Rural Hospice Social Work: Recommendations for Preparing Students for End-of-Life Work with Limited Resources

Overview: Rural hospice agencies face immense challenges in terms of accessibility, and service delivery. This presentation examines the experiences of 9 rural hospice social workers. Key findings, including dual relationships, beyond the scope of practice, autonomy, and more, along with implications for practice and emerging practitioners, will be discussed.Proposal text: Rural areas with small-scale and low-density settlement patterns make it more costly for communities and businesses to provide critical services. Distance and inaccessibility obstruct many rural areas from being connected to urban centers of economic activity. Additionally, changes in the availability of natural resources affect the residents who earn a living from them, as well as those who develop leisure and other benefits from them in rural communities. The provision of quality end-of-life (EOL) care available through a hospice model is an important area of service provision constrained in rural areas.
Hospice care provides medical care, pain and symptom management, emotional and spiritual support for individuals, and their family members, who have been diagnosed with a life-limiting illness through an interdisciplinary team approach. In line with a holistic approach to serving the patient and family, hospice services are provided in a patient’s home.
The challenges facing rural hospices are well-documented. Small hospices face an enigmatic combination of higher operating costs and lower reimbursement payments (Frenzen, 1997). Virnig, Ma, Hartman, Moscovice and Carlin (2006) report that the current Medicare hospice reimbursement rules are well suited to the expense structure of large volume hospices; however, it is not clear that they apply as abundantly to smaller volume, rural hospices. Small hospices may be incapable of absorbing the additional staffing and travel expenses associated with serving clients in geographically distant, sparsely populated areas. The residual effects of these challenges make it difficult to increase the number of patients served, and therefore difficult to increase the agencies income. According to Virnig et al. (2006) without an adjustment to the current reimbursement structure, it is not clear that hospice services will be accessible for all persons in need, in rural areas. Currently 7% of all US zip codes do not have hospice services available, which highlights the reality of how many are currently dying, without access to hospice services (Nelson & Stover Gingerich, 2010).
This research highlights insights from qualitative interviews with 9 rural hospice social workers across organizations in Texas and New Mexico. A maximum variation sampling technique was used to purposefully sample social workers from hospice agencies in areas deemed as rural by the Association of Rural Communities in Texas (Association of Rural Communities in Texas, 2016), with fewer than 200,000 occupants in their counties. The interviews were recorded and transcribed, and then coded using the constant comparative method of thematic content analysis by 3 researchers (Glaser & Strauss, 1967; Lincoln & Guba, 1985). The researchers met and coded the first interview together, then separately coded the remaining 8 interviews and then met to align their coding of the 8 independently coded interview. All codes were agreed upon and a final codebook was produced. Key findings included the following: limited services, rural community support, the culture of rural social work, misinformation, tasks required beyond the scope of practice, dual relationships, and autonomy. This presentation will explore these findings as well as recommendations for preparing students to work with end-of-life patients in rural areas.