Hospice Care in the Nursing Home

1
Hospice Care in the Nursing Home

• Purpose To provide LTC facilities with an
  overview and guidelines for partnering with
  Medicare-certified hospices to benefit terminally
  ill residents and their families and review
  responsibilities of the facility and hospice to
  provide palliative care.

2
Objectives

• Define hospice and identify the scope of care.
• State the general criteria in determination of
  hospice eligibility.
• Differentiate between the responsibilities of the
  LTC facility and those of the hospice team when
  collaborating in caring for the terminally ill.
• Know how to formulate a coordinated plan of care
  to be used by the skilled nursing facility and
  hospice.

3
Definition of Hospice Care

• Residents entitled to hospice services per both
  state and federal statutes.
• Regulations establish that the LTC facility is
  the residents home.
• Hospice offers the patient, the caregiver system,
  and the family a program of care defined in the
  Medicare/Medicaid hospice benefit.

4
Definition of Hospice Care, cont.

• Federal and State Definition
• Hospice care is intended to meet the physical,
  emotional and spiritual needs of patients and
  their families facing life ending illnesses. The
  goal of hospice care is to provide comfort to the
  patient by assisting with pain and symptom
  management and to enhance the quality of life for
  both the patient and the family.

5
Definition of Hospice, cont.

• Resident electing hospice are not giving up.
• Resident electing hospice are not receiving less
  care.
• Nursing home patients receive the benefit of LTC
  staff and the added benefit provided by the
  professional hospice team focused on palliation
  and comfort.

6
Definition of Hospice, cont.

• Challenge in providing hospice care
• Providers must cooperate with each other.
• Providers must communicate with each other.
• Providers must establish and agree upon
  coordinated services.
• Providers must be responsive to the unique needs
  of the resident and his/her desires.
• Both providers must be knowledgeable and
  attentive to the regulations of the other.
  
  

7
Hospice Services

• The hospice scope of care includes
• Skilled Nursing
• Medical Social Services
• Personal Care
• Spiritual Care
• Volunteer Support
• Bereavement Support
• Physician Services

8
Hospice Services, cont.

• Benefits of hospice
• By selecting hospice, resident has clearly asked
  that his/her care be focused on palliation.
• Added attention to pain management and other
  symptoms related to life-ending illness.
• One-on-one emotional support for the resident and
  the family.
• May have financial relief due to Hospice paying
  for medication, supplies, and equipment related
  to the terminal illness.
• Volunteers visit residents and provide
  interaction with the resident and/or family.

9
Determination of Hospice Eligibility

• General criteria for hospice eligibility, the
  patient must be
• Diagnosed with a terminal or life ending illness
• Have a life expectancy of 6 months or less, as
  determined by the physician and the hospice
  interdisciplinary team
• Seeking palliative (pain and symptom relief)
  rather than curative treatment.

10
Determination of Hospice Eligibility, cont.

• Additionally
• Patient, family and physician must understand
  that artificial, life-prolonging procedures are
  not consistent with hospice care and
• That admission to hospice services is approved by
  the attending physician and the hospice medical
  director.

11
Determination of Hospice Eligibility, cont.

• Centers for Medicare/Medicaid Services (CMS)
• Local Medical Review Policy (LMRP)
• Defines prognostic criteria by disease to
  determine if patient is eligible. The guideline
  examines documentable evidence that if the
  disease follows its normal course the prognosis
  is for 6 months or less.

12
Determination of Hospice Eligibility, cont.

• Current guidelines include
• Lung disease
• Heart disease
• Kidney failure
• HIV
• Stroke and coma
• Dementia
• Liver failure

13
Determination of Hospice Eligibility, cont

• ALS,
• Lung Cancer
• Prostate Cancer
• Breast Cancer
• Decline in Health Status
• http//www.iamedicare.com/Provider/policy/
• policyhome.htm

14
Core Services

• Core services which must be provided by hospice
  employees, many provided in collaboration with
  the LTC facility
• Physician services
• Nursing services
• Medical social services
• Spiritual counseling
• Bereavement counseling
• Dietary counseling
• Volunteer services

15
Core Services, cont.

• Collaboration is essential for both providers.
• Hospice provides core services 24-hour/day, 7
  days a week, on-call system.
• The interdisciplinary hospice team and its
  resources are available not only to the patient
  and family but also to facility staff.

