Navigating Cancer Care: How Concurrent Hospice and Treatment Can Improve Veteran Outcomes
"Discover how the VA's approach to concurrent cancer care—combining hospice with treatments like chemo—is reshaping end-of-life experiences for veterans, offering hope and preserving vital relationships."
For individuals battling advanced cancer, the decision between pursuing hospice care and continuing treatments like chemotherapy or radiation presents a significant dilemma. The Veterans Health Administration (VA) is pioneering a different approach: concurrent care. This model allows veterans to receive both hospice services and cancer treatments, provided the care is coordinated and non-duplicative. While data is limited, recent trends suggest an increase in concurrent care within the VA, driven by the expansion of hospice services.
Outside the VA, opportunities for concurrent care are rare, with the exception of the Medicare Care Choices Model, which remains in a demonstration phase. Studies suggest that many people desire concurrent care, highlighting its potential to improve outcomes. However, a deeper understanding is needed regarding how care is coordinated across different settings and clinicians, especially given the absence of standardized models for care coordination.
This article explores the findings of a qualitative study aimed at understanding the factors influencing the provision of concurrent cancer care within the VA system. By examining the perspectives of clinicians and staff at VA medical centers and community hospices, this study sheds light on the benefits, challenges, and implications of this integrated approach to end-of-life care for veterans.
Concurrent Care Trends and Patient Outcomes
Among veterans dying from cancer, the share receiving chemotherapy or radiation remained approximately 45%, while hospice use increased from 55% to 68% as concurrent care expanded acsjournals.onlinelibrary.wiley.com. A review of 72 hematology-oncology patients enrolled in concurrent care at the Hines Veterans Affairs Medical Center from December 2018 through April 2021 found that 63.6% died at home, 13.6% in inpatient hospice, and 3% in the hospital ascopubs.org. The study’s authors said concurrent hospice can remove the need to choose between comfort care and cancer-directed treatment, a choice that may otherwise be a barrier to earlier hospice enrollment.
Hospice Eligibility and Concurrent Treatment
VA directive 1139 describes hospice as part of the primary hospice care continuum, focused on comfort and quality of life, with goals informed by the Veteran or surrogate and family and bereavement support for families. It defines hospice eligibility as a prognosis of six months or less if the disease follows its normal course, as determined by a VA physician va.gov. Veterans with advanced cancer can receive hospice alongside treatments such as chemotherapy or radiation, but concurrent care remains relatively rare and varies across VA medical centers ncbi.nlm.nih.gov. A 2015 study reported that concurrent receipt of hospice and cancer therapy increased among veterans dying from cancer without reducing receipt of cancer therapy, in the context of VA policy allowing both acsjournals.onlinelibrary.wiley.com.
Concurrent Care: Preserving Hope and Relationships
The study revealed that clinicians and staff view concurrent care as a valuable option for veteran cancer patients. Hospice services are recognized for their ability to improve quality of life through expert symptom management and increased health security, often facilitated by frequent home visits from hospice staff. In some instances, staff members even provide veterans with their personal phone numbers to prevent unnecessary emergency room visits.
- Honoring Patient Values: Concurrent care respects the treatments patients value, easing the transition to comfort-focused care as veterans and their families evaluate the benefits and burdens of chemotherapy/radiation.
- A Humane Approach: Participants see concurrent care as a more humane approach to care, as veterans and families consider effects of chemotherapy/radiation on quality of life.
- Maintaining Access: Concurrent chemotherapy patients can still feel like they can access us [VA] when they need to.
Emerging Evidence and VA Care Coordination
A 2024 conference report says initial national VA data in lung cancer suggested concurrent care may outperform traditional hospice by reducing aggressive treatments, ICU hospitalizations, and medical costs ascopubs.org. The report presents this as an early finding rather than a definitive conclusion. A review of hospice use among patients with cancer notes that VA medical centers use dedicated liaisons—often nurse managers, oncologists, or palliative care physicians—to coordinate care and educate patients doi.org. The review suggests non-VA cancer organizations could consider these aspects of the VA model.
Uneven Use and Implementation Concerns
Concurrent care is used by a small number of veterans with advanced cancer, and its availability and delivery vary across VA medical centers link.springer.com. In interviews, VA staff valued having the option as a bridge to hospice, while hospice staff said it improved coordination with VA medical centers pc3i.upenn.edu. The same report noted that concerns about Medicare compliance may temper use. These findings point to implementation and coordination challenges alongside perceived benefits.
Expanding Concurrent Hospice at the VA
Dr. Ann Broderick describes concurrent hospice as an important part of VA care and recounts arriving at the VA Medical Center in Iowa City to direct its Hospice and Palliative Care Program. She describes the challenge of expanding a palliative care team within a large, integrated health care system capc.org. This account highlights program expansion in a VA setting, but the available source does not provide comparative outcome figures or a direct comparison with traditional hospice.
The Future of Concurrent Care
The study highlights the critical role of dedicated liaisons within VAMCs to facilitate concurrent care and educate hospices. These individuals, often nurse managers, oncologists, or palliative care physicians, serve as points of contact, ensuring seamless coordination between the VA and community hospices.
Evaluating Concurrent Care and End-of-Life Outcomes
A study evaluated concurrent hospice care and cancer-directed treatment within the Veterans Health Administration alongside aggressive care at the end of life pmc.ncbi.nlm.nih.gov. A separate cohort study used a modified difference-in-differences design to assess whether concurrent cancer treatment and hospice were associated with less aggressive end-of-life care and lower costs among veterans jamanetwork.com. The supplied summaries describe the questions and study designs, but do not provide results or effect estimates. Accordingly, they establish the outcomes being investigated without supporting a specific conclusion about the size or certainty of any benefit.
Despite its benefits, concerns about compliance with Medicare hospice regulations remain a significant barrier to the widespread adoption of concurrent care. Differing interpretations of guidelines and anxieties regarding payment responsibility for chemotherapy/radiation can lead to hesitancy among hospices.
As concurrent care models gain traction in alternative payment systems, addressing these challenges is essential for refining end-of-life care delivery. Clear policies, enhanced communication, and a focus on person-centered care are crucial to ensuring that veterans have access to the full range of services they deserve.