Providing Quality EndofLife Care Hospice Care in Assisted Living

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Providing Quality End-of-Life CareHospice Care
in Assisted Living

• Georgia Association of Homes and Services
• for the Aging
• Assisted Living Symposium
• February 22, 2008
• Visiting Nurse Hospice Atlanta
• Mary Stack, MSW - Coordinator, Senior Living
  Communities
• Detrie Bell, RN - Clinical Manager
• Mary Arthur, MSW - Director, Senior Living
  Initiatives

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Objectives

• At the end of this session you will
• Understand what hospice is (eligibility
  requirements, philosophy and practice)
• Understand levels of hospice care and payor
  sources
• Determine how partnering with a hospice
  organization(s) could benefit your community
• Know how to incorporate hospice care and services
  successfully in your community

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• Your experience with hospice care?

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Hospice 101 Eligibility, Philosophy and Practice

• Expected length of life is 6 months or less, if
  disease runs its normal course
• Wide range of diagnoses are included in
  eligibility
• Resident (or representative, when necessary) and
  the patients physician must be emotionally ready
  to receive hospice care and services
• Resident care goals are focused on palliative
  care, not curative care (strong clinical emphasis
  on pain and symptom management, comfort, resident
  autonomy)
• Philosophy of dying gracefully

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Hospice 101 (continued)

• Medical care requirements
• Because hospice is a skilled service, physician
  order is required
• Certification of terminal status must be signed
  by residents attending physician and hospice
  Medical Director
• Residents attending physician must be willing to
  work with hospice interdisciplinary care team or
  request Hospice Medical Director to assume care
• Interdisciplinary hospice care team
• Nursing (RN, LPN, CNA)
• Medical Social Work (LCSW, LMSW, MSW)
• Physician
• Pastoral Care (Chaplains)
• Rehabilitation (physical, occupational and speech
  therapists)
• Volunteers
• Bereavement Services
• Resident and family/friends
• Senior living community staff

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Hospice 101 (continued)

• Hospice care is provided to residents in their
  home, whenever possible
• To receive hospice services, resident must ELECT
  the hospice benefit, thereby waiving other
  medical and health care services specifically for
  the terminal illness
• Resident can revoke hospice services at any time

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RegulationsFour Levels of Hospice Care

• Routine (average Length of stay 39 days)
• General inpatient (average Length of stay13
  days)
• Respite (up to 5 days in acute care hospice
  facility)
• Continuous care (short-term crisis intervention
  in residents/patients apartment maximum _at_ 3
  days)

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Hospice Payor Sources

• Medicare
• Medicaid
• VA
• Commercial insurance (e.g. Kaiser, BC/BS, Aetna,
  United)
• Self-pay

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How Does Payment Work?

• Routine, respite and inpatient levels of care
  per diem rate
• Covers hospice interdisciplinary staff,
  medications related to terminal diagnosis,
  medical supplies, medical equipment, on-call
  staff (24/7), telephone support, transportation
  to/from inpatient hospice center
• Special Note All expenses related to terminal
  diagnosis must be approved by the hospice team
  (see next slide)
• Continuous care hourly rate
• Paid only if at least 8 hours of care in the 24
  hour period are provided and if at least 1 hour
  is from an RN, and if _at_ least 50 of time is
  provided by a licensed nurse
• Most hospice organizations do not accept patients
  with commercial insurance
• Commercial payors do not always contract to pay
  for all levels of care
• Commercial pay rates vary often significantly
  less than Medicare and Medicaid

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Hospice ELECTED BenefitPayment Considerations

• Per diem rate must cover all services specific to
• terminal diagnosis
• Emergency room visits
• Medications not related to diagnosis
• Aggressive medical treatments
• DME (e.g. electric wheelchair)
• Palliative care treatments
• 911 emergency calls
• Resident (patient), family, and staff education
  regarding end-of-life care and options extremely
  important
• Resident (patient) and family maintain right to
  choose services preferred

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Partnering to Provide Hospice Care

• Essential Components for Partnership
• Understanding hospice and assisted living
  eligibility criteria
• Understanding where AL and Hospice integrate and
  separate
• Written agreement between senior living community
  and hospice organization that defines operational
  expectations (see next slide)
• Specialized training for hospice and assisted
  living
• Staff
• Residents
• Families/Friends

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Operational Considerations

• Defining clear expectations
• Communication (frequency and methods)
• Residents, families, AL staff and hospice staff
• Physician communication between patient/resident,
  attending physician and hospice medical director
• Care Planning
• Attendance at joint care planning meetings
• Development of a coordinated individual plan of
  care (IPOC)
• Customer Service
• Other

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Benefits of Hospice CareAssisted Living and
Personal Care Communities

• Resource and support to staff, residents and
  families regarding end of life care (philosophy
  and practice)
• Promotes self-determined life closure based on
  resident preference
• Provide education palliative vs. curative care,
  medication management, comfort, dying gracefully
• Reduces physician office visits, emergency room
  visits and hospitalizations
• Evidence-based research indicates that quality of
  life is enhanced when people receive hospice care
• Number one resident preference staying in their
  home