Number 33 n January 19, 2011

Complementary and Alternative Therapies in Hospice:
 

The National Home and Hospice Care Survey:
 

United States, 2007
 by Anita Bercovitz, Ph.D.; Manisha Sengupta, Ph.D.; Adrienne Jones, B.S.; and Lauren D. Harris-Kojetin, Ph.D.

Division of Health Care Statistics

Abstract

Objective—This report presents national estimates on the provision and use

of complementary and alternative therapies (CAT) in hospice. Comparisons of

organizational characteristics of hospice care providers are presented by whether

the provider offered CAT. Comparisons of selected characteristics of patients

discharged from hospice are presented by whether they received care from a

provider that offered CAT, and whether they received a CAT service.

Methods—Estimates are based on data from the 2007 National Home and

Hospice Care Survey (NHHCS), conducted by the Centers for Disease Control

and Prevention’s National Center for Health Statistics.

Results—In 2007, 41.8% of hospice care providers offered CAT services,

had a CAT provider on staff or under contract, or both. Among hospice care

providers offering CAT, over one-half offered massage (71.7%), supportive group

therapy (69.0%), music therapy (62.2%), pet therapy (58.6%), or guided imagery

or relaxation (52.7%). Of the hospice care providers that offered CAT, 21.5% had

at least one discharged hospice patient who received CAT during hospice care.

Overall, 4.9% of all discharged hospice patients received at least one CAT from

the hospice care provider. Over one-half of discharged patients (56.5%) received

care from a provider that offered CAT, and of those, 8.6% received at least one

CAT from the hospice care provider during their stays. There were no differences

in demographics, health, functional status, or admission diagnoses between

patients discharged from hospice either by whether they received care from a

provider that offered CAT or whether they received CAT.

Keywords: end-of-life and palliative care • quality of care • pain management •

advance directives

Introduction

The use of complementary and

alternative therapies (CAT)—products

and practices not part of standard care

(1)—is widespread, with a 2007 survey

noting that almost 40% of

noninstitutionalized U.S. adults used

some form of CAT in the previous 12

months. (2) CAT is commonly used by

persons with cancer and other chronic

conditions (3–6). A primary focus of

both CAT and end-of-life hospice care is

to provide comfort and alleviate pain

and symptoms such as dyspnea or

anxiety.

Clinical studies have found that

some types of CAT use are associated

with abatement of symptoms, including

anxiety and pain, and improvements in

mood and sense of control (7–15). Use

of CAT may provide another avenue in

addition to or instead of allopathic

medicine to address the hospice goal of

improving quality of life at the end of

life. Hospice funding for CAT is

currently primarily provided by

volunteers or donations rather than by

health insurance (16).

Several studies have found that the

provision and use of CAT were

relatively common in end-of-life care; at

least one-half of hospices offered CAT,

and approximately one-third to one-half

of patients at end of life used some

form of CAT. However, these studies

were not based on nationally

representative information, and thus

their generalizability is limited (17–20).

Using nationally representative data, this

report compares hospice care providers

that offer CAT to those that do not offer

CAT and discharged hospice patients

who did receive CAT to those who did

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Disease Control and Prevention 

National Center for Health Statistics 
Page 2 National Health Statistics Reports n Number 33 n January 19, 2011

not receive CAT. We compare hospice

care providers that offer CAT to those

that do not because there may be

organizational differences related to the

decision to offer or not offer CAT,

especially since CAT is often not

covered by health insurance. We

compare discharged hospice patients

who received CAT to those who did not

to explore whether certain patient

characteristics are related to CAT access

or CAT use.

Methods

Data source

Data from hospice care providers

participating in the 2007 National Home

and Hospice Care Survey (NHHCS)

were used for these analyses. The 2007

NHHCS is one in a series of nationally

representative, cross-sectional sample

surveys of U.S. home health and

hospice agencies. It is designed to

provide descriptive information on home

health and hospice agencies, their staffs,

their services, and their patients.

NHHCS was first conducted in 1992

and was repeated in 1993, 1994, 1996,

1998, 2000, and most recently in 2007.

All agencies that participated in the

2007 NHHCS were either certified by

Medicare, Medicaid, or both, or were

licensed by a state to provide home

health services, hospice services, or both

and currently or recently served home

health or hospice patients. Agencies that

provided only homemaker services or

housekeeping services, assistance with

instrumental activities of daily living

(IADLs), or durable medical equipment

and supplies were excluded from the

survey. Further information on the

sampling, survey design, and other

survey methodology is available in the

‘‘Technical Notes’’ and documentation

provided at: http://www.cdc.gov/nchs/

nhhcs.htm and in Dwyer et al. (2010)

(21).

The 2007 NHHCS collected

information from each participating,

sampled hospice care provider on a

sample of patients discharged from

hospice during a 3-month period starting

4 months before the month of the

interview. A sample of patients

discharged from hospice care is more

likely to include patients with short

stays and multiple discharges compared

with a sample drawn from hospice

patients receiving care at the time of

sample selection. Thus, the sample

analyzed in this study—patients

discharged from hospice care—is

representative only of discharges from

hospice care, rather than hospice

patients being treated by the agency at

the time of the survey. For the

remainder of this report, patients

discharged from hospice care are termed

‘‘discharged patients.’’

Data analysis

All analyses were performed in

SAS-callable SUDAAN to account for

sampling weights and the complex

sampling design (22). Differences

among subgroups were evaluated using

chi-square, and t-tests were used to test

for significance at the p <0.05 level.

However, if the difference between

subgroups was smaller than the

percentage of missing data for the

variable of interest, significance testing

was not performed. Differences between

subgroups were also not evaluated if

one of the estimates was not considered

reliable (as defined in the ‘‘Technical

Notes’’ section on Standard errors). No

adjustments were made for multiple

comparisons. The difference between

any two estimates is mentioned in the

text only if it is statistically significant.

However, if a comparison is not made

or mentioned, it may or may not be

significant. Otherwise, terms such as

‘‘similar’’ or ‘‘no significant

differences’’ are used to denote that the

estimates being compared are not

statistically significantly different.

Four separate logistic regression

models were run, each using the same

independent variables. Three of these

models were run to identify the

independent contributions of variables to

whether a hospice care provider offered

CAT. Among these three models, one

included all hospice care providers, the

second included only providers that

offered hospice care only, and the third

included only providers that offered

both home health and hospice care. The

fourth regression model examined the

independent contributions of variables to

whether at least one discharged patient

used CAT, with the population including

only providers that offered CAT. All

models included the following variables:

whether the hospice care provider

offered only hospice care or both home

health and hospice care; ownership (for

profit; non-profit, government, and

other); chain membership (yes, no);

main referral source (hospital, physician,

and all other); hospice type

(freestanding; hospital and nursing home

based); whether the provider had

dedicated hospice facilities (yes, no);

contract with a residential care provider

(yes, no); contract with a hospital (yes,

no); contract with managed care or

provide insurance provider (yes, no);

contract with a skilled nursing facility

(yes, no); location (metropolitan

statistical area; micropolitan and other);

number of years providing hospice care

(20 years or fewer, more than 20 years);

number of hospice patients served at

time of survey (35 or fewer, more than

35); and number of services offered

(mean or fewer, greater than the mean).

The adjusted percentages reported are

the predicted marginal probabilities

estimated for the average hospice care

provider after adjusting for all other

variables noted in the model. For further

description see the ‘‘Technical Notes.’’

In this report, hospice care

providers were categorized as providing

CAT if they either offered CAT or had

CAT providers on staff or contract. All

other hospice care providers, including

6.4% that were missing information on

whether they offered CAT or had CAT

providers, are categorized as not

providing CAT. Information on whether

discharged hospice patients received a

CAT from the agency was missing for

1.5% of discharged hospice patients.

Discharged hospice patients with

missing information on whether they

received a CAT from the agency were

categorized as not receiving CAT. For

further explanation see the ‘‘Technical

Notes.’’

