comparison of the hospice systems in the united states japan and taiwan

O R I G I NA L A R T I C L E Comparison of the Hospice Systems in the United States, Japan and Taiwan Chung Yul Lee1, RN, PhD, Hiroko Komatsu2, RN, PhD, Weihua Zhang3, RN, PhD, Yann-Fen Chao4, RN, PhD, Ki Kyong Kim5, RN, PhD, Gwang Suk Kim6*, RN, PhD, Yoon Hee Cho7, RN, PhD, Ji Sook Ko8, RN, MSN Professor, Nursing Policy Research Institute, College of Nursing, Yonsei University, Korea Professor, Faculty of Nursing and Medical Care, Keio University, Japan Clinical Assistant Professor, School of Nursing, Emory University, USA Professor, College of Nursing, Taipei Medical University, Taiwan Associate Professor, Department of Nursing, College of Medicine, Yonsei University Wonju Campus, Korea Assistant Professor, Nursing Policy Research Institute, College of Nursing, Yonsei University, Korea Full-time Instructor, College of Nursing, Eulji University, Korea Teaching Assistant, College of Nursing, Yonsei University, Korea Purpose The aim of hospice care is to provide the best possible quality of life both for people approaching the end of life and for their families and carers The Korean government has been implementing a pilot project for hospital hospice services and trying to develop the national hospice system To assist in the development of the Korean hospice system, the Korean government supported the present study comparing the hospice systems of three countries, United States, Japan, and Taiwan, which currently have a developed hospice system Methods Data from three countries were collected in the following ways: reviewing hospice related literature, searching government documents on the Internet, collecting government hospice data, surveying six hospice institutions in each country, and conducting an international workshop Results The hospice system was evaluated by comparing hospice management systems and hospice cost systems The comparison of the hospice management system included five items of hospice infra structures and four items of hospice services The hospice cost system included four items: funding source, hospital hospice cost, day care hospice cost, and home hospice cost Conclusions Based on the comparison of three countries, the most interesting thing was that home hospice care accounted for more than 90% of all hospice services in the United States and Taiwan The results of this study will aid the countries that are in the process of developing a hospice system including Korea, which has been implementing a pilot project only for hospital hospice services [Asian Nursing Research 2010;4(4):163–173] Key Words hospices, Japan, Taiwan, United States *Correspondence to: Gwang Suk Kim, PhD, RN, Assistant Professor, Nursing Policy Research Institute, College of Nursing, Yonsei University, 250 Seongsanno, Seodaemun-gu, Seoul 120-752, Korea E-mail: gskim@yuhs.ac Received: June 25, 2010 Asian Nursing Research ❖ December 2010 ❖ Vol ❖ No Revised: September 30, 2010 Accepted: November 8, 2010 163 C.Y Lee et al INTRODUCTION Cancer has recently become the leading cause of death in many countries and the number of terminal cancer patients has been increasing Since the year 2000, the primary cause of death in Korea has been cancer According to the 2007 statistics, 64,731 people died from cancer and over 300,000 family members of cancer patients suffered physical, social, and psychological pain (Korea National Statistical Office, 2008) In a survey asking whether the respondents were planning on using hospice in the future, 57.4% of the people responded affirmatively in 2004 and 84.6% in 2008 (Jung, 2009) Hospice treatment is designed to provide comfort and support to patients and their families when a lifelimiting illness no longer responds to cure-oriented treatments Hospice care neither prolongs life nor hastens death Hospice staff and volunteers offer a specialized knowledge of medical care, including pain management (Hospice Foundation of America, 2009) Patients who have received hospice services experience a better quality of life during their terminal stage Bretscher et al (1999) showed that hospice patients’ quality of life was relatively high and stable over time with appropriate palliative services Li et al (2006) investigated the influence of hospice care on the quality of life and psychological state of elderly inpatients nearing death Before and after a minimum of month of hospice care, all the indexes including quality of life, appetite, spirit, and sleep quality were higher than the control patients that received conventional nursing services Europe and North America have been developing hospice services for more than 30 years The first modern hospice service was started in England in 1967 (Wood & Gatrell, 2002) There were 253 hospice institutions and 250,000 hospice patients in England in 2005 (Help the Hospices, 2006) Similarly, since the establishment of the first hospice facility in the United States in 1974, the number of hospice institutions increased from 8,000 in 1992 to 11,400 in 2002, and 1,460,000 patients in the United States utilized hospice services as of 2006 (National 164 Center for Health Statistics & National Health Care Survey, 2006) Among Asian countries, Japan was the first