16
Responsibilities of Providers

• Nursing Services
• LTC Facility Staff provides daily care as
  with all patients
• Hospice RN coordinates care plan, makes
  intermittent
  visits, educates
• staff/families, reviews
  record,
• assigns and supervises
  hospice aide
• as needed.

17
Responsibilities of Providers, cont.

• Nursing Services
• Collaborative Relationship
• Maintain communication to fulfill the plan of
  care and inform each other of changes in the care
  plan.

18
Responsibilities of Providers, cont.

• Physician Services
• LTC Facility Attending physician and LTC
• Medical Director will
  continue
• to follow visitation
  schedule.
• Hospice Hospice medical director as a
• resource on palliation.

19
Responsibilities of Providers, cont.

• Physician Services
• Collaborative relationship
• Each provider shall identify lines of
  communication for medical care.

20
Responsibilities of Providers, cont.

• Medical Social Services, Spiritual Counseling,
  Dietary Counseling, Bereavement and Other
  Counseling
• LTC Facility As agreed upon in the plan of
  care in accordance with
• regulations.
• Hospice Provides spiritual, emotional,
• nutritional counseling for
  resident and
• family as indicated in the
  plan of care.

21
Responsibilities of Providers, cont.

• Medical Social Services, Spiritual Counseling,
  Dietary Counseling, Bereavement and Other
  Counseling
• Collaborative Relationship
• Maintains open communication between the hospice
  and facility for services performed and for
  changes in the patients status that affect the
  plan of care.

22
Eligibility/Admission Process

• Hospice inquiries may be made by anyone directly
  involved with the patient.
• LTC staff are most sensitive to the readiness of
  hospice acceptance.
• It is the patients right to access hospice
  services if the resident qualifies for that
  benefit.

23
Eligibility/Admission Process, cont.

• LTC Staff
• Identify potential hospice patients.
• Review legal paperwork, identify legal
  representative who can make decisions.
• Obtain a physicians order for hospice evaluation
  and potential admission.
• Educate resident/legal surrogate regarding
  treatment alternatives.

24
Eligibility/Admission Process, cont.

• LTC Staff, cont.
• Provide patient/surrogate with listing of hospice
  providers and offer brochures.
• Contact hospice provider selected and schedule an
  appointment.
• Assure that patient has signed release of
  confidential information.

25
Eligibility/Admission Process, cont.

• LTC Staff, cont.
• Provide hospice with documentation necessary to
  determine eligibility.
• Provide hospice copy of IM-62, if applicable.
• Notify LTC business office of change.
• Evaluate the need for MDS reassessment for
  significant change.
• Notify hospice of care plan meetings.

26
Eligibility/Admission Process, cont.

• Hospice Staff
• Provide information for facility to give to
  patients and families.
• Respond to request to assess patient using
  guidelines to confirm eligibility.
• Report findings to attending physician, hospice,
  LTC facility and patient/legal surrogate.

27
Eligibility/Admission Process, cont.

• Hospice Staff, cont.
• Verify hospice order for admission.
• Explain hospice services, conduct the intake
  process, and obtain a signed election statement.
• Verify patient financial status and educate
  patient and family about financial issues.
• Notify LTC of hospice election.

28
Eligibility/Admission Process, cont

• LTC/Hospice Staff Collaboration
• Hospice and nursing facility must have a mutually
  agreed on contract before services can be
  provided.
• Review LMRP guidelines in appendix, or at
• www.iamedicare.com/Provider/policy/policyhome.htm
• Modify the Plan of Care to reflect the change in
  needs/services.

29
Integrated Plan of Care

• Purpose is to provide a structure for the
  delivery of care and treatment through the use of
  measurable objectives and timelines .
• Content includes problems, goals, and
  interventions, and designates role of each team
  member.
• Hospice plans address pain, symptom management,
  preparation for death and bereavement, and
  end-of-life tasks.

30
Integrated Plan of Care, cont.

• Hospice service retains overall professional
  management of the plan of care related to the
  terminal illness.

31
Integrated Plan of Care, cont.

• LTC Staff
• Provides relevant physicians orders.
• Comprehensive assessment (MDS)
• Care Planning through RAI process.
• Medication list
• Durable Medical Equipment list
• Social Service notes needed to initiate
  palliative plan of care.

32
Integrated Plan of Care, cont.

• LTC Staff, cont.
• Modify the LTC plan of care to reflect palliative
  care wishes.
• LTC continues providing daily care and
  communicates to hospice any change in condition
  or need.
• Informs patient/legal surrogate and hospice of
  scheduled patient care plan meetings.