For the categorical variables used in

the analyses, nonresponses, ranging

from 0 to 6.9%, were recoded as

‘‘unknown’’ and included in the

analyses. Marital status at admission had
TENS 

Art therapy 

Aromatherapy 

Therapeutic touch 

Guided imagery

 or relaxation 

Pet therapy 

Music therapy 

Supportive 

group therapy 

Massage 

20.9 

37.7 

39.7 

48.3 

52.7 

58.6 

62.2 

69.0 

71.7 

0 20 40 60 80 10

Percent of hospice care providers offering CAT 

NOTES: Hospice care providers offered CAT or had a CAT provider on staff or contract. Providers may offer more than one 

therapy. TENS stands for Transcutaneous Electrical Nerve Stimulation. 

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 2007.
 

National Health Statistics Reports n Number 33 n January 19, 2011	 Page 3

a nonresponse rate of 5.6% and whether

patients had a colostomy or difficulty

controlling bowels had a nonresponse

rate of 6.9%. The rest of the categorical

variables had nonresponse rates of less

than 5%, with the majority less than

2%. For continuous variables, unknowns

were excluded when calculating

estimates. The percentage missing for

continuous variables used in this report

are: number of hospice patients at time

of survey (2.0%), number of beds in

dedicated hospice facilities (0.1%),

number of years the agency has

provided hospice care (1.9%), and

length of hospice service (0.2%). The

ranges of values for the three continuous

variables were large, and the means and

medians were quite different. Because

the median is less affected by the range

of responses, medians are presented in

the tables.

Results

The proportion of hospice

care providers offering CAT

+ In 2007, 41.8% of all hospice care

providers offered CAT. The

proportion offering CAT was greater

among providers of hospice care only

(54.0%) than providers of both home

health and hospice care (22.9%)

(Figure 1 and Tables 1 and III).

NOTE: Hospice care providers offered CAT or had a CAT provider on staff or contract. 

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 2007. Percent of hospice care providers 

0 

20 

40 

60 

80 

100 

41.8 

22.9 

54.0 

Provide hospice 

care only 

Provide both 

home health and 

hospice care 

Hospice care 

providers 

Figure 1. Percentage of hospice care providers offering complementary and alternative

therapies (CAT): United States, 2007

CAT) than those that did not offer

CAT (Table 2).

+	 Ownership and total number of

services offered were significantly

associated with offering CAT, among

all hospice care providers. After

adjusting for other differences among

agencies, 28.7% of for-profit

providers (95% confidence interval

(CI) = 15.9%–41.4%) and 51.9%

(95% CI = 43.0%–60.8%) of

non-profit, government and other

Types of CAT offered by

hospice care providers

+ Of hospice care providers offering

CAT, the most commonly provided

were massage (71.7% of providers),

supportive group therapy (69.0%),

music therapy (62.2%), pet therapy

(58.6%), guided imagery and

relaxation (52.7%), and therapeutic

touch (48.3%) (Figure 2).

Characteristics of hospice

care providers by whether

they offered CAT

+ On average, hospice care providers

offered 19 services excluding CAT

(median 20). Hospice care providers

that offered CAT offered significantly

more services overall (excluding

0 

Figure 2. Types of complementary and alternative therapies (CAT) offered by hospice care

providers: United States, 2007
5.1% 

51.1% 43.8% 

Hospice care provider offered CAT, 

patient discharged from hospice 

received CAT 

Hospice care provider did not 

offer CAT 

Hospice care provider offered CAT, 

patient discharged from hospice 

did not receive CAT 

NOTES: Hospice care providers offered CAT or had a CAT provider on staff or contract. Percentages may not add to 100% 

because the denominator includes a category of unknowns not included in the figure. 

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 2007.
 

Page 4	 National Health Statistics Reports n Number 33 n January 19, 2011

providers offered CAT. In facilities

that offered the mean or fewer

services 28.2% offered CAT (95%

CI = 16.8%–39.5%), compared with

51.6% of providers that offered more

than the mean number of services

(95% CI = 41.6%–61.7%). (Results

not shown.)

+ Chain affiliation, ownership, and

number of services provided were

significantly associated with whether

the provider offered CAT. This

finding applied to providers of

hospice care only. Adjusted models

estimate that 38.4% of for-profit

providers (95% CI = 23.3%–53.4%)

and 68.3% of non-profit, government,

and other providers offered CAT

(95% CI = 57.6%–79.0%). In

facilities that offered the mean or

fewer services 38.3% offered CAT

(95% CI = 23.9%–52.7%), compared

with 70.1% of providers that offered

more than the mean number of

services (95% CI = 58.7%–81.5%).

Among providers that were part of a

chain 75.1% offered CAT (95% CI =

64.0%–86.2%) compared with 47.9%

of unaffiliated providers (95% CI =

35.0%–60.8%). (Results not shown.)

+ Ownership and contracts with

hospitals were significantly associated

with whether providers of both home

health and hospice care offered CAT.

Adjusted models estimate that 8.6%

of for-profit providers (95% CI =

0.1%–17.1%) and 31.0% of nonprofit, government, and other

providers offered CAT (95% CI =

20.3%–41.6%). Among providers

with contracts with hospitals 34.4%

offered CAT (95% CI = 23.6%–

45.3%), compared with 12.5% of

providers without contracts with

hospitals (95% CI = 5.6%–19.4%).

(Results not shown.)

Characteristics of patients

discharged from hospice by

availability and use of CAT

+	 Although 56.2% of discharged

patients received care from a provider

of hospice care that offered CAT,

only 5.1% of all discharged patients

received at least one CAT from the

provider during their episode of care

(Figure 3).

+	 Discharged patients who received

care from a hospice care provider

who offered CAT had a longer mean

length of service (71 days) than those

who received care from a hospice

care provider that did not offer CAT

(58 days) (Table 3).

+	 A greater proportion of discharged

patients receiving care from a hospice

Figure 3. Discharged patients by availability and use of complementary and alternative

therapies (CAT): United States, 2007

care provider offering CAT had

impaired cognitive functioning

(41.0%) than discharges receiving

care from a provider not offering

CAT (34.6%). Table 4 shows selected

admission diagnoses of discharged

patients from hospice, by availability

of CAT.

+	 Among discharged patients receiving

care from a hospice care provider that

offered CAT, 8.6% received at least

one CAT from the provider during

their episode of care (Table 5).

+	 A smaller proportion of discharged

patients who received CAT from the

hospice care provider were married

(32.3%) than discharged patients who

did not receive CAT (41.5%).

+	 The majority of all discharged

patients had a do not resuscitate order

(DNR), but the proportion varied by

whether the discharged patient

received CAT from the provider.

Among discharged patients who

received CAT, 91.5% had a DNR,

greater than the 75.8% who received

care from providers not offering CAT.

A greater proportion of discharged

patients who did not use CAT

although it was available, had a DNR

(82.9%) than discharged patients who

received care from providers not

offering CAT (Figure 4).

+	 Among discharged patients who

received CAT, 60.8% had a durable

power of attorney (DPA) or health

care proxy or surrogate, greater than

the 39.2% who did not use CAT,

although it was available, and patients

receiving hospice care from providers

not offering CAT (39.5%).

+	 Among discharged patients who

received CAT, 36.3% had a living

will greater than the 22.4% receiving

hospice care from providers not

offering CAT.

+	 The proportion of discharged patients

with a standing order for pain

medication was greater among those

who had received CAT (82.3%) than

among those who did not receive

CAT, although it was available,

(66.6%) and those receiving care

from a provider that did not offer

CAT (60.8%) (Figure 5).
Hospice care provider Hospice care provider Hospice care provider 

offered CAT and patient offered CAT but patient did not offer CAT 

discharged from hospice discharged from hospice 

used at least one service did not use CAT 

0 

20 

40 

60 

80 

100 

Percent of discharged hospice patients

91.5 

82.9 

75.8 

60.8 

39.2 39.5 36.3 

26.6 22.6 

28.0 

15.7 15.7 

Do not Durable power of Living will Comfort care 

resuscitate attorney or health 

order care proxy or surrogate 

Type of advance directive 

NOTES: Comfort care includes feeding or medication restrictions, a do not hospitalize order, and other orders for comfort 

care. Discharged hospice patients may have had more than one type of advance directive.
 

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 2007.
 

