African-American Family

The National Hospice and Palliative Care Organization's annual report, “NHPCO Facts and Figures: Hospice Care in America,” shows that, while hospice utilization is on the rise, African Americans, Hispanics, and Latinos continue to be 25% to 65% less likely to access hospice benefits. Numerous investigations using primarily surveys and focus groups have attempted to understand and describe factors probably contributing to this trend.1-10 Among the factors consistently identified by focus groups are lack of information and misconceptions about hospice. Minority focus group participants consistently report awareness that hospice is an end-of-life service while simultaneously expressing frustration over not being told what hospice entails or receiving recommendations about when to choose hospice.1,2 Awareness of popular misconceptions may help hospice agencies adjust their targeted marketing to minorities and the community and adjust some of their physician education efforts.  Among these studies attempting to identify barriers to hospice care, recurring themes include:


  • Hospice will be too expensive: Participants in these studies were wholly unaware that Medicare pays 100% for hospice. In addition, they were unaware of how Medicare benefits become enhanced under hospice care – specifically, that the costs for hospice diagnosis-related supplies, equipment, and medications become 100% covered.
  • Hospice will result in isolation of the patient: Hospice was rarely equated to home care and was more often equated to long-term nursing home care. Focus group participants concurred that hospice meant isolating patients in a closed room where they are checked on once or twice per day. The truth of the matter is that most hospice services are delivered in a patient’s home, giving family and friends greater ability to play a meaningful role in the care and emotional support of their loved-ones.
  • Hospice is avoiding familial responsibilities: The desire of family to meet their obligations during end-of-life emerged as a major theme. One focus group participant made the comment that letting hospice take care of the loved one would be the equivalent of bringing food that you bought instead of bringing food you made. It’s cheating.  Hospice programs aware of these cultural subtleties can work with families to better enable them to play a meaningful role in the care of a family member with terminal disease while being careful to not usurp what the family perceives as the family's role. Among families that have a strong desire to have family leading the patient care efforts, it may be helpful to avoid language of direct patient care when describing hospice, and instead talk about how hospice supports the family caregivers by providing training, counseling on what to expect, equipment, supplies, and medications. Direct care for patients can be described as providing occasional relief and support for the primary family caregivers. When talking to these families, it may be helpful to point out how hospice increases the family’s ability to take a lead role in patient care when this is desired. Marketing materials to these audiences can also emphasize the medical treatments and specialized care that would be beyond what these family members would expect of themselves.
  • Medicare-paid programs will be of lesser quality: Noting that hospice agencies have programs in place to ensure care is delivered without regard to payor source may help overcome this misconception. In private conversations, agency representatives can mention that Medicare is the preferred payer source for this program, when and if appropriate. Related to the Medicare – quality misconception is the common perception among participants that hospice would result in increased pain for the patient.  Research shows that home hospice is the most effective program and care setting in regards to terminal illness symptom control.11 Patients and referring clinicians need to be made fully aware of this fact.
  • Brochures and Websites Lacking Diversity: Study participants repeatedly state they think hospice services are not for them because the marketing materials only depict white, non-Hispanic patients. All healthcare providers should review their brochures, websites, and other marketing collateral and verify that the photography used includes the racial diversity of the service area.
  • Mistrust of the healthcare system: Among African Americans participating in focus groups, distrust of healthcare providers was a recurring theme.  In some cases, participants described hospice referrals as doctors’ attempts to avoid providing top quality care to minorities.1,2,8-10  When describing the hospice option, it may be helpful to emphasize how, when the prognosis is six-months or less, home hospice is a high-quality health care option. You can support this assertion with the fact that home hospice traditionally garners higher patient and family satisfaction scores, achieves greater pain control, includes the services of multiple disciplines, achieves greater satisfaction with family education, and correlates with improved survival by days to months.11-18  The empirical evidence demonstrates this, but it will take a consistent, and quality effort on the part of hospice agencies to make these facts well known and endorsed by their local medical community. Wham-bam sales focused on asking for the referral is valuable, but will not accomplish this important groundwork. 


Hospice Marketing Matters

Attention hospice providers: All hospice professionals know that hospice is generally underutilized, both in prevalence and length of enrollment. Are your doctors getting these facts? Evidence-based arguments with sufficient repetition (a core principle of marketing) prove an effective and available means for improving the hospice referral patterns of your doctors. Let Brazzell Marketing Agency help. Start here: Hospice Newsletters



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  2. Born W, Greiner A, Sylvia E, et al. Knowledge, attitudes, and beliefs about end-of-life care among inner-city African Americans and Latinos. Journal of Palliative Medicine. 2004; 7 (2): 247-256.
  3. Jackson F, Schim S, Seely S, et al. Barriers to hospice care for African Americans: problems and solutions. J Hosp Palliat Nurs. 2000; 2(2); 65-72.
  4. Burrs F. The African American experience: breaking the barriers to hospice. Hosp J. 1995; 10 (2): 15-18.
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  8. Blackhall L, Frank G, Murphy S, et al . Ethnicity and attitudes towards life-sustaining technology. Soc Sci Med. 1999; 48 (12): 1779-1789.
  9. Cort M. Cultural mistrust and use of hospice care: challenges and remedies. J Palliat Med. 2004; 7 (1): 63-71.
  10. Krakauer E, Crenner C, Fox K. Barriers to optimum end-of-life care for minority patients. J Am Geriatr Soc. 2002; 50 (1): 182-190.
  11. Teno J, et al. Family perspectives on end-of-life care at the last place of care. JAMA. 2004; 291: 88-93.
  12. Keyser E, Reed B, Lowery W, et al. Hospice enrollment for terminally ill patients with gynecologic malignancies: Impact on outcomes and interventions. Gynecol Oncol. 2010: 118 (3): 274-7.
  13. Connor S, Pyenson B, Fitch K, et al. Comparing hospice and nonhospice patient survival among aptients who die within a three-year window. J Pain Symptom Manage. 2007 Mar; 33 (3): 238-46.
  14. Christakis N, Iwashyna T, Zhang J. care after the onset of serious illness: a novel claims-based dataset exploiting substantial cross-set linkages to study end-of-life care. J Palliat Med. 2002; 5: 515-529.
  15. Christakis N. Predicting patient survival before and after hospice enrollment. Hosp J. 1998; 13: 71-87.
  16. Connor S. Hospice: Practice, pitfalls, and promise. Philadelphia, PA: Taylor and Francis, 1998. 118-119.
  17. Forster L, Lynn J. the use of physiologic measures and demographic variables to predict longevity among inpatient hospice applicants. Am J Hosp Care. 1989; 6: 31-34.
  18. Axoulay D, Jacobs J, Cialic R, et al. Opioids, survival, and advanced cancer in the hospice setting. Journal of the American Medical Directors Association. 2011; 12 (2): 129-134.