Discussion | In this study, nearly one-third of hospices did not enroll undocumented immigrants or limited the number enrolled, and 23% of referrals were not accepted. Restricted enrollment was more common among for-profit and smaller hospices, which is not surprising given the financial challenges of enrolling patients without a funding source. Hospice reduces health care costs and improves end-of-life care quality. 5 Undocumented immigrants unable to access hospice may be forced to seek treatment for symptoms and psychosocial needs through emergency services or hospitalization, which may increase costs for health systems and compromise end-of-life care.This study has several limitations. Of the 230 agencies responding to the full survey, 51 (22.2%) did not complete the survey questions pertaining to undocumented immigrants, and only 15 (8.4%) agencies responding to these questions came from the US West census region, where many undocumented immigrants reside and demand is likely high. Also, the proportion of for-profit hospices was low relative to their representation nationwide. These factors may limit generalizability and lead to overestimation of access.Our data demonstrate existing demand for hospice for undocumented patients, and suggest hospice access may be disproportionately limited in areas with predominately smaller, for-profit agencies. As the proportion of for-profit hospice agencies continues to grow nationally, barriers to hospice access for undocumented patients may increase. While some cities and states are expanding health care for undocumented immigrants, 6 for many, health care access remains limited. Based on this study, such limitations persist through endstage illness. Policies that reduce barriers to hospice for this population may improve end-of-life care and reduce costs.
Experiences in coordinating care for women Veterans with gynecologic malignancies receiving concurrent VA and community cancer care reveal challenges inherent in delivering care across health care systems, as well as potential approaches for addressing them.
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