Hospice care provider Hospice care provider Hospice care provider

offered CAT and patient offered CAT but patient did not offer CAT 

discharged from hospice discharged from hospice 

used at least one service did not use CAT 

100 

82.3 

66.6 

60.8 

91.2 

85.3 

80.2 81.8 

39.2 

35.7 

60 

Percent of discharged hospice patients

80 

40 

20 

0 

Standing order for PRN order for Nonpharmacological 

pain medication pain medication methods 

NOTES: PRN is an order for medication to be provided on an as-needed basis. Nonpharmacological methods include 

distraction, heat or cold, massage, positioning, or music. Discharged hospice patients may have received more than one 

pain treatment approach. Data are from all discharged hospice patients. 

SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 2007. 

National Health Statistics Reports n Number 33 n January 19, 2011	 Page 5

+ Discharged patients who received

CAT were more likely to have a PRN

order for pain medication (91.2%)

than discharged patients who received

care from a provider not offering

CAT (80.2%).

+ A greater proportion of discharged

patients who received CAT received

nonpharmacological methods for pain

control (81.8%) than those who did

not receive CAT (39.2%), or received

care from a provider that did not

offer CAT (35.7%).

Characteristics of hospice

care providers that offered

CAT by whether at least one

discharged patient received

at least one CAT from the

provider

Figure 4. Advance directives among discharged patients by availability and use of

complementary and alternative therapies (CAT): United States, 2007

+	 Twenty-one and one-half percent of

hospice care providers that offered

CAT had at least one discharged

patient who received at least one

CAT from the agency. (Results not

shown.)

+	 Having a contract with a hospital was

related to whether at least one patient

used CAT among hospice care

providers that offered CAT

controlling for other factors. Among

at least one patient who used CAT

(95% CI = 0–14.2%). (Results not

hospice care providers that offered

CAT 25.7% of providers with

contracts with a hospital (95% CI =

16.6%–35.0%) and 6.5% of providers

without contracts with a hospital had

shown.)

Discussion

Results from NHHCS indicate that

41.8% of all hospice care providers

offered CAT; however, it was more

common for hospice care providers to

offer CAT than for discharged patients

to receive CAT from the provider. More

than one-half of providers that offered

CAT offered massage, supportive group

therapy, music and pet therapy, and

Figure 5. Pain treatment among discharged patients by availabiity and use of guided imagery and relaxation.

complementary and alternative therapies (CAT): United States, 2007 Providers of hospice care only were

more likely to offer CAT than providers
Page 6	 National Health Statistics Reports n Number 33 n January 19, 2011

of both home health and hospice care.

Of the providers that offered CAT, about

one-fifth had at least one discharged

patient who used at least one CAT from

the provider during an episode of

hospice care.

Hospice care providers that were

non-profit or government owned were

more likely to offer CAT. Additional

characteristics associated with offering

CAT varied depending on whether the

provider offered both home health and

hospice care or hospice care only.

Providers of hospice care only, which

offered a greater number of services and

were part of a chain, were more likely

to offer CAT, while providers of both

hospice and home health care with

contracts with hospitals were more

likely to offer CAT. However, the

facility characteristics associated with

whether a provider offered CAT were

not the same as the characteristics

associated with whether at least one

patient used CAT. Among hospice care

providers offering CAT, only having

contracts with hospitals was associated

with having at least one patient use

CAT.

The proportion of discharged

hospice patients receiving CAT is much

lower than previously published

estimates of use of CAT among the

nonhospice population (2). Several

factors may account for this difference.

NHHCS asked only about CAT provided

by the hospice care provider. However,

patients may have been receiving CAT

through sources other than the hospice

care provider. These services would not

be included as a service from the

NHHCS provider. Kutner et al. found

that most CAT was not provided by

hospice personnel (18). In addition, data

from the National Health Interview

Survey on trends in personal health

expenditures on CAT suggest a shift

from receipt of CAT from health care

professionals to increasing use of

self-care therapies (23). The definition

of CAT may also be an important factor.

A hospice may have offered therapies,

such as supportive group therapy, music,

or pet therapy, which were considered

CAT for NHHCS, but which the hospice

survey respondent did not consider CAT.

There were very few differences in

demographics, health, functional status,

and admission diagnosis among

discharged hospice patients by

availability and use of CAT. The only

significant differences found in the

variables analyzed were that a greater

proportion of patients discharged from

hospice providers offering CAT had

impaired cognitive functioning and a

smaller proportion of discharged hospice

patients that used CAT were married.

However, there were some

consistent differences in some aspects of

quality of hospice care by availability

and use of CAT. The length of time a

discharged patient received hospice care

was longer among discharged patients

receiving care where CAT was offered

compared with patients where CAT was

not offered. There were also consistent

differences in pain management

approaches and advance directive

adoption between discharged patients

receiving CAT and those receiving care

from a provider that did not offer CAT.

Compared with patients where CAT was

not offered, patients who received CAT

were more likely to have a standing

order for pain management, a PRN

order for pain management, a DNR, a

DPA or health care proxy, and a living

will.

Although NHHCS lacks both the

design and content to explain these

observed associations, it is possible that

discharged patients that are more likely

to have an advance directive are also

more likely to be more selective about

their care. They may choose providers

that offer more amenities, CAT being

one of them, or be more proactive in

requesting approaches for pain

management. Conversely, providers

offering CAT may be more flexible and

proactive in meeting their patients’

perceived needs, including encouraging

completion of advance directives, and

approaches toward pain management, as

well as offering a greater variety of

services.

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Vital Health Stat 1(53). 2010.

22. SUDAAN (Release 9.0.1). 2005:

Research Triangle Institute: Research

Triangle Park, NC.

23. Nahin RL, Barnes PM, Stussman BJ,

et al. Costs of complementary and

alternative medicine (CAM) and

frequency of visits to CAM
Page 8 National Health Statistics Reports n Number 33 n January 19, 2011

Table 1. Characteristics of hospice care providers, by whether they offer complementary and alternative therapies: United States, 2007

Provide hospice care Provide hospice care only

Provide both home

health and hospice care

Provider characteristic Total1

Offer

CAT1

Do not

offer

CAT1 Total1

Offer

CAT1

Do not

offer

CAT1 Total1

Offer

CAT1

Do not

offer

CAT1

Number

Total ................................ 3,700 1,500 2,100 2,200 1,200 1,000 1,400 300 1,100

Ownership Number Percent Number Percent Number Percent

For profit .............................

Not for profit, including government .............

Location of agency:

Metropolitan statistical area2 ....... .......

Micropolitan and other statistical area3,4 .... ....

1,200

2,400

2,400

1,200

†28.5

71.5

74.4

25.6

37.9

62.1

61.3

38.7

900

1,300

1,600

600

†33.1

66.9

80.2

19.8

†46.7

53.3

†63.4

36.6

†400

1,100

800

600

*

88.1

†53.4

46.6

†29.7

70.3

59.3

40.7

Affiliation

Chain ...............................

Independent ...........................

Total median number of patients served at time of

survey ..............................

Median number of hospice patients at time of survey . .

900

2,800

64

32

†28.9

71.1

63

47

19.9

80.1

64

24

600

1,600

47

47

†33.2

66.8

57

57

†21

79.0

34

34

†300

1,200

133

19

*

87.2

144

27

†19

81.0

126

18

Major referral source

Hospital ..............................

Physicians office.........................

All other5 . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .

Type of hospice

Freestanding..........................

Hospital, nursing home, or home health based.....

1,300

1,600

600

2,100

1,500

39.7

43.6

†15.8

68.3

31.6

32.0

45.5

18.1

47.7

48.0

700

900

500

1,700

400

38.1

43.1

*

80.8

†19.1

†24.7

41.9

†24.4

71.2

†19.8

600

700

†200

400

1,100

†45.7

†45.4

*

*

77.1

38.7

48.9

*

†25.9

74.0

Operates dedicated hospice facilities or units

Yes .................................

Median number of beds ....................

No .................................

600

11

2,900

30.1

12

69.9

†8.9

9

86.7

600

11

1,600

34.7

12

65.3

†14.9

8

76.1

†100

12

1,400

*

13

86.6

*

11

96.6

Formal contracts with outside

agencies or organizations

Skilled nursing facility:

Yes .................................

No .................................

2,800

800

82.2

†17.8

72.4

23.2

1,700

†400

81.9

*

70.1

†20.9

1,100

300

83.5

*

74.5

25.4

Hospital

Yes .................................

No .................................

2,400

1,100

75.7

24.3

59.2

36.5

1,700

†400

75.4

*

76.6

†14.4

700

700

76.8

†23.2

43.1

56.8

Managed care or private insurance provider

Yes .................................