country to establish a hospice facility in 1981 There were 162 hospice institutions in Japan by 2006 (Hospice Palliative Care Japan, 2006) Taiwan began hospice services in 1990 with 32 hospice institutions (Hospice Foundation of Taiwan, 2007) Some studies have been conducted to analyze the role of hospice care in relation to medical costs accrued by cancer patients Emanuel (1996) reported that one third of the total medical cost expended for cancer treatment was used during the last month before the patient’s death Biskupiak and Korner (2005) reported when cancer patients received hospice services during the month before their death, they saved 46.5% of the total cost compared to patients that used conventional medical services Lo (2002) found that the average patient spent $110,267 for conventional medical care, $86,968 for hospital hospice care, and $56,283 for home hospice care In Korea, Lee, Lee, and Kim (2000) also reported that a patient spent 6% less for home hospice compared to hospital hospice care Although many studies have shown the efficiency of hospice care, not many countries have developed hospice institutions for terminal patients The Korean government began a hospice demonstration project in 2003 by selecting four hospitals In 2007, 27 Korean hospitals were enrolled in the hospice demonstration project As a part of this project, the Korean government began to develop a management system, cost system, and law for hospice To develop a Korean hospice system, the Korean government supported this study to benchmark other countries’ hospice systems The aim of the present study was to analyze and compare the hospice system in the United States, Japan, and Taiwan, focusing on the following specific objectives: (a) to analyze and compare the hospice management system of the three countries; (b) to analyze and compare the hospice cost system of the three countries The results of this study will contribute to the development of hospice systems not only for Korea, but also for other countries that plan to develop a hospice system Asian Nursing Research ❖ December 2010 ❖ Vol ❖ No Comparison of the Hospice Systems METHODS Study subjects To compare the hospice systems, we selected one country from North America, the United States, and two countries from Asia, Japan and Taiwan, which have already developed a hospice system and have health care delivery systems similar to Korea In this study, hospice cost system was one of the elements of comparison between countries However, in most of the European countries the cost of hospice care is supported by the government, so European countries were not included in this study The representative nursing schools and nominated researchers were contacted using the collaborative network of Yonsei University College of Nursing to collect the data on the hospice care in the United States, Japan and Taiwan Data collection The data for this study was collected in two ways The following hospice data was collected on a national level: definition of hospice client, the number of facilities nationwide, disease distribution of hospice patients, duration of hospice coverage, average length of stay, out-of-pocket hospice payment, eligibility criteria for hospice service, criteria for termination of hospice services, registration requirements, manpower, facilities, and equipment, average hospice cost per client per year, hospice payment types and rates, hospice cap (amount per year) The researcher in each country collected the national hospice data through literature review and government document search, internet search, and interviewing governmental people The second set of data was taken from surveying six hospice institutions in each country through interviews to analyze the hospices on the institutional level The following factors were considered in the survey: institutional type, manpower criteria, type of clients, financial structure, hospice services facility and equipment requirements for inpatient services, management of the dying, activities for quality improvement and education The researcher in each country selected the three home hospice institutions and three hospital-based hospice institutions in the Asian Nursing Research ❖ December 2010 ❖ Vol ❖ No city where the university was located The survey was done during January, 2008 Based on the data collection, the hospice management system was analyzed using nine different factors, five hospice infrastructures and four hospice services The hospice infra structures included the types of hospice institution, definition of the hospice client, Room specification of hospice facility, hospice quality control, and hospice law The hospice services included hospice team, initiation of hospice service, duration of hospice service, and contents of hospice service Four items of the hospice cost system were analyzed: funding source, hospital hospice services, day care hospice, and home hospice To organize and compare each country’s data, an international workshop with researchers from the United States, Japan, Taiwan, and Korea was held in Korea.The data of the study was analyzed and summarized by descriptive analysis This study was approved by the IRB in the College of Nursing,Yonsei University RESULTS The