Hospice has dated back since biblical times and has been adopted all over the world. Cicely Saunders, a medical social worker and nurse from London, opened the first modern hospice called St. Joseph’s Hospice, to professionally administer pain management and provide a compassionate caregiving to the dying. Following the hospice movement, the US opened St. Christopher’s, the Hospice of Connecticut in 1974. Since then, hospice in the US became a home-care based program. If not for the works of Ida Cannon, Florence Wald, Dr. Richard Cabot, and Cicely Saunders, medical social work roles in a hospice would not be what it is today. Medical social workers engage in the traditional social roles but have also been adopted to work within the hospice setting. Over the centuries, hospice care has been modified to accommodate end-of-life care.
Specht and Craig’s (1982) definition of social work as a ‘profession with a dual purpose: to assist individuals and groups whose needs are not adequately met and to help change institutions so that they are more responsive to individual and group needs’ (p. 11). This definition applies equally to the mission of hospice, in which the individuals and groups are terminally ill patients and their families, and the institution in need of change is traditional medicine. Modern social work values are characterized by a holistic, ecological perspective that views people, and the social environments they inhabit as constantly influencing one another (Rusnack et al., 1988).
Similarly, social work is concerned with the whole person as a dynamic amalgam of interdependent spiritual, emotional, physical, and social needs. Germain and Gitterman (1980) wrote, ‘For social work, ecology appears to be a more useful metaphor than the older, medical disease metaphor because social work has always been committed to helping people and promoting more human environments’ (p. 5). This viewpoint distinguishes hospice care from mainstream terminal care. From its consideration of the patient and family as the unit of care to its commitment to addressing multiple needs of the individual (NHO, 1982), hospice practice demonstrates a philosophy adapted directly from the fundamental tenets of social work.
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On October 1983, Medicare approved hospice programs to provide continued care, whatever setting the patient entered. Later, in 1985, Medicare payments were made for hospice service. Variation across the US in where people die largely reflects the availability of hospital beds. The more availability, the more they’re used. ‘Under the conditions defined by Medicare eligibility, Medicare pays a predetermined daily rate for the total management of hospice care, including the provision of all core hospice services (physicians, nurses social worker, counselor, clergy, volunteers) and all additional services (pharmacist, physical therapist, occupational therapist, home health aide) as well as drugs and medical equipment'(Beder). In addition to this, families are not required to submit claims or pay bills for hospice services. To fulfill the paperwork aspect, hospice staff work with social workers to eliminate the paperwork. However, the National Hospice Organization recommends the core team also include trained volunteers as well as a social worker with a Master’s.
It is estimated that about 38.5% of deaths are under hospice care. Just under half of hospice care organizations are for-profit (46%), half are non-profit (50%), and 4% are operated by the government (e.g., U.S. Department of Veterans Affairs). Nearly all hospice care is paid for through the Medicare or Medicaid Hospice Benefit, which covers about 89% of hospice patients. Paradis and Cummings (1986) noted the drift toward organizational homogeneity in a hospice. Other observers have expressed concern about the constraints Medicare certification may have placed on a hospice’s ability to respond to diverse human needs (Butterfield-Picard & Magno, 1982; Kaplan & O’Conner, 1987).
Another current problem is Medicare’s per diem reimbursement for hospice care is that the organization must decide which services it can afford to provide for the per diem rate. This sometimes means settling for optimum team composition and services. Due to the nature of the work, there’s often a blurring of the roles from the interdisciplinary team. This in turn causes limited availability in the need for social workers because of overlapping roles and in part, cuts costs.