No .................................

1,900

1,700

56.5

43.5

49.3

46.3

1,200

1,000

53.3

46.7

50.7

40.3

800

700

68.0

†32

48.0

51.9

Assisted living facility, board and care home,

life care, or continuing care retirement community

Yes .................................

No .................................

1,700

1,900

53.6

46.4

41.9

53.8

1,200

1,000

54.9

45.1

48.7

42.3

600

900

†48.8

51.2

35.6

64.3

Number of years providing hospice care

20 or fewer (1987 and later) .................

More than 20 (prior to 1987) .................

2,400

1,100

63.7

35.0

65.0

28.3

1,400

700

61.9

37.1

64.6

25.8

1,000

400

70.1

†27.4

65.3

†30.7

† Estimate does not meet standards of reliability or precision because the sample size is between 30 and 59, or sample size is greater than 59 but has a relative standard error of 30% or more.
 

* Estimate does not meet standards of reliability or precision because the sample size is less than 30.
 1

CAT is complementary and alternative therapies. Providers were categorized as offering CAT, if they offered CAT, or had CAT providers on staff or contract. All other providers, including those
 

missing information on whether they offered CAT, are categorized as not offering CAT. 6.4% of providers were missing information on whether they offer CAT, although this estimate does not meet
 

standards of reliability or precision because the sample size is less than 30.
 2

A metropolitan statistical area is a county or group of contiguous counties that contains at least one urbanized area of 50,000 or more population. May also contain other counties that are
 

economically and socially integrated with the central county as measured by commuting.
 3

A micropolitan statistical area is a nonmetropolitan county or group of contiguous nonmetropolitan counties that contains an urban cluster of 10,000 to 49,999 persons. May include surrounding
 

counties if there are strong economic ties between the counties, based on commuting patterns.
 4

Other locations are nonmetropolitan counties that are not classified as part of a micropolitan statistical area.
 5

Includes nursing home; assisted living facility; outpatient medical or surgical center; rehabilitation facility; patient, family, or friends; other home health or hospice agency; insurance provider or
 

payer source; community organization; and other.

NOTES: Numbers may not add to totals because of rounding or because totals and percent distributions include a category of unknowns not reported in the table. Percentages are based on the

unrounded numbers.

DATA SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 2007.
National Health Statistics Reports

n Number 33n January 19, 2011 Page9

care providers, by whether offer complementary and alternative therapies: United States, 2007

Provide hospice care Provide hospice care only Provide both home health and hospice care

Do not offer

Offer CAT1 CAT1 Offer CAT1 Do not offer CAT1 Offer CAT1 Do not offer CAT1

Standard Standard Standard Standard Standard Standard

Percent error Percent error Percent error Percent error Percent error Percent error

........ 100.0 . . . 100.0 . . . 100.0 . . . 100.0 . . . 100.0 . . . 100.0 . . .

........ 99.7 (0.2) 86.8 (4.4) 99.7 (0.2) 88.1 (8.0) 99.7 (0.2) 85.7 (4.1)

........ 99.5 (0.2) 87.9 (4.3) 99.6 (0.2) 87.7 (7.9) 99.4 (0.6) 88.2 (3.9)

........ 99.0 (0.4) 83.3 (4.6) 99.2 (0.4) 81.3 (7.8) 98.5 (1.4) 85.2 (5.2)

........ 98.0 (0.6) 89.1 (4.3) 98.3 (0.7) 85.6 (7.9) 96.6 (1.3) 92.3 (3.4)

........ 96.7 (1.3) 90.0 (4.1) 97.7 (1.2) 83.3 (7.8) 93.3 (4.0) 96.2 (2.2)

........ 96.7 (0.9) 84.4 (4.5) 97.7 (1.0) 87.4 (7.9) 93.0 (2.1) 81.7 (4.8)

........ 96.7 (1.0) 82.4 (4.3) 96.3 (1.2) 77.0 (7.7) 98.2 (1.4) 87.4 (3.8)

. . . . . . . . 96.3 (2.2) 87.8 (4.3) 96.2 (2.8) 90.4 (8.0) 96.6 (1.3) 85.4 (4.0)

........ 95.0 (2.3) 81.8 (5.4) 95.2 (2.9) 84.5 (7.9) 94.2 (2.0) 79.3 (7.5)

........ 95.0 (1.4) 79.7 (4.5) 94.6 (1.7) 71.2 (7.9) 96.3 (1.7) 87.4 (3.9)

........ 94.3 (2.9) 90.4 (4.1) 94.0 (3.5) 84.4 (7.8) 95.4 (3.4) 95.9 (2.2)

........ 93.9 (1.5) 67.4 (4.7) 98.4 (1.2) 82.0 (7.8) 77.4 (4.6) 54.0 (6.4)

........ 93.0 (1.6) 67.8 (4.7) 99.9 (0.1) 84.5 (7.9) 68.0 (5.8) 52.4 (6.5)

........ 90.5 (2.0) 63.3 (5.2) 97.4 (0.8) 84.9 (7.8) 65.2 (6.3) 43.3 (6.5)

........ 90.3 (5.3) 81.3 (5.3) 88.1 (6.6) 77.8 (9.9) 98.2 (0.9) 84.6 (3.9)

........ 89.2 (4.2) 86.5 (4.4) 88.7 (5.3) 80.2 (7.9) 91.2 (3.8) 92.3 (3.4)

. . . . . . . . 85.8 (4.9) 61.7 (5.4) 85.2 (6.2) 76.2 (7.8) 87.8 (2.9) 48.3 (6.5)

........ 78.8 (4.0) 53.3 (5.2) 86.2 (4.3) 62.0 (8.0) 51.5 (6.4) 45.3 (6.9)

........ 77.0 (5.5) 64.5 (5.3) 79.7 (6.9) 76.6 (7.9) 67.1 (5.4) 53.3 (6.8)

........ 73.4 (5.2) 45.9 (5.2) 81.5 (6.3) 62.9 (7.8) †43.6 (†6.2) 30.3 (5.8)

........ 71.9 (4.6) 35.8 (4.7) 76.9 (5.3) 46.0 (7.9) †53.7 (†6.3) 26.3 (5.5)........ 65.6 (6.2) 48.0 (5.1) 65.5 (7.7) 52.6 (8.3) 66.2 (5.5) 43.8 (6.2)

........ 63.4 (6.5) 52.7 (5.3) 59.1 (7.9) 35.3 (6.6) 79.0 (5.5) 68.7 (5.6)

........ 58.8 (6.0) 30.6 (5.3) 59.2 (7.5) †28.4 (†7.2) 57.3 (6.2) †32.6 (†7.6)

........ 53.4 (6.1) 27.2 (5.0) 61.5 (7.6) 44.6 (8.3) * (*) †11.1 (†3.1)

........ 35.3 (6.4) 15.9 (3.7) 43.1 (7.8) †25.9 (†7.0) * (*) * (*)

........ 35.1 (6.2) †12.0 (†2.7) 39.4 (7.6) †15.7 (†4.3) * (*) * (*)

ng

. . . . . . . . 22 (0.1) 18 (0.1) 23 (0.1) 20 (0.1) 21 (0.1) 17 (0.1)

recision because the sample size is between 30 and 59, or sample size is greater than 59 but has a relative standard error of 30% or more.

ecision because the sample size is less than 30.

e the sample size is between 30 and 59, or the ratio of the standard error to the reported estimate is 30 percent or more.

e size for the estimate is less than 30, which does not meet the standards of reliability or precision.

oviders were categorized as offering CAT if they either offered CAT or had CAT providers on staff or contract or both. All other providers, including those missing information on whether they offered CAT,

s were missing information on whether they offer CAT, although this estimate does not meet standards of reliability or precision because the sample size is less than 30.

ollowing services to participate in Medicare: nursing care (on a 24-hour basis) provided by or under the supervision of an RN functioning within a medically approved plan of care, medical social services

cluding dietary and bereavement counseling) with respect to care of the terminally ill individual and adjustment to death. (Source: State Operations Manual, Section 2080B, Centers for Medicare and

Services. Available from: (http://www.cms.gov/CertificationandComplianc/07_Hospices.asp.)

ounding or because totals and percent distributions include a category of unknowns not reported in the table. Percentages are based on unrounded numbers.

spice Care Survey, 2007.
Page 10 National Health Statistics Reports

n Number 33n January 19, 2011

unctional status of discharged patients from hospice, by availability of complementary and alternative therapies: United States, 2007

Patients discharged Patients who received care Patients who received care

from hospice from provider that offered CAT1 from provider that did not offer CAT1

Standard Standard Standard Standard Standard

Number error Number error Number error Number error Number error

1,045,100 (42,741) 585,900 (42,567) 100.0 . . . 459,100 (39,370) 100.0 . . .