33
Integrated Plan of Care, cont.

• Hospice Staff
• Provides initial hospice nurse assessment.
• Completes guidelines for hospice appropriateness.
• Medication list indicating payor source
• Physicians orders certifying 6-month prognoses.
• Hospice plan of care.

34
Integrated Plan of Care, cont.

• Hospice Staff, cont.
• Provide a copy of hospice plan of care to the
  facility.
• Secure needed DME and hospice-related medication
  and supplies.
• Update as condition and needs change.
• Hospice assumes case management of patients
  terminal condition.

35
Integrated Plan of Care, cont.

• Hospice Staff, cont.
• Documents the provision of care and services,
  which reflects the hospice philosophy, including
  the management of pain and other uncomfortable
  symptoms.
• Participates in patient care plan meeting and
  assists facility in establishing palliative care
  goals.

36
Integrated Plan of Care, cont.

• LTC Staff and Hospice Staff Collaborate
• Establish date and time to meet and formulate
  initial plan of care.
• 24-48 hours from admission to hospice.
• Collect data, encourage patient/family
  participation.
• Determine patients DME, medication and treatment
  needs
• Designate discipline responsible for care.
• Identify payor source of items/treatments.

37
Integrated Plan of Care, cont.

• LTC Staff and Hospice Staff Collaborate, cont.
• Develop and implement an integrated plan of care.
• Create and maintain communication system
• Hospice, LTC staff, pt/family, and physician set
  clear palliative care goals AND communicate them
  to all parties.

38
Physician Orders

• Policy and protocol development to address
  medical orders.
• The physician shall participate in development of
  the plan of care.
• The attending physician must comply with the LTC
  standards related to physicians orders.
• A hospice patient may elect a different physician
  to assist in managing pain and symptoms related
  to the terminal diagnoses.
• Hospice is responsible to ALL parties for
  coordinating, communicating, and ensuring proper
  documentation of terminal illness orders.

39
Physician Orders, cont

• LTC Staff
• Secure and document orders with the primary and
  consulting physician in compliance with state and
  federal regulations.
• Notify primary physician of consulting physician
  order changes.
• LTC staff will communicate changes in physician
  orders with hospice in a timely manner.

40
Physician Orders, cont

• Hospice Staff
• Secure and document orders with the primary and
  consulting physician in compliance with hospice
  state and federal regulations.
• Identify and communicate with facility and the
  pharmacy regarding the payor source of meds,
  treatments, and supplies ordered by physicians.
• Hospice will communicate changes in orders with
  the facility in a timely manner.

41
Physician Orders, cont.

• LTC Staff and Hospice Collaboration
• Hospice IDT and LTC staff will jointly determine
  the relationship of all physician
  orders/treatments to the residents terminal
  diagnoses and make recommendations to the
  physicians related to palliation.
• Develop a predetermined plan for communication
  with physicians as reflected in the plan of care.
• Establish and abide by policy and protocol to
  supply and maintain supplies, meds, and DME.

42
Medical Records Management

• Clinical records in accordance with accepted
  standards of practice.
• LTC facility and hospice should decide what
  portions of the clinical record should be copied
  and which agency should retain originals.
• Confidentiality of records maintained.
• Written authorization to share information.

43
Medical Record Management, cont.

• LTC Facility
• Establish and maintain clinical record in
  accordance with LTC regulations.
• LTC record shall be available to hospice.
• Missouri Medicaid
• LTC will bill hospice for per diem room and
  board rate minus surplus.

44
Medical Record Management, cont.

• Hospice
• Maintain a clinical record in accordance with
  hospice regulations.
• Provide appropriate documentation and consents to
  support interventions.
• Missouri Medicaid
• Hospice will file the paperwork to ensure
  timely Missouri Medicaid billing.

45
Medical Record Management, cont.

• LTC and Hospice Collaboration
• Decide where hospice documentation should be in
  the chart.
• Determine best method to communicate to all
  disciplines that resident has elected hospice.
• Establish a method to clearly identify hospice
  contact information.
• Devise system to thin charts.
• Establish mutually acceptable procedure for
  timely Medicaid billing and reimbursement.

46
Utilization of Therapy Services

• Ancillary therapies, including tube feedings,
  IVs physical, occupational, and speech
  therapies may be part of care for a hospice
  patient.
• The hospice IDT is responsible for determining if
  these services are consistent with the residents
  palliative care needs.
• The hospice IDT and the attending physician must
  make prior authorization for therapy services.