evaluation of the hospice system in the three countries was performed by comparing the hospice management systems (Tables and 2) and hospice cost systems (Table 3) Comparison of the hospice management system Hospice Infrastructure Types of hospice institution There were significant differences in the types of institutions in the three countries In the United States, most of the hospice institutions were home hospice institutions, such as home health agencies and freestanding home hospice agencies Specifically, there were 1,648 free-standing home hospice agencies in the United States, which accounted for more than 50% of the total hospice agencies in the country In Taiwan, hospitals provided both hospital hospice care and home hospice services In Japan, although many community medical clinics and visiting nursing stations provide home hospice services, only the 165 166 Taiwan Hospice Organization Survey for family members after patient death Terminal AIDS, cancer patient No life expectancy limit Japan Council for Quality Health Care Peer review Audit of nursing plan No single hospice law Related laws: National Health Insurance Law, Long Term Care Insurance Law, Cancer Law Hospice and Palliative Act Designated in 2000 Terminal patient No life expectancy limit No disease limit Contains four beds 7.5 m2 for a single patient room There are separate guidelines for the distance between bed, foot of the bed and the wall, and door size Hospital-based (163) Community clinic Visiting nursing station Type of hospice Hospital-based (551) institution Skilled nursing facility (13) (no of institutions) Home health agency (672) Freestanding agency (1,648) Definition of Patients who have a life expectancy of hospice client less than months No disease limit Hospice room Contains four beds facility 100 square feet (about 9.29 m2) for a single patient room 80 square feet (about 7.43 m2) for each patient for a multipatient room Equipped with device for calling the staff member on duty Hospice quality National Hospice and Palliative Care control Organization Survey for family members after patient death Hospice Law Hospice Act Designated in 1981 Contains five beds m2 for a single patient room m2 for each patient for a multipatient room Taiwan only offers hospital-based hospice services However, only a short stay in the hospital is permitted, and more than 90% of the services are home hospice care provided by the hospital Hospital-based (32) Taiwan Most of the hospice services are hospital hospice services, however home hospice services are increasing Japan Characteristics Among all hospice services, more than of hospice service 90% are home hospice services Most of the home hospice care is provided by a free standing home hospice agency United States Comparison of Hospice Infrastructure in Three Countries Table C.Y Lee et al Asian Nursing Research ❖ December 2010 ❖ Vol ❖ No Comparison of the Hospice Systems Table Comparison of Hospice Services in Three Countries United States Hospice team Medical doctor Nurse Social worker Clergy or counselor No hospice education requirement for hospice team Initiation of hospice service Duration of hospice service (d) Hospice services Approval of attendant physician (nurse practitioner included) and hospice doctor M = 52.5 Median = 21.4 First 90 da Second 90 da Third 60 d without limit Plan of care Assessment Service plan for symptom management Service plan for patient and family Hospice services Nursing care Medical social services Physician services Consultation Home care aid Homemaker services Supply medical equipment Physical and occupational therapies Speech-language pathology service 10 Bereavement services Japan Taiwan Medical doctor Nurse Social worker Volunteer Hospice palliative team: doctor for physical care, doctor for psychological care, hospice experienced nurse No hospice education requirement for hospice team Approval of physicians Medical doctor Nurse Social worker Nurse’s aid Others (i.e., nutritionist, pharmacist) Hospice education requirement for workers Doctor: 80 hr (20 hr of practice) Nurse: 80 hr (20 hr of practice) Social worker: 100 hr (40 hr of practice) Volunteer: 30 hr Approval of physicians M = 25 No limit of service duration M = 14 No limit of service duration Hospice services Hospice services Care plan Symptom control Pain/symptom Physical care control Psychological, social, and Physical, spiritual care for patient psychological, social, and family and spiritual care Terminal care Terminal care a The duration of hospice service was limited to 90 days for the first time and for the second time in each statistics on hospital-based hospice institutions were available In the United States and Taiwan, home hospice care accounted for more than 90% of all hospice Asian Nursing Research ❖ December 2010 ❖ Vol ❖ No services However, institutions providing home hospice care were quite different in the United States than the institutions in Taiwan While most of the home hospice institutions were free-standing home 167 C.Y Lee et al Table Comparison of Hospice Cost System in Three Countries Funding source Hospital hospice cost United States Japan Taiwan Medicare (age ≥ 65 yr) Medicaid (low income) Private insurance Inpatient respite care: $135.3/d