........ 177,000 (11,442) 98,400 (9,721) 16.8 (1.1) 78,600 (8,868) 17.1 (1.3)

........ 161,000 (12,960) 91,000 (11,822) 15.5 (1.6) 70,000 (8,133) 15.2 (1.4)

........ 308,000 (16,635) 164,300 (13,883) 28.0 (1.6) 143,600 (14,577) 31.3 (1.8)

........ 399,100 (22,757) 232,100 (20,311) 39.6 (1.7) 166,900 (18,347) 36.4 (2.2)

........ 575,500 (26,951) 335,200 (26,705) 57.2 (1.8) 240,300 (21,537) 52.3 (2.1)

........ 469,500 (24,781) 250,800 (20,970) 42.8 (1.8) 218,800 (22,202) 47.7 (2.1)

. . . . . . . . 948,100 (39,266) 527,400 (38,785) 90.0 (1.4) 420,700 (35,829) 91.6 (1.4)

....... 96,900 (11,345) 58,500 (9,447) 10.0 (1.4) 38,400 (7,394) 8.4 (1.4)

........ 41,400 (7,556) 27,500 (6,980) 4.7 (1.1) 13,900 (3,205) 3.0 (0.7)

........ 960,700 (41,533) 540,900 (39,946) 92.3 (1.4) 419,700 (37,911) 91.4 (1.7)

........ 447,400 (24,883) 238,600 (21,103) 40.7 (1.9) 208,800 (20,953) 45.5 (2.4)

ed ...... 539,000 (27,708) 309,700 (25,961) 52.9 (2.3) 229,200 (22,814) 49.9 (2.4)

........ 65 (3) 71 (5) . . . . . . 58 (4) . . . . . .

........ 16 (1) 18 (2) . . . . . . 15 (1) . . . . . .

........ 802,100 (38,019) 439,200 (34,558) 75.0 (2.2) 362,900 (33,270) 79.0 (2.4)

........ 228,100 (17,504) 138,500 (15,092) 23.6 (2.0) 89,600 (12,760) 19.5 (2.3)

........ 119,300 (10,669) 71,200 (9,341) 12.1 (1.3) 48,100 (7,093) 10.5 (1.2)

........ 907,400 (38,756) 505,800 (37,749) 86.3 (1.7) 401,600 (34,818) 87.5 (1.5)

........ 767,400 (35,675) 434,600 (34,276) 74.2 (1.9) 332,800 (31,074) 72.5 (2.1)

........ 246,500 (15,971) 135,200 (13,087) 23.1 (1.6) 111,300 (12,708) 24.2 (2.0)

olling

. . . . . . . . 542,100 (32,633) 322,700 (30,553) 55.1 (2.6) 219,400 (24,376) 47.8 (3.0)

ling

. . . . . . . . 431,200 (23,937) 226,000 (19,326) 38.6 (2.4) 205,200 (20,829) 44.7 (2.8)
National Health Statistics Reports

n Number 33n January 19, 2011 Page 11

unctional status of discharged patients from hospice, by availability of complementary and alternative therapies: United States, 2007—Con.

Patients discharged

from hospice

Patients who received care

from provider that offered CAT1

Patients who received care

from provider that did not offer CAT1

Number

Standard

error Number

Standard

error Number

Standard

error Number

Standard

error Number

Standard

error

........

........

or severe

........

297,400254,900353,400

(20,405)(16,067)(21,645)

155,700138,300

211,000

(15,135)(13,204)(19,868)

30.226.941.0

(2.0)(1.8)(2.2)

141,700

116,600

142,300

(17,793)(12,868)(15,537)

34.528.434.6

(2.9)(2.2)(2.4)

. . . . . . . .

. . . . . . . .

367,400535,300

(24,609)(27,785)

196,400306,700

(19,917)(26,104)

38.159.6

(2.6)(2.7)

171,100228,600

(20,067)(21,557)

41.655.6

(2.9)(2.8)

oviders were categorized as offering CAT if they offered CAT or had CAT providers on staff or contract. All other providers, including those missing information on whether they offered CAT, are

ere missing information on whether they offer CAT, although this estimate does not meet standards of reliability or precision because the sample size is less than 30.

tive state at time of admission to the agency were not assessed for cognitive and ADL functioning and were excluded from these estimates.

ounding or because totals and percent distributions include a category of unknowns not reported in the table. Percentages are based on unrounded numbers.

spice Care Survey, 2007.
Page 12 National Health Statistics Reports

n Number 33n January 19, 2011

es of discharged patients from hospice, by availability of complementary and alternative therapies: United States, 2007

Patients discharged Patients who received care from Patients who received care from provider

de1 from hospice provider that offered CAT2 that did not offer CAT2

Standard Standard Standard Standard Standard

Number error Number error Number error Number error Number error

............ 1,045,100 (42,741) 585,900 (42,567) 100.0 . . . 459,100 (39,370) 100.0 . . ............. 454,600 (24,919) 246,400 (21,468) 42.1 (2.0) 208,100 (21,131) 45.3 (2.1)

............ 165,100 (12,450) 90,100 (10,035) 15.4 (1.4) 75,000 (9,640) 16.3 (1.6)

780–799) ...... 127,400 (10,482) 73,400 (8,410) 12.5 (1.2) 54,100 (7,862) 11.8 (1.5)

rgans (320–389). . 81,400 (8,350) 50,500 (6,839) 8.6 (0.9) 30,900 (5,710) 6.7 (1.0)

............ 77,900 (6,828) 43,700 (5,662) 7.4 (0.8) 34,300 (4,788) 7.5 (0.9)

29) .......... 31,700 (4,613) 20,400 (3,926) 3.5 (0.6) 11,300 (2,678) 2.5 (0.6)

............ 18,100 (3,477) †11,900 (†3,003) †2.0 (†0.5) †6,200 (†1,828) †1.4 (†0.4)

recision because the sample size is between 30 and 59, or the sample size is greater than 59 but has a relative standard error of 30% or more.

e the sample size is between 30 and 59, or the ratio of the standard error to the reported estimate is 30% or more.

s, Ninth Revision, Clinical Modification.

oviders were categorized as offering CAT if they offered CAT or had CAT providers on staff or contract. All other providers, including those missing information on whether they offered CAT, are

ere missing information on whether they offer CAT, although this estimate does not meet standards of reliability or precision because the sample size is less than 30.

ounding or because totals and percent distributions include a category of unknowns not reported in the table. Percentages are based on the unrounded numbers.
National Health Statistics Reports

n Number 33n January 19, 2011 Page 13

unctional status of discharged patients who received care from a hospice provider that offered complementary and alternative therapies, by

Discharged patients who

received hospice care Patients who received at least Patients who did not receive

from a provider that one CAT from the provider during CAT from the provider during

offered CAT1 their hospice stay their hospice stay

Standard Standard Standard Standard Standard

Number error Number error Number error Number error Number error

............ 585,900 (42,567) 50,400 (11,917) 100.0 0.0 535,500 (39,937) 100.0 0.0

............ 98,400 (9,721) †8,500 (†2,698) †16.9 (†4.1) 89,900 (8,924) 16.8 (1.1)

............ 91,000 (11,822) †8,600 (†2,393) †17.1 (†5) 82,400 (11,412) 15.4 (1.7)............ 164,300 (13,883) †11,900 (†4,246) †23.6 (†4.4) 152,500 (13,335) 28.5 (1.7)

............ 232,100 (20,311) 21,400 (6,228) 42.5 (5.5) 210,700 (18,566) 39.3 (1.7)

............ 335,200 (26,705) 28,500 (6,518) 56.4 (4.9) 306,700 (25,220) 57.3 (1.9)

............ 250,800 (20,970) 22,000 (6,305) 43.6 (4.9) 228,800 (19,674) 42.7 (1.9)

............ 527,400 (38,785) 47,300 (10,806) 93.8 (2.5) 480,100 (36,473) 89.7 (1.5)

............ 58,500 (9,447) * (*) * (*) 55,400 (9,004) 10.3 (1.5)

............ 27,500 (6,980) * (*) * (*) 26,300 (6,959) 4.9 (1.2)

............ 540,900 (39,946) 47,700 (10,803) 94.5 (2.2) 493,300 (37,392) 92.1 (1.5)

............ 238,600 (21,103) 16,300 (3,865) 32.3 (4.3) 222,400 (20,507) 41.5 (2.1)

ed........... 309,700 (25,961) 32,200 (8,789) 63.9 (5.8) 277,500 (23,877) 51.8 (2.5)

............. 71 (5) 101 (23) . . . . . . 69 (5) . . . . . .

