Why Hospice Care Belongs in Nursing Homes, Part 2.

Hospice care can benefit both residents and the facility--but only if the staffs know how to work together

This article focuses on the operational aspects of delivering hospice care in a long-term care facility, including the specifics of Medicare's hospice benefit, contracting between the hospice care provider and the facility, and ways to develop and deliver coordinated care. It proceeds on the assumption that facilities recognize the benefits of such a collaboration, as described in "Why Hospice Care Belongs in Nursing Homes, Part 1," April 2001 Nursing Homes/Long Term Care Management, p. 46.

It is important to understand that much of the care provided by a hospice care provider in a nursing facility is paid for under Medicare's hospice benefit (Figure 1). Hospice care is an optional benefit under the Medicaid program, with 43 states offering a Medicaid hospice benefit, as well (the exceptions being Connecticut, Maine, Nebraska, New Hampshire, Oklahoma, Tennessee and Louisiana). The Medicaid benefit mirrors the Medicare benefit, but the payment varies. Because of the importance of Medicare's hospice benefit, there must be mutual and clear understanding of what the benefit does and does not cover.

Medicare's hospice benefit covers medical care and palliative care services for terminally ill Medicare beneficiaries who elect it. Beneficiaries who elect hospice care are required to waive Medicare coverage for care related to their terminal illness that is provided outside the hospice setting. In other words, under Medicare's hospice benefit, beneficiaries elect to receive noncurative treatment and services for their illness and waive standard Medicare benefits for treatment of the terminal illness.

For eligible residents (see Table), Medicare's hospice benefit covers all treatments defined in the care plan where the goal is to relieve symptoms related to the terminal illness, including:

* pain and symptom management

* bereavement care

* nursing and certified nursing assistant (CNA) visits and volunteer visits

* physical, occupational and speech therapy

* drugs, durable medical equipment (DME) and supplies related to the terminal condition

* wound care and consulting services

It is important to note that the costs of room and board are not covered under Medicare's hospice benefit. If a resident is dually eligible for both Medicaid and Medicare, however, the Medicaid program will reimburse for room and board. In most states, the Medicaid program reimburses the hospice care provider, which in turn must reimburse the nursing facility. Although states' rules vary, regulatory guidance over the past few years has generally limited the nursing facility payment to 95% of the per diem. This has discouraged some nursing facilities from securing contracts with hospice providers, and a number of state Medicaid programs--specifically in Oklahoma, Oregon, South Carolina, Pennsylvania and New Mexico--have established policies to pay the nursing facility directly. In addition, Medicare's hospice benefit does not cover costs for attending physicians, although it does cover the cost of the medical director.

There are four levels of care under Medicare's hospice benefit. For each level, the hospice care provider is paid a per diem for each day the resident is under that level of care. The four levels are:

* Routine home care, which can include a nursing facility or assisted living facility as the resident's home.

* Continuous home care, provided during brief periods of crisis in increments of at least eight hours.

* Inpatient respite care, provided when the family needs short-term relief to prevent caregiver burnout and at infrequent intervals of no more than five consecutive days.

* General inpatient care, provided to a resident who meets hospice acute care criteria.

Only two of these levels of care, routine home care and general inpatient care, have major applicability to a nursing facility. It is important for a nursing facility that contracts with a hospice care provider to understand in detail the care that is provided by the hospice directly for each of these levels.

Of all levels, routine home care is used most often (Figure 2). It enables hospice staff to visit the resident and provide services, and it is generally not applicable to skilled beds. The hospice provides the same services to a resident in a nursing facility that it would normally provide at the resident's personal home. Under Hospice Medicare Conditions of Participation, the nursing facility can expect the hospice care provider to provide:

* professional management of the resident

* services provided in the nursing facility or assisted living facility

* registered nurse, social worker, spiritual counselor, aide and volunteer visits and physical, occupational and speech therapy visits, when authorized (frequency of visits is determined by the care plan)

* DME, medications, labs and medical supplies related to the terminal illness

* discharge planning provided by a hospice social worker

General inpatient care can be provided in a hospital bed or a skilled nursing facility bed. Candidates for acute care might be suffering from a variety of conditions, which might necessitate rapidly escalating/complicated pain management and/or management of acute agitated delirium, intractable nausea and vomiting, respiratory distress, severe infection and psychosocial issues. Hospice provides clinical oversight of inpatient hospice care in a nursing facility by:

* assuming professional management of resident

* providing the services in a skilled bed

* making daily visits (by a registered nurse at least five times; social worker at least twice; and chaplain and volunteer visits)

* attending the resident care team meeting

* providing DME, medications, labs and medical supplies

* having a hospice social worker provide discharge planning

* paying the facility an all-inclusive perdiem rate covering room and board, facility staff services, medications, supplies, DME, laboratory tests and physical, occupational and speech therapy

Making the Relationship Work

The relationship between hospice care providers and long-term care providers is not easy to develop but, once forged, confers great benefits to the residents and the facility. One of the problems to be addressed is that hospice nurses who act autonomously in a patient's home sometimes have difficulty in a nursing facility, where appropriate consultation and coordination among the care staff is essential. In turn, nursing facility staff are not accustomed to having care directed by an external provider. Further complexity is added by the need to adhere to both the hospice and nursing facility Conditions of Participation. Some larger hospice providers, such as Hospice and Palliative Care of Metropolitan Washington, have responded by establishing separate nursing home teams.