General inpatient care: $581.82/d Patient payment: 5% National health insurance Long-term care insurance National health insurance $378/d Patient payment: 10–30% depending on age of patient < yr old: 20% 3–69 yr old: 30% ≥ 70 yr old: 10% Private room charge by patient 3–6 hours: $100 6–8 hours: $150 Patient charge 10% of total cost and food expenses (approximately $3) $90/d Patient charge: 10–30% depending on age of patient ≤ 16 d: $138/d > 16 d: $82.8/d Patient payment Private room charge by patient Food cost Daycare hospice cost – Home hospice cost Routine home care: $130.79/d Continuous home care: $763.36/d hospice agencies in the United States, the home hospice institutions in Taiwan were connected to hospitals In Japan, hospice services were typically provided by hospitals, although the prevalence of home hospices has gradually been increasing Definition of hospice client The requirements for a patient to be enrolled in hospice care included life expectancy and specified disease In the United States, hospice client were patients who had a life expectancy of less than months However, in Japan and Taiwan, there was no limit to the life expectancy of the patients Patients were admitted to hospice institutions in the United States and Taiwan regardless of disease type However, in Japan, although all patients were 168 – Doctor fee 1st visit: $60 Additional visits: $30 Nurse fee ≤ 1-hr visit: $33 > 1-hr visit: $45 Social worker: $21 Dying care: $75 eligible for home hospice services, only terminal AIDS and cancer patients were accepted for hospital hospice services Room specification of hospice facility There were guidelines for the hospice hospital room and the number of hospice patients in a hospital room The size of the hospice patient room was required to be 100 square feet (about 9.29 m2) in the United States, m2 in Japan, and 7.5 m2 in Taiwan In rooms with more than patients, the room was required to be 80 square feet (about 7.43 m2) per patient in the United States and m2 per patient in Japan In Taiwan, there were separate guidelines for the distance between beds, the distance between the foot of each bed and the wall, and the patient’s Asian Nursing Research ❖ December 2010 ❖ Vol ❖ No Comparison of the Hospice Systems door size The maximum number of hospice patients in a single hospital room was four in the United States and Taiwan, and five in Japan Hospice quality control Each of the three countries has designated an institution for hospice quality control: The National Hospice and Palliative Care Organization in America, the Japan Council for Quality Health Care, and the Taiwan Hospice Organization While a nursing plan was considered as an important component of hospice quality in Japan, a survey taken by family members after a patient’s death was the major source of data for hospice quality in the United States and Taiwan Hospice law In terms of hospice law, the Hospice Act was designated in 1981 in the United States (Hospice Patients Alliance, 2010) and the Hospice and Palliative Act was passed in Taiwan in 2000 (Hospice Foundation of Taiwan, 2010) In Japan, there was no single hospice law However, hospice-related laws such as the National Health Insurance Law, Long Term Care Insurance Law, and Cancer Law were utilized to manage hospice services Hospice services Hospice team The hospice team consisted of a medical doctor, nurse, and social worker in all three countries However, in the United States, a member of the clergy or a counselor was also included in the hospice team In Japan, a volunteer was included in the hospice team In Taiwan, a nurse’s aid, nutritionist, and pharmacist were included in the hospice team In Japan, in the case when a hospice patient was admitted to the general ward in a hospital, a separate hospice palliative team is assigned to the patient to provide hospice care, which included a medical doctor for physical care, a medical doctor for psychological care, and a hospice experienced nurse Although there is an education requirement for hospice workers in Taiwan, there is no hospice education requirement in the United States or Japan Asian Nursing Research ❖ December 2010 ❖ Vol ❖ No Initiation of hospice service Approval from two medical doctors was required for enrollment in hospice services in all three countries However, a nurse practitioner could be substituted for a medical doctor in the United States, but not in Japan or Taiwan Duration of hospice service In the United States, once the patients were accepted as hospice clients, they could receive hospice services for 90 days If the patients survived longer than 90 days, they were eligible to receive an additional 90 days of hospice care If the patients survived after this period, they were supported every 60 days without limitation In the United States, the mean hospice duration was 52.5 days and the median was 21.4 days Unlike the United States, there were no limitations for hospice service duration in Japan and Taiwan The mean hospice duration was 25 days in Japan and 14 days in Taiwan Contents of hospice services Hospice services included hospice care plans and detailed hospice service contents in the United States and Japan In particular, the hospice care plan was an important factor