. . ........... 18 (2) 28 (11) . . . . . . 17 (1) . . . . . .

............ 439,200 (34,558) 35,000 (7,297) 69.3 (5.9) 404,300 (32,755) 75.5 (2.3)

............ 138,500 (15,092) †15,500 (†5,712) †30.7 (†5.9) 123,000 (14,200) 23.0 (2.1)

. . . . . . . . . . . . 71,200 (9,341) * (*) * (*) 65,300 (8,479) 12.2 (1.3)

............ 505,800 (37,749) 44,400 (10,650) 88.0 (3.9) 461,400 (35,621) 86.2 (1.7)

............ 434,600 (34,276) 40,900 (11,245) 81.0 (5.6) 393,800 (31,664) 73.5 (2.0)

............. 135,200 (13,087) †9,500 (†2,678) †18.8 (†5.6) 125,700 (12,546) 23.5 (1.7)

olling bowels .... 322,700 (30,553) †34,700 (†10,875) 68.8 (7.7) 288,000 (27,729) 53.8 (2.6)

lling bowels ..... 226,000 (19,326) 15,200 (3,546) 30.2 (7.6) 210,800 (18,284) 39.4 (2.3)
Page 14 National Health Statistics Reports

n Number 33n January 19, 2011

unctional status of discharged patients who received care from a hospice provider that offered complementary and alternative therapies, by

Discharged patients who

received hospice care

from a provider that

offered CAT1

Patients who received at least

one CAT from the provider during

their hospice stay

Patients who did not receive

CAT from the provider during

their hospice stay

Number

Standard

error Number

Standard

error Number

Standard

error Number

Standard

error Number

Standard

error

............

.............

155,700138,300

(15,135)(13,204)

13,500

†14,900

(3,307)

(†5,573)

30.433.5

(5.6)(6.6)

142,200123,300

(14,151)(12,217)

30.226.2

(2.1)(1.8)

or severe cognitive

............ 211,000 (19,868) 16,100 (3,856) 36.1 (4.3) 195,000 (19,504) 41.5 (2.3)

L)3

............

............

196,400306,700

(19,917)(26,104)

16,60027,800

(4,531)(6,850)

37.462.4

(4.4)(4.4)

179,700278,900

(19,272)(24,602)

38.259.3

(2.8)(2.9)

recision because the sample size is between 30 and 59, or sample size is greater than 59 but has a relative standard error of 30% or more.

te the sample size is between 30 and 59, or the ratio of the standard error to the reported estimate is 30 percent or more.

ecision because the sample size is less than 30.

e size for the estimate is less than 30, which does not meet the standards of reliability or precision.

oviders were categorized as offering CAT if they offered CAT or had CAT providers on staff or contract. All other providers, including those missing information on whether they offered CAT, are

ere missing information on whether they offer CAT, although this estimate does not meet standards of reliability or precision because the sample size is less than 30.

tive state at time of admission to the agency were not assessed for cognitive and ADL functioning and were excluded from these estimates.

ounding or because totals and percent distributions include a category of unknowns not reported in the table. Percentages are based on unrounded numbers.

spice Care Survey, 2007.
National Health Statistics Reports n Number 33 n January 19, 2011	 Page 15

Technical Notes

Sample design

The sampling design for NHHCS

was a stratified, two-stage probability

design. The first stage consisted of the

selection of a stratified sample of

agencies. The primary sampling strata of

agencies were defined by agency type

and metropolitan statistical area (MSA)

status. The second stage of sample

selection was the selection of up to 10

current home health patients per home

health agency, up to 10 hospice

discharges per hospice agency, and a

combination of up to 10 current home

health patients and hospice discharges in

agencies providing both home health

and hospice care. This stage of sample

selection was done using a computer

algorithm to obtain systematic

probability samples of current home

health patients and hospice discharges.

This study used data only from hospice

discharges and hospice care providers.

Data collection

Data for NHHCS were collected

through personal interviews with agency

directors and staff who used

administrative records to answer

questions about the agencies, staffs,

services, and programs, and medical

records to answer questions about

current home health patients and hospice

discharges. The agency component of

NHHCS was completed for 1,036

agencies. The patient component of the

NHHCS was completed for 4,733

hospice discharges. The unweighted

response rate across the two sampling

stages (agency and hospice discharge)

was 67%. The response rate across the

two sampling stages (agency and

hospice discharge) weighted by the

inverse of the probability of selection

was 57%. For further information on the

sampling design and data collection, see

Dwyer et al. ‘‘Redesign and Operation

of the National Home and Hospice Care

Survey, 2007’’ (21).

Estimation

Using the complex multistage

design of the NHHCS, NCHS computed

a weight that took all sampling stages

into account. This weight was used to

inflate the sample numbers to national

estimates, and included three other basic

components: inflation by reciprocals of

selection probabilities, adjustment for

nonresponse, and population ratio

adjustment. For further information on

the NHHCS estimation, see Dwyer et al.

‘‘Redesign and Operation of the

National Home and Hospice Care

Survey, 2007’’ (21).

Standard errors and relative

standard errors

The standard error (SE) is primarily

a measure of the sampling variability

that occurs by chance because only a

sample is surveyed, rather than the

entire universe. SEs were calculated

using Taylor series approximations in

SUDAAN.

NCHS bases publication of

estimates for NHHCS on the relative

standard error (RSE)—also known as

the coefficient of variation—of the

estimate and the number of sample

records on which the estimate is based.

The RSE is a measure of variability and

is calculated by dividing the SE of an

estimate by the estimate itself. The

result is then converted into a

percentage by multiplying it by 100.

+	 If the estimate is based on fewer than

30 sample cases, then the value of the

estimate is not reported. This is

indicated with an asterisk (*) in the

tables and figures.

+	 If the estimate is based on a sample

of 30–59 cases or on 60 or more

cases and the RSE is 30% or more,

then the estimate is reported but

should not be assumed reliable. This

is indicated with a dagger (†)

preceding the estimate in tables and

figures.

+	 If the estimate is based on 60 or

more sample cases and the RSE is

less than 30%, then the estimate is

reported and is considered reliable.

Definition of terms

Terms related to hospice care

providers

Hospice care—focuses on relieving

pain and uncomfortable symptoms of

individuals with terminal illness and

providing emotional and spiritual

support to both the terminally ill and

their family members.

Major referral source—Respondents

were first shown a card and asked what

the agency’s patient referral sources

were. The card included the following

options:

1. Hospital

2. Nursing home

3. Assisted living facility

4. Physician’s office

5. Outpatient medical or surgical center

6. Rehabilitation facility

7. Patient or family or friend

8. Other home health hospice agency

9. Insurance provider or payer source

10. Community organization

11. Other

Respondents were then asked which of

the referral sources identified refers the

greatest number of patients to the

agency.

Services offered—The respondent

was asked ‘‘Which of these services

does this agency offer?’’ with additional

instruction to include services offered as

a result of contractual arrangements.

Respondents were asked to identify all

services from a list on show cards.

Services were grouped and several show

cards were used. The groupings and

services included in each group are

shown in Table I.

All agencies missing information on

whether the agency provided the service

were coded as not providing the service.