The staff relationships must be discussed at the beginning, with agreement on the respective roles of the hospice and nursing facility; how admissions will be processed; the procedure for hospice staff to follow on entering nursing and assisted living facilities; the outline of in services provided; and how the care plan and discharge will be handled. All of this must be done, of course, within the context of the Medicare Conditions of Participation. Specific steps include:

Step 1: Establishing a written contract. We believe it is most appropriate to have separate contracts for routine home care/respite care and for general inpatient care. While these could be combined, we have found that the reimbursement and Conditions of Participation issues are so different that keeping them separate is helpful. Specific advice:

* It is critical for the contract to specify fees for services and how pass-through billing will be handled, including defining exclusions.

* It is also vital that operating procedures, including hospice responsibilities, nursing facility responsibilities and coordinating the care plan be agreed upon and such agreement reflected in the contract.

Step 2: Understanding the roles of each provider and how these joint roles must be reflected in a coordinated plan of care. The role of the nursing facility is to ensure education, communication and integrated care plans. In addition, its purpose in using hospice care is to enhance residents' end-of-life care and to continue to educate nursing facility staff on hospice issues.

The role of the hospice care provider is to educate hospice staff on long-term care regulations, guidelines and eligibility criteria; educate long-term care staff on hospice, pain management, death! dying, the grieving process, eligibility rules and other regulations; cooperate with long-term care facilities to integrate care; and provide a hospice liaison to facilitate relationships and help resolve issues. In addition, the hospice must ensure that its involvement on issues such as dehydration, delirium and fecal impaction is well documented.

Step 3: Developing a plan for accomplishing their joint responsibilities, which are specified in each provider's Conditions of Participation. Admission to hospice. Nursing facility providers should be aware that hospice care providers are required to complete the assessment and care plan within 48 hours of admission. The steps in the admission process for hospice staff are:

* Admission nurse visits with resident/family and completes assessment and consent forms;

* Admission nurse calls physician for new orders and orders equipment, supplies and medications;

* Admission staff reviews the assessment with nursing facility staff (in particular, the MDS coordinator) to begin a coordinated plan of care; and

* Admission nurse notifies appropriate staff and business office of the admission.

Creating a single, coordinated care plan. The care plan is the most important area of cooperation-and one of the most difficult. It should reflect the participation of the hospice, the facility and the resident. The care plan includes directives for managing pain and other symptoms and is revised and updated as necessary to reflect current status. Drugs and medical supplies are provided as needed for palliation and management of the terminal illness. The hospice and facility communicate with each other when any changes are indicated to the care plan, and they are aware of each other's responsibilities in implementing it. Interventions are determined together.

Discharges. The nursing facility and the hospice must set up processes that involve the care plan team and ensure that a clear understanding and effective communication exist before discharge is discussed with the resident or family. Also, the hospice must notify the long-term care facility business office when a hospice care resident's payer source changes.

Suggested Action

If your nursing facility is seeking to bring the benefits of improved end-of-life care to your residents, we suggest the following:

* Consider establishing a hospice contract with a high-quality provider in your community, or

* Seek to imp rove your relationship with the existing hospice care provider.

* Develop a written statement on end-of-life principles for your organization.

* Educate facility staff on pain management and end-of-life care.

For additional resources, The National Hospice and Palliative Care Organization has prepared a Nursing Home Tool Kit designed to facilitate the relationship between the hospice and the nursing facility.

David English is the president and CEO of Hospice and Palliative Care of Metropolitan Washington, one of the nation's Largest nonprofit Medicare-certified hospice providers and the umbrella organization for Hospice of Northern Virginia, Hospice Care of D.C. and Hospice of Suburban Maryland. Jade Gong, a consultant in long-term care, serves on the Board of Hospice and Palliative Care of Metropolitan Washington.

                    Sources of financing for hospice
                      care in nursing facilities.
Private Insurance  12%
Medicaid            4%
Other               7%
Medicare           77%
Note: Table made from pie chart
                   How Medicare's hospice benefit is
                       used for nursing facility
                               residents.
Routine Home Care       86%
Continuous Home Care     3%
General Inpatient Care  10%
Inpatient Respite Care   1%
Note: Table made from pie chart

Eligibility Criteria for Medicare's Hospice Benefit.

* Medicare Part A eligibility

* a progressive, life-limiting disease

* prognosis of 6 months or less if illness runs its normal course, as certified by referring physician and hospice medical director (The Medicare, Medicaid, and SCHIP Benefits Improvement and Beneficiary Protection Act, passed in December 2000, provided the following clarification language: "...shall be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness.")

* hospice service elected by resident or family