47
Utilization of Therapy Services

• LTC Staff
• May recommend therapies to the hospice team.
• Ancillary services may be purchased through the
  LTC facility (i.e. PT, OT, ST).
• If LTC using outside resources, a contract must
  be in place.

48
Utilization of Therapy Services, cont.

• Hospice
• Obtain orders and make arrangements for therapy
  services.
• Therapy services, goals, duration, and
  interventions will be included in the integrated
  plan of care and in the hospice progress notes.
• Maintain appropriate personnel records on all
  therapists contracted through the facility.
• Provide required orientation and ongoing
  inservicing for LTC contract therapists.

49
Utilization of Therapy Services, cont.

• LTC and Hospice Collaboration
• Scope and frequency of therapy services will be
  agreed upon and documented.
• Both will monitor the efficacy and communicate
  recommendations.
• There must be a mutually agreed upon method to
  provide ancillary services.

50
Loss and Grief Services

• Bereavement and grief support services are
  available to the family and significant others
  from admission through one year following the
  death of the patient.
• LTC staff share with hospice information related
  to familys coping, support and grief needs.
• Hospice does ongoing risk assessment explains
  and offers grief support identifies other
  community support resources provides individual
  care in the home setting.

51
Loss and Grief Services, cont.

• LTC and hospice formulate a joint care plan
  addressing bereavement needs.
• LTC staff provides grief support LTC staff and
  residents.
• Hospice provides grief education and support for
  LTC facility and identified community resources
  as needed.
• LTC and Hospice assess need for hospice to
  provide grief support.

52
Responsibilities at the Time of Death

• Collaboration is critical during this time!
• Determine in advance who is responsible for
  notifying the physician, pharmacy, mortuary, and
  coroner (per county procedure).

53
At the time of Death, cont.

• LTC Staff
• Calls hospice to inform them of imminent death.
• Provides support for pt, family, staff and
  residents.
• Determine who will contact family to report
  imminent death.

54
At the time of Death, cont.

• LTC Staff
• At time of death, LTC facility will return or
  destroy meds per facility protocol.
• Follows post death protocol for LTC facility.
• Notifies LTC facility staff and resident of death
  and funeral arrangements.

55
At the Time of Death, cont.

• Hospice
• Makes visit to dying resident as needed.
• Provides counseling, spiritual, and volunteer
  support for family.
• Offers visit at time of death and assists with
  arrangements.
• Manages extreme psychosocial response of family
  by involving hospice counselors and chaplains.
• Notifies hospice IDT of death and funeral
  arrangements.

56
At the Time of Death, cont.

• LTC Staff and Hospice Collaboration
• Determine care/support needs ensure needs are
  met and addressed.
• Support family members and follow pre-determined
  protocols for dealing with difficult behaviors.
• Attend visitation/funeral as desired.
• Provide ongoing support to LTC staff and
  residents.

57
Hospitalization and Emergency Care

• Consistent with the patients stated wishes in
  advance directives.
• LTC staff to timely call hospice of any changes
  for care plan revisions.
• LTC staff should obtain prior approval before
  transferring the resident when the transfer is
  related to the terminal condition.
• When unrelated to the terminal condition, contact
  hospice as soon as possible.
• All emergency care related to the terminal
  illness requires approval and coordination by
  hospice.

58
Hospitalization and Emergency Care, cont.

• LTC Staff
• Determine a need for emergent care.
• Contacts hospice for relationship to terminal
  illness.
• Contacts family/legal surrogate and physician
  about change in condition.
• Makes arrangement for transportation, if
  unrelated to terminal illness.
• Prepare transfer form, identify hospice status
  and advance directive.
• Will receive discharge orders from the hospital.

59
Hospitalization and Emergency Care

• Hospice Staff, cont.
• Respond to LTC and determines necessary actions.
  
• Provide emotional support for resident and
  family.
• If hospice related transfer, hospice will assist
  in arranging for ambulance.
• Hospice will send hospice plan of care, advance
  directive, current meds/treatments. Hospice will
  continue to manage treatment of the terminal
  illness while patient is in the hospital and will
  work to ensure pt returns as soon as symptoms are
  controlled.

60
Hospitalization and Emergency Care, Cont.

• LTC Staff and Hospice Collaboration
• Develop protocols in advance-both staffs
  coordinate with each other on transfers.
• LTC and hospice will know the residents
  resuscitation status and abide by the residents
  wishes.
• LTC and hospice will predetermine which entity
  will be responsible for receiving updates and
  reports.
• LTC and hospice will change the plan of care to
  reflect changes in condition.