and was included in hospice service evaluations in the United States The hospice services in Japan and Taiwan have the following similarities: symptom and pain control, physical, social, and psychological care, terminal care and bereavement care Unlike Japan and Taiwan, the hospice institutions of the United States included the following additional hospice service items: home care aid, homemaker service, medical equipment service, physical and occupational therapies, and speechlanguage pathology service Comparison of Hospice Cost System Funding source All three countries had national hospice funding sources The National Health Insurance and Longterm Care Insurance of Japan and the National Health Insurance of Taiwan were the major hospice funding sources in Japan and Taiwan, respectively In the United States, the hospice-funding sources available 169 C.Y Lee et al varied depending on the age and income level of the patient If the hospice client was over 65 years old, Medicare was the hospice-funding source, and if the hospice client was considered to have a low income, then Medicaid was the hospice-funding source In the United States, private health insurance could also be used to fund hospice services if the hospice client had private health insurance Hospital hospice cost All three countries had a designated hospital room charge per day for hospice clients: $581.82 per day in the United States, $378 in Japan, and $83–138 in Taiwan In the United States, when the hospice caregiver required time-off, he could admit the hospice patient for up to days and get “inpatient respite care” support The government paid $135.3 per day for “inpatient respite care.” In Taiwan, the hospice funding scales varied depending on the number of days that the patient was enrolled in hospice care If the hospice client was admitted for up to 16 days, the admission fee was $138 per day, and if the patient used hospice care for more than 16 days, the fee became $83 per day Day care hospice cost Unlike the United States and Taiwan, Japan provided day care hospice services The fee for these services varied depending on the necessary service hours: $100 for 3–6 hours and $150 for 6–8 hours The hospice client paid 10% of the total cost and approximately $3 for food expenses Home hospice cost The daily cost of home hospice services for each country was $130.79 in the United States and $90 in Japan In Japan, hospice clients paid 10–30% of the total cost, depending on their age The home hospice cost in Taiwan varied depending on the provider and the number of service hours The first time the medical doctor visited the home hospice client in Taiwan, the cost was $60, and $30 for the second visit When a nurse visited a home hospice patient, the cost was $30 for the first hour, and $45 for each additional hour The cost for a social worker’s visit was $21 170 In the United States and Taiwan, there are also terminal care costs In the United States, if the hospice client received terminal care for more than hours per day, the cost was $763.36, and in Taiwan, the cost was $75 Based on the comparison of the hospice management and the cost systems, the followings are some strength of three countries: (a) Not only hospitalbased hospice services, but also home hospice services were the major hospice services in United States and Taiwan (b) Hospice day care service and cost system were developed in Japan, but not in United States and Taiwan (c) Unlike Japan, there were no disease limitation for hospice clients in United States and Taiwan (d) Unlike the United States, there were no life expectancy limits for hospice clients in Japan and Taiwan (e) All three countries had developed the hospice quality control systems (f) There were hospice laws developed in United States and Taiwan, but not in Japan (g) Unlike the United States and Japan, there were continuing education requirements for hospice health workers in Taiwan (h) Nurse practitioner can approve the hospice clients in the United States, but not in Japan and Taiwan DISCUSSION There were several differences in the characteristics of the hospice institutions in each of the three countries In the United States, home hospice institutions accounted for more than 90% of the hospice services The hospice services in Japan and Taiwan were typically based in hospitals However, in Taiwan, hospitals not only provided hospital hospice services, but also provided home hospice care and attempted to reduce the number of hospital admissions According to Seymour, Payne, Chapman, and Hollogway (2007), Chinese elders prefer hospital hospice care compared to white elders However, Taiwan developed two strategies to encourage home hospice care; one is different admission fees by the number of admission days and health education for hospice patients and family members For example, in Taiwan, if the hospice patient stayed over 16 days in the hospital, the support for hospital hospice cost from the government Asian Nursing Research ❖ December 2010 ❖ Vol ❖ No Comparison of the Hospice Systems decreased Also, the care team explains the advantages of home hospice compared to hospital hospice to hospice patients and family members (Chao, 2007) As a result, in Taiwan, home hospice care accounted for