Title: Hospice Care in the Nursing Home
1Hospice 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.
2Objectives
- 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.
3Definition 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.
4Definition 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.
5Definition 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.
6Definition 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.
7Hospice Services
- The hospice scope of care includes
- Skilled Nursing
- Medical Social Services
- Personal Care
- Spiritual Care
- Volunteer Support
- Bereavement Support
- Physician Services
8Hospice 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.
9Determination 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.
10Determination 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.
11Determination 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.
12Determination of Hospice Eligibility, cont.
- Current guidelines include
- Lung disease
- Heart disease
- Kidney failure
- HIV
- Stroke and coma
- Dementia
- Liver failure
13Determination of Hospice Eligibility, cont
- ALS,
- Lung Cancer
- Prostate Cancer
- Breast Cancer
- Decline in Health Status
- http//www.iamedicare.com/Provider/policy/
- policyhome.htm
14Core 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
15Core 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.
16Responsibilities 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.
-
-
17Responsibilities 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.
18Responsibilities 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.
19Responsibilities of Providers, cont.
- Physician Services
- Collaborative relationship
- Each provider shall identify lines of
communication for medical care.
20Responsibilities 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.
21Responsibilities 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.
22Eligibility/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.
23Eligibility/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.
24Eligibility/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.
25Eligibility/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.
26Eligibility/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.
27Eligibility/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.
28Eligibility/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.
29Integrated 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.
30Integrated Plan of Care, cont.
-
- Hospice service retains overall professional
management of the plan of care related to the
terminal illness.
31Integrated 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.
32Integrated 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.
33Integrated 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.
34Integrated 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.
35Integrated 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.
36Integrated 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.
37Integrated 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.
38Physician 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.
39Physician 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.
40Physician 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.
41Physician 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.
42Medical 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.
43Medical 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.
44Medical 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.
45Medical 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.
46Utilization 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.
47Utilization 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.
48Utilization 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.
49Utilization 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.
50Loss 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.
51Loss 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.
52Responsibilities 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).
53At 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.
54At 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.
55At 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.
56At 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.
57Hospitalization 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.
58Hospitalization 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.
59Hospitalization 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.
60Hospitalization 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.
61Revocation/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.
62Respite 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.
63Respite 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.
64Hospice 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.
65Hospice 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.
66Long-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.
67Long-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.
68Long-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.
69Long-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.
70Long-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.
71Long-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.
72Long-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.
73In Summary
- Communicate!
- Communicate!!
- Communicate!!!