National data shows that Black Medicare patients and their families are not making the move to comfort care as often as white patients are.
This article was published on Monday, January 10, 2022 in Kaiser Health News.
Willie Murphy died the day after Thanksgiving 2021. His wife, Mary, cared for him in their Nashville, Tennessee, home with the help of a new hospice agency focused on serving Black patients.
This time, it didn't take much persuading for Mary Murphy to embrace home hospice. When her mother was dying from Alzheimer's disease in 2020, she had been reluctant until she saw what a help it was. So when her husband, Willie, neared the end of his life, she embraced hospice again.
The Murphys' house in a leafy Nashville neighborhood is their happy place — full of their treasures.
"He's good to me — buys me anything I want," she said, as she pulled a milky glass vase out of a floor-to-ceiling cabinet with mirrored shelves.
Willie bought Mary the display case to help her to show off the trinkets she picks up at estate sales.
Down the hall, Willie was lying in their bed, now unable to speak. His heart was giving out.
"You gonna wake up for a minute?" she asked, cradling his head. She patted his back while he cleared his throat. "Cough it out."
Mary had been the primary caregiver for her husband, but she gets help from a new hospice agency in Nashville focused on increasing the use of end-of-life comfort care by Black families. Heart and Soul Hospice is owned and operated by people who share the same cultural background as the patients they aim to serve.
In their application to obtain a certificate of need in Tennessee, the hospice owners made it clear they are Black and intend to serve everyone but will focus on African Americans, who are currently underserved. Tennessee data shows that in Nashville just 19% of hospice patients are Black although they make up 27% of the capital city's population.
Though the area already had numerous hospice agencies, regulators granted Heart and Soul permission to operate, based primarily on the value of educating an underserved group.
In Murphy's first hospice experience, her mother had been living with dementia for decades. Still, Murphy had concerns about transitioning her mother to hospice. She felt as if she was giving up on her mom.
"My first thought was death," she said.
National data shows that Black Medicare patients and their families are not making the move to comfort care as often as white patients are. Roughly 41% of Black Medicare beneficiaries who died in 2019 were enrolled in hospice, compared with 54% of white patients, according to data compiled annually by the National Hospice and Palliative Care Organization.
Murphy's mother survived nearly three years on hospice. The benefit is meant for those in the final six months of life, but predicting when the end will come is difficult, especially in cases of dementia. Hospice provides palliative care for the dying and support for caregivers for a long as the process lasts.
Murphy did most of the caregiving — which can be overwhelming — but hospice helped with a few baths a week, medication in the mail and any medical equipment they needed.
And most important to Murphy was the emotional support, which came mostly from her hospice nurse.
"Wasn't no doctor going to come here, hold my hand, stay here until the funeral home came for her," she said about the day her mother died.
Last year, on the day after Thanksgiving, Willie Murphy died. And the same hospice nurse was at the Murphy home within minutes. She'd already stopped by that morning to check on him and returned as soon as Mary called and told her he wasn't breathing.
"If you don't feel like, 'Oh my God, thank God I have hospice,' if you can't say that, then we're doing something wrong," said Keisha Mason, Heart and Soul's director of nursing.
Mason, like Murphy, is Black and said that in her view there's nothing fundamental keeping Black patients from using hospice except learning what the service can offer and that it's basically free to patients — paid for by Medicare, Medicaid and most private health plans.
"I say to them, 'If you see a bill, then call us, because you should not,'" she said.
As Mason helped launch this new hospice agency, she began using new language, calling hospice more than a Medicare benefit. She describes it as an entitlement.
"Just as you are entitled to unemployment, as you are entitled to Social Security, you are entitled to a hospice benefit," she said.
The investors in Heart and Soul include David Turner, owner of CNS Hospice in Detroit; Nashville pastor the Rev. Sandy McClain; and André Lee, a former hospital administrator on the campus of Meharry Medical College, a historically Black institution in Nashville.
Lee and Turner also started a Black-focused hospice agency in Michigan and have plans to replicate the model in other states.
More families need to consider home hospice as an alternative for end-of-life care, Lee said. Nursing homes are pricey. And even with Medicare, a hospital bill can be hefty.
"You'll go in there and they'll eat you alive," he said. "I hate to say [something] bad about hospitals, but it's true."
Hospice research hasn't come up with clear reasons to explain the gap between white and Black families' use of the benefit. Some experts speculate it's related to spiritual beliefs and widespread mistrust in the medical system due to decades of discrimination.
The hospice industry's national trade group, the NHCPO, released a diversity and inclusion toolkit and a guide to reaching more Black patients. It recommends connecting with influential DJs, partnering with Black pastors and simply hiring more Black nurses.
Bridging the gap is not overly complicated, Lee said.
"A lot of hospices don't employ enough Black people," he said. "We all feel comfortable when you see someone over there that looks like you."
Well-established hospice agencies have attempted to minimize barriers with their own diversity initiatives. Michelle Drayton of Visiting Nurse Service of New York said her large agency has met with ministers who counsel families dealing with failing health.
"Many of them did not fully understand what hospice was," she said. "They had many of the same sort of misperceptions."
Every hospice company, whether it's an upstart or one of the nation's oldest, can promote end-of-life education and ease care disparities, Drayton said. "We're not just handing out a brochure," she added.
“A lot of hospices don't employ enough Black people. We all feel comfortable when you see someone over there that looks like you.”
André Lee, Health and Soul Hospice
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.
Roughly 41% of Black Medicare beneficiaries who died in 2019 were enrolled in hospice, compared with 54% of white patients.
The NHCPO released a diversity and inclusion toolkit and a guide to reaching more Black patients.
It recommends connecting with influential DJs, partnering with Black pastors and simply hiring more Black nurses.