The number of services an agency

provided (excluding complementary and

alternative medicine) was summed to

create a continuous variable from 0 to

27. For logistic regressions the number

of services was dichotomized based on

the mean number of services provided

in the sample being analyzed. Thus,

when the sample was all hospice care

providers the mean number of services

provided was 19, and the number of

services was divided into providers that

offered 19 or fewer services and more

than 19 services. For the sample of

hospice care only providers the mean

was 21 and for agencies providing both

home health and hospice care the mean
Page 16	 National Health Statistics Reports n Number 33 n January 19, 2011

Table I. Services offered by hospice care providers Terms related to hospice

Service grouping	 Services listed discharges

• Complementary and alternative medicine

• Dietary and nutritional services

• Enterostomal therapy

• IV therapy

• Physician services

• Podiatry services

• Skilled nursing or nursing services

• Wound care

• Durable medical equipment

• Pharmacy services

• Occupational therapy

• Physical therapy

• Respiratory therapy

• Speech therapy/audiology

• Companion services

• Continuous home care

• Homemaker services

• Meals on wheels services

• Assistance with ADLs

• Transportation services

• Volunteer services

• Pastoral services/spiritual counseling

• Mental health services

• Referral services

• Respite care

• (Medical) social services

• Ethical issues counseling

• Grief/bereavement counseling

Medical and skilled nursing ............ 
 

Equipment and medication ............ 
 

Personal care .................... 
 

Psychosocial ..................... 
 

Counseling ...................... 
 

Age—Refers to discharge’s age at

time of discharge. Calculated based on

birth date and discharge date.

Hispanic or Latino origin—A

person of Mexican, Puerto Rican,

Cuban, Central or South American, or

other Spanish culture or origin,

regardless of race. Based on question

‘‘Was he/she of Hispanic or Latino

origin?’’

Race—Consistent with the U.S.

Office of Management and Budget’s

1997 Standards for the Classification of

Federal Data on Race and Ethnicity.

Respondents were shown a card and

asked to select all that applied for the

discharge.

+ American Indian or Alaska Native

+ Asian

+ Black or African American

+	 Native Hawaiian or Other Pacific

Islander

+ White

+ Other

For the purposes of data analysis in this

report, race was dichotomized to white

and other, where other included all

categories listed above other than white.

Marital status—Marital status at

time of discharge. Based on question

‘‘Is/was (DISCHARGE) married,

divorced, separated, never married, or

living with a partner in a marriage-like

relationship?’’ Additional information to

be read if necessary was ‘‘at time of

discharge.’’

Length of hospice care—Calculated

as the difference between the date of

admission and date of discharge.

Discharges may have been discharged

dead or alive.

Comatose—Based on question

‘‘Was (DISCHARGE) comatose or in a

vegetative state at the time he/she was

admitted to this agency for hospice

care?’’ Questions on ADL and cognitive

functioning were not asked about

comatose discharges.

Continence—Refers to when

receiving hospice care. Respondents

were asked whether either discharge had

a catheter, a colostomy or ileostomy,

and whether they had difficulty

was 16. When the sample was all

hospice care providers that offered CAT,

the mean number of services provided

was 22, and the number of services was

divided into providers that offered 22 or

fewer services, and more than 22

services.

Complementary and alternative

therapies (CAT)—For the purposes of

this report, an agency that offered CAT

was defined as one that responded either

that they offered CAM as a service or

said that they had CAM providers on

staff or as contract personnel. All other

agencies, including those missing

information, were categorized as not

offering CAT. The responses were based

on the following questions:

1) As described above, respondents

were asked to identify all services

from a list on a show card.

Complementary and alternative

medicine (CAM) was one option.

If the respondent chose CAM

he/she was then asked ‘‘Which of

these complementary and alternative

medicine therapies does this agency

use?’’ Respondents were shown

another card and asked to identify

all the therapies the agency uses.

Show card options included:

1. Acupuncture

2. Aromatherapy

3. Art therapy

4. Guided imagery or relaxation

5. Massage

6. Music therapy

7. Pet therapy

8. Supportive group therapy

9. Therapeutic touch

10. TENS (Transcutaneous

Electrical Nerve Stimulation)

11. Other

2) The self-administered

questionnaire included the following

question: ‘‘Does this agency have

any of the following types of staff

or contract personnel who provide

services to patients served by this

agency?’’ One of the options was

‘‘Complementary Alternative

Medicine (CAM) Providers.’’
National Health Statistics Reports n Number 33 n January 19, 2011 Page 17

controlling bladder during hospice care.

If respondents noted the discharge had a

urinary catheter, respondents were not

asked whether the discharge had

difficulty controlling bladder. If

respondents noted the discharge had a

colostomy or ileostomy, respondents

were not asked whether the discharge

had difficulty controlling bowels. For

this analysis, discharges with either a

catheter or difficulty controlling bladder

were combined, as were discharges with

a colostomy or ileostomy or difficulty

controlling bowels.

Cognitive functioning—These

questions were not asked of comatose

discharges. Based on the following

question ‘‘Please look at this card and

tell me which category best describes

(DISCHARGE)’s cognitive functioning

or current mental status at the time

he/she was admitted to this agency for

hospice care.’’ Respondents were

referred to the most recent Outcome and

Assessment Information Set (OASIS)

form, item MO560. Respondents were

shown a card and asked which category

best described the discharge’s cognitive

functioning or current mental status on

admission. Categories included:

1. No cognitive impairment

2. Required only occasional reminders

in new situations

3. Required some assistance or direction

in certain situations (is easily

distracted)

4. Required a great deal of assistance or

direction in routine situations

5. Severe cognitive impairment

(constantly disoriented, comatose,

delirium)

For the purposes of this report,

categories 2 and 3 were combined and

categories 4 and 5 were combined and

termed ‘‘impaired cognitive

functioning.’’

Activities of daily living—These

questions were not asked of comatose

discharges. ADLs include bathing,

dressing, toileting, eating, and

transferring. Based on response to the

following question: ‘‘At admission, did

(DISCHARGE) need any help from

another person with any of the

following activities?’’ Respondents were

asked to refer to the most recent OASIS

form (items MO650, 660, 670, 680,

690, and 710), or if not available, obtain

most recent information in records.

Advance directives—Respondents

were asked ‘‘Now please look at this

card and tell me which of the following

advance directives are listed in

(DISCHARGE)’s medical records.’’

Respondents were then shown a card

with the following options and asked to

select all that apply:

1. Living will

2. Do not resuscitate

3. Do not hospitalize or do not send to

emergency department

4. Feeding restrictions

5. Medication restrictions

6. Comfort measures only

7. Durable power of attorney

8. Health care proxy or surrogate

9. Organ donation

10. No advanced directives provided

11. Other

For the purposes of this analysis

categories 3–6 were combined, and

categories 7 and 8 were combined.

Pain management strategies—Based

on the following question ‘‘According to

(DISCHARGE)’s medical record, what

strategies on this card were used to

manage his/her pain’’ Respondents were

shown a card and asked to select all

strategies used. The card contained the

following options:

1. Standing order for pain medication

2. PRN order for pain medication

3. Nonpharmacological methods

(distraction, heat or cold, massage or

positioning, and music therapy)

4. No strategies specified

5. Other

Receipt of CAT—Based on the

question: ‘‘What services on this card

did (DISCHARGE) receive from this

agency while a hospice patient?’’

Additional information to be read if

necessary was ‘‘Include services

received from (AGENCY) as a result of

contractual arrangements.’’ One of the

options on the show card was

‘‘complementary and alternative

medicine (CAM).’’ There was no

information on the number of times the

discharge received CAT, thus the

discharge could have received CAT only

once or multiple times. Missing

information was coded as not having

received the service.

Level of care—Refers to the level

of care received at time of discharge.

Respondents were asked ‘‘Which level

of hospice care on this card was

(DISCHARGE) receiving at the time of

his/her discharge?’’ They were then

shown a card that included the

following options:

1. Routine home care for patients

receiving hospice services in their

homes

2. Continuous home care provided 8 to

24 hours per day primarily by skilled

hospice personnel

3. General inpatient care provided by

skilled hospice staff

4. Inpatient respite care to relieve the

primary caregiver

For the purposes of this analysis,

categories 1 and 2 were combined, and

categories 3 and 4 were combined.