more than 90% of all hospice services Japanese patients preferred to stay at general hospital wards rather than receive hospice care within a hospital ward, so hospice palliative care is provided by a hospice palliative team for the hospital admission of terminal patients and explained to hospital terminal patients about the availability of the hospice palliative care team (Komatsu, 2007) A model for delivering hospice care has been developed to concentrate expertise in multiprofessional teams that work in hospital, inpatient units (Carr, Higginson, & Robinson, 2003) Gott et al (2009) pointed out that a proportion of patients dying in hospital experience very poor care in England More than half of the complaints concerned end of life care, with most relating to staff providing inadequate information to patients and their families before death A hospice palliative care team in acute care setting like Japan could be the way to improve the quality of life for hospice patients Before establishing a hospice system, it is important to determine which requirements each patient will be expected to meet to be enrolled in hospice services In Korea, only cancer patients were recommended to be included in the hospice services (Korea Ministry of Government Legistration, 2008) because the prognosis of a cancer patient is relatively predictable and cancer is the leading cause of death in Korea (Korea National Statistical Office, 2008) While in Japan, hospital hospice services were exclusively offered to patients with AIDS or cancer, in the United States and Taiwan, all sick patients were eligible for hospice care In the United States, there were guidelines to identify the patients eligible for hospice care regardless of the patients’ diseases Lunney, Lynn, Foley, Lepson, and Guralnik (2003) recommended that health care system must find ways of supporting hospice patients with serious chronic illness or multiple chronic problems Countries starting hospice should consider including hospice services not only for cancer patients, but also for chronic illness patients Asian Nursing Research ❖ December 2010 ❖ Vol ❖ No To initiate hospice service, approval from two medical doctors was required in each of the three countries analyzed in this study In the United States, a nurse practitioner can be substituted for a medical doctor, and this substitution has been utilized since the 1970s (Lee, 1999) Many studies have shown the efficiency of nurse practitioners (Choe et al., 2005; Srivastava, Tucker, Draper, & Milner, 2008; Viale & Yamamoto, 2004; Ypenburg, Verwey, & van der Wall, 2007) However, in Japan and Taiwan, a nurse practitioner system has not yet been well developed There were several differences between the hospice care teams in each of the three countries analyzed in this study Since Christianity is the most common religion in the United States, a member of the clergy was included in the hospice team in the United States Buddhism is the most common religion in Taiwan; however, monks were not included in the hospice team Volunteerism is popular in Japan, thus volunteers were included in the hospice team There is the possibility of systematic error due to different data collection methods (Lee et al., 2007) The data were collected by researchers from three countries They collected the national hospice data and in addition to interviews of hospice institutions Therefore, the depth and coverage of the data might be different and may have lead to systematic errors However, since most of the data were verified by the national hospice data, the systematic error should be minimized CONCLUSION Based on the results of this study, several recommendations could be suggested to countries starting national hospice system like Korea Not only cancer patients, but also patients with chronic illness should be considered as hospice clients Home hospice and hospice day care should be included with hospitalbased hospice service for quality of life in hospice clients.To increase the home hospice, strategies should be developed using a systematic approach in addition to educational approach for health workers and community people To support national hospice system, 171 C.Y Lee et al development of hospice law should be considered From the beginning of developing stage of hospice system, hospice quality control system should be included Like in America, utilizing nurse practitioner could be the option for hospice services ACKNOWLEDGMENTS This work was supported by Promoting Research and Development Project of Conquer Cancer, Ministry of Health and Welfare Fund REFERENCES 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Insurance and Longterm Care Insurance of Japan and the National Health Insurance of Taiwan were the major hospice funding sources in Japan and Taiwan, respectively In the United States, the hospice- funding... of the Hospice Systems door size The maximum number of hospice patients in a single hospital room was four in the United States and Taiwan, and five in Japan Hospice quality control Each of the. .. quality in the United States and Taiwan Hospice law In terms of hospice law, the Hospice Act was designated in 1981 in the United States (Hospice Patients Alliance, 2010) and the Hospice and Palliative