a process of document selection and review which was designed to isolate aspects of social work practice and to determine concordance with domains and guidelines detailed in the interdisciplinary consensus document, Clinical Practice Guidelines for Quality Palliative Care, a publication of the National Consensus Project for Quality Palliative Care (http://www.nationalconsensusproject.org). In addition, a group of documents written by colleagues in medicine and nursing were chosen for evaluation as they reflect the emerging and valued incorporation of palliative care principles into specialties such as pediatrics and intensive care. This second review was focused on determining the nature and scope of social work presence and participation and on understanding if the role of the profession was clearly articulated in these specialty areas. This article discusses the historical context and relevant findings that may contribute to the growth of the profession in this rich and burgeoning specialty.

Hospice Care for Patients with Dementia

Dementia is a leading cause of death in the USA. Although guidelines exist to determine hospice eligibility for dementia, only a small percentage of patients dying with this condition receive hospice care. Hospice recipients with dementia have not been well characterized, and little is known about the quality of care they receive. The Family Evaluation of Hospice Care (FEHC) survey was adopted by the National Hospice and Palliative Care Organization (NHPCO) in 2003 as a standard benchmarking tool. The FEHC collects data from bereaved families regarding the quality of hospice care. An online repository of 2005 FEHC data was used to describe hospice recipients over 65 years of age who died with dementia and to examine their families' evaluation of hospice care. Decedents with cancer and chronic terminal conditions were also analyzed for comparison purposes. A total of 77,123 surveys submitted by 796 hospices nationwide met the study's eligibility criteria. Decedent diagnoses were as follows: dementia, n = 8,686 (11.3%); cancer, n = 35,693 (46.3%); and other chronic diseases, n = 32,744 (42.4%). Decedents with dementia were more likely to be >85 years, female, and have length of stays >180 days. Evaluation of care in all FEHC domains did not significantly differ between groups. Approximately three-quarters of bereaved family members of decedents in all groups perceived the overall quality of care as excellent; however, opportunities to improve care were also identified. These data suggest that the evaluation of hospice care for older patients is generally high, and does not vary with respect to terminal diagnoses.

National Associations Survey: Advancing Hospice and Palliative Care Worldwide

As part of a cooperative effort among several international associations to advance hospice and palliative care worldwide, and in connection with the Second Global Summit of National Hospice and Palliative Care Associations in Seoul, South Korea, the U.S.-based National Hospice and Palliative Care Organization (NHPCO) conducted a survey of all known national hospice/palliative care organizations between November 2004 and March 2005. The goals of this data-gathering effort were twofold: first, to obtain descriptive data about national-level associations to feed into an internationally available database; and second, to assess the status of the provision of palliative services across countries, including strengths and needs, particularly in the areas of standards development and access to care.

Family Evaluation of Hospice Care: Results from Voluntary Submission of Data Via Website

The Family Evaluation of Hospice Care (FEHC) survey is a 61-item questionnaire that surveys family members about care provided to the decedent by the hospice. Hospices submit their data to the National Hospice and Palliative Care Organization (NHPCO), where results are tabulated. For the first two quarters of 2004, a total of 29,292 surveys were tabulated. On average, respondents rated their overall satisfaction with care as 47.1 on a 50-point composite scale of five measures of satisfaction. Opportunities for improvement were identified for attending to family needs for support (18.2% of those surveyed reported at least one unmet need), attending to family needs for communication (10–29%), and coordination of care (22.1%). Surrogate reporting of unmet needs for pain, dyspnea, or emotional support ranged from 5.3% to 9.8%. The FEHC is a useful tool for measuring hospice performance and identifies a number of opportunities for improvement.