Admission diagnosis—Based on the

following question: ‘‘According to

(DISCHARGE)’s medical records, what

was the primary diagnosis or condition

at the time he/she was admitted to this

agency (that is, on or around

(ADMISSION DATE)’’ Diagnoses were

coded according to the International

Classification of Diseases, Ninth

Revision, Clinical Modification (ICD–9–

CM). For analysis, the ICD–9–CM

codes were collapsed into categories as

per Table II.

Table II. ICD–9–CM codes and collaped

categories for analysis

Category ICD–9–CM codes

Malignant neoplasms ..... 140–208, 230–234

Diseases of the nervous

system and sense organs. . 320–389

Diseases of the circulatory

system ............. 390–459

Diseases of the respiratory

system ............. 460–519

Diseases of the digestive

system ............. 520–579

Diseases of the genitourinary

system ............. 580–629

Symptoms, signs, and

ill-defined conditions ..... 780–799

NOTE: ICD–9–CM is International Classification of Diseases,

Ninth Revision, Clinical Modification.
Page 18 National Health Statistics Reports n Number 33 n January 19, 2011

Table III. Standard errors for characteristics of providers of hospice care by whether they offer complementary and alternative therapies:

United States, 2007

Provider characteristic Provide hospice care Provide hospice care only

Provide both home health

and hospice care

Total1

Offer

CAT1

Do not

offer

CAT1 Total1

Offer

CAT1

Do not

offer

CAT1 Total1

Offer

CAT1

Do not

offer

CAT1

Total ................................ (250) (3.9) (4.0) (210) (5.5) (5.3) (145) (3.2) (4.5)

Ownership

For profit .............................

Not for profit, including government .............

(172)

(208)

(†5.7)

(5.7)

(5.2)

(5.2)

(156)

(167)

(†7.2)

(7.2)

(†8.3)

(8.3)

(†72)

(130)

(*)

(4.2)

(†5.7)

(5.7)

Location of agency

Metropolitan statistical area2 .................

Micropolitan and other statistical area 3,4 .........

(243)

(60)

(3.2)

(3.2)

(4.0)

(4.0)

(208)

(31)

(3.1)

(3.1)

(†5.8)

(5.8)

(135)

(54)

(†6.0)

(6.0)

(5.6)

(5.6)

Affiliation

Chain ...............................

Independent ...........................

Total median number of patients served at time of

survey ..............................

Median number of hospice patients at time of survey . .

(130)

(232)

(8)

(4)

(†5.9)

(5.9)

(10.2)

(7)

(3.5)

(3.5)

(13.7)

(4)

(114)

(193)

(7)

(7)

(†7.3)

(7.3)

(6.1)

(8)

(†4.7)

(4.7)

(8.0)

(6)

(†63)

(133)

(25)

(3)

(*)

(4.8)

(36.7)

(3)

(†5.1)

(5.1)

(19.8)

(3)

Major referral source

Hospital ..............................

Physicians office ........................

All other5 .............................

(168)

(166)

(116)

(6.1)

(6.0)

(†3.9)

(4.8)

(5.1)

(4.3)

(128)

(139)

(108)

(7.7)

(7.5)

(*)

(†5.5)

(7.7)

(†7.7)

(110)

(94)

(†41)

(†6.2)

(†6.4)

(*)

(7.0)

(6.7)

(*)

Type of hospice

Freestanding ...........................

Hospital, nursing home, or home health based ......

(187)

(167)

(5.4)

(5.4)

(5.2)

(5.1)

(178)

(99)

(6.6)

(†6.6)

(7.9)

(†4.6)

(61)

(136)

(*)

(5.2)

(†5.1)

(5.1)

Operates dedicated hospice facilities or units

Yes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mean number of beds .....................

Median number of beds ....................

No .................................

(111)

(0.8)

(1.1)

(227)

(5.9)

(1.1)

(1.1)

(5.9)

(†1.7)

(1.1)

(1.0)

(4.0)

(110)

(0.9)

(1.2)

(178)

(7.4)

(1.2)

(1.2)

(7.4)

(†3.5)

(1.3)

(1.1)

(7.7)

(†15)

(1.0)

(1.3)

(146)

(*)

(1.3)

(1.6)

(3.5)

(*)

(1.5)

(2.8)

(1.0)

Formal contracts with outside

agencies or organizations

Skilled nursing facility:

Yes ...............................

No ................................

(212)

(133)

(5.6)

(†5.6)

(5.0)

(4.0)

(165)

(†124)

(7.0)

(*)

(8.9)

(†6.9)

(140)

(47)

(4.2)

(*)

(4.5)

(4.5)

Hospital

Yes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

No .................................

(185)

(170)

(6.3)

(6.3)

(5.3)

(4.9)

(169)

(†118)

(7.8)

(*)

(7.8)

(†3.6)

(85)

(123)

(5.3)

(†5.3)

(6.4)

(6.4)

Managed care or private insurance provider

Yes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

No .................................

(185)

(178)

(6.3)

(6.3)

(5.2)

(5.1)

(143)

(157)

(7.7)

(7.7)

(8.2)

(7.5)

(120)

(89)

(5.9)

(†5.9)

(6.8)

(6.8)

Assisted living facility, board and care home,

life care, or continuing care retirement community

Yes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

No .................................

(201)

(161)

(6.1)

(6.1)

(5.4)

(5.4)

(166)

(132)

(7.6)

(7.6)

(8.2)

(7.3)

(115)

(96)

(†6.4)

(6.4)

(7.3)

(7.3)

See footnotes at end of table.
National Health Statistics Reports n Number 33 n January 19, 2011 Page 19

Table III. Standard errors for characteristics of providers of hospice care by whether they offer complementary and alternative therapies:

United States, 2007—Con.

Provider characteristic Provide hospice care Provide hospice care only

Provide both home health

and hospice care

Total1

Offer

CAT1

Do not

offer

CAT1 Total1

Offer

CAT1

Do not

offer

CAT1 Total1

Offer

CAT1

Do not

offer

CAT1

Number of years providing hospice care

20 or fewer (1987 and later) .................

More than 20 (prior to 1987) .................

(209)

(149)

(5.5)

(5.5)

(5.4)

(4.8)

(189)

(96)

(6.9)

(6.9)

(7.9)

(5.3)

(95)

(114)

(5.2)

(†5.1)

(7.4)

(†7.6)

(†) Standard errors accompanied by a dagger indicate the sample size is between 30 and 59, or the ratio of the standard error to the reported estimate is 30 percent or more.
 

(*) The standard error is not reported when the sample size for the estimate is less than 30, which does not meet the standards of reliability or precision.
 1

CAT is complementary and alternative therapies. Providers were categorized as offering CAT if they offered CAT or had CAT providers on staff or contract. All other providers, including those
 

missing information on whether they offered CAT, are categorized as not offering CAT. 6.4% of providers were missing information on whether they offer CAT, although this estimate does not meet
 

standards of reliability or precision because the sample size is less than 30.
 2

A metropolitan statistical area is a county or group of contiguous counties that contains at least one urbanized area of 50,000 or more population. May also contain other counties that are
 

economically and socially integrated with the central county as measured by commuting.
 3

A micropolitan statistical area is a nonmetropolitan county or group of contiguous nonmetropolitan counties that contains an urban cluster of 10,000 to 49,999 persons. May include surrounding
 

counties if there are strong economic ties between the counties based on commuting patterns.
 4

Other locations are nonmetropolitan counties that are not classified as part of a micropolitan statistical area.
 5

Includes nursing home; assisted living facility; outpatient medical or surgical center; rehabilitation facility; patient, family, or friends; other home health or hospice agency; insurance provider or
 

payer source; community organization; and other.
 

NOTES: Numbers may not add to totals because of rounding or because totals and percent distributions include a category of unknowns not reported in the table. Percentages are based on
 

unrounded numbers.
 

DATA SOURCE: CDC/NCHS, National Home and Hospice Care Survey, 2007.
 
Page 20 National Health Statistics Reports n Number 33 n January 19, 2011

Suggested citation

Bercovitz A, Sengupta M, Jones A, HarrisKojetin LD. Complementary and alternative

therapies in hospice: The National Home and

Hospice Care Survey: United States, 2007.

National health statistics reports; no 33.

Hyattsville, MD: National Center for Health

Statistics. 2010.

Copyright information

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source, however, is appreciated.

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for Science
 

Division of Health Care Statistics

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U.S. DEPARTMENT OF

HEALTH & HUMAN SERVICES

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