61
Revocation/Decertification/Transfer

• Residents right to discontinue or transfer
  hospice services at any time.
• Resident/surrogate may revoke the hospice
  benefit.
• If resident no longer meets the criteria, the
  hospice may discontinue hospice services or
  decertify the patient.
• The resident may transfer his care to another
  hospice if he moves or prefers a different
  hospice.

62
Respite and Acute Patient Care in the Nursing Home

• Respite Care Patient may be admitted to a
  facility to relieve family members or other
  caregivers for up to five consecutive days.
• General In-Patient Patient requires admission
  to SNF for pain or acute/chronic symptom
  management, which cannot be handled in the home
  setting.

63
Respite and Acute Patient Care in the Nursing Home

• LTC must have 24-hour on-site RN coverage in a
  Medicare/Medicaid certified facility.
• Hospice provides transportation and arranges
  admission to SNF.
• Mutually agreed upon contract must be in place
  BEFORE services can be provided.
• Hospice provides copy of paperwork for SNF chart.
• Hospice and LTC staff develop integrated plan of
  care.

64
Hospice Reimbursement

• Medicare Hospice Benefit Reimburses hospice
  providing and managing all care related to the
  terminal diagnoses including visits by all
  hospice team members, supplies, medical
  equipment, and medications. Hospice required to
  pay ONLY for services that have been PREAPPROVED
  by the hospice program.

65
Hospice Reimbursement, cont.

• Medicaid Hospice The Medicaid Hospice Benefit
  mirrors the Medicare Hospice Benefit for Hospice
  services.
• Medicaid Room and Board Hospice bills Medicaid
  for room and board, then reimburses the LTC
  Facility.
• Private Insurance Plans verify in coverage.
  Hospice and SNF must collaborate regarding
  reimbursement issues.

66
Long-Term Care Regulations and Expectations of
Hospice Services

• State Operations Manual (SOM)
• pp. 53 54
• When a resident has elected the Medicare hospice
  benefit, the hospice and the nursing facility
  must communicate, establish, and agree upon a
  coordinated plan of care which reflects the
  hospice philosophy, and is based on an assessment
  of the individuals needs and unique living
  situation in the facility.

67
Long-Term Care Regulations and Expectations of
Hospice Services

• SOM, cont.
• The hospice must designate a registered nurse
  from the hospice to coordinate the implementation
  of the plan of care.
• This coordinated plan of care must identify the
  care and services which the SNF/NF and hospice
  will provide in order to be responsive to the
  unique needs of the resident and his/her
  expressed desire for hospice care.

68
Long-Term Care Regulations and Expectations of
Hospice Services

• SOM, cont.
• The SNF/NF and the hospice are responsible for
  performing each of their own respective functions
  that have been agreed upon and included in the
  plan of care. The hospice retains overall
  professional management responsibility for
  directing the implementation of the plan of care
  related to the terminal illness.

69
Long-Term Care Regulations and Expectations of
Hospice Services

• SOM, cont.
• For residents receiving the hospice benefit, the
  surveyor should evaluate
• Plan of care that reflects participation of
  hospice, facility and the resident.
• Plan of care includes directives for managing
  pain and other symptoms and is revised and
  updated to current status.
• Drugs and medical supplies are provided as needed.

70
Long-Term Care Regulations and Expectations of
Hospice Services

• Surveyor should evaluate, cont
• Hospice and facility communicate on changes in
  pan of care.
• Hospice and facility are aware of the others
  responsibilities.
• Facilities services are consistent with the plan
  of care developed in coordination with the
  hospice.

71
Long-Term Care Regulations and Expectations of
Hospice Services

• Surveyor should evaluate, cont
• Hospice patient/resident in a SNF/NF does not
  lack any SNF/NF services or personal care because
  of his/her status as a hospice patient.
• The SNF/NF offers the same service to its
  residents who have elected the hospice benefit as
  it furnishes to its resident who have not
  elected the hospice benefit.

72
Long-Term Care Regulations and Expectations of
Hospice Services

• CMS Identified Problem Areas
• Four Major Areas of Concern
• Care and services do not reflect the hospice
  philosophy.
• Coordination, delivery, and review of the care
  plan.
• Ineffective systems to monitor effectiveness of
  the plan of care for pain management and symptom
  control.
• Poor communication between hospice and facility
  staff.

73
In Summary

• Communicate!
• Communicate!!
• Communicate!!!