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Hospice Care in the Nursing Home

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									Hospice Care in the Nursing
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.
• 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
    Definition of Hospice Care
• Residents entitled to hospice services per
  both state and federal statutes.
• Regulations establish that the LTC facility
  is the resident’s home.
• Hospice offers the patient, the caregiver
  system, and the family a program of care
  defined in the Medicare/Medicaid hospice
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.”
    Definition of Hospice, cont.
• Resident electing hospice are not “giving
• 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.
    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.
            Hospice Services
The hospice scope of care includes:
• Skilled Nursing
• Medical Social Services
• Personal Care
• Spiritual Care
• Volunteer Support
• Bereavement Support
• Physician Services
        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.
      Determination of Hospice
  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.
     Determination of Hospice
         Eligibility, cont.
• 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.
   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
      Determination of Hospice
          Eligibility, cont.
Current guidelines include:
• Lung disease
• Heart disease
• Kidney failure
• Stroke and coma
• Dementia
• Liver failure
       Determination of Hospice
           Eligibility, cont
•   ALS,
•   Lung Cancer
•   Prostate Cancer
•   Breast Cancer
•   Decline in Health Status
                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
         Core Services, cont.
• Collaboration is essential for both
• 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.
   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.
Responsibilities of Providers,
            Nursing Services

Collaborative Relationship:
Maintain communication to fulfill the plan
of care and inform each other of changes in
the care plan.
  Responsibilities of Providers,
            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.
Responsibilities of Providers,
           Physician Services

Collaborative relationship:
Each provider shall identify lines of
communication for medical care.
   Responsibilities of Providers,
 Medical Social Services, Spiritual Counseling,
   Dietary Counseling, Bereavement and Other
LTC Facility: As agreed upon in the plan of
              care in accordance with
Hospice:      Provides spiritual, emotional,
              nutritional counseling for resident and
              family as indicated in the plan of care.
Responsibilities of Providers,
    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 patient’s status that
affect the plan of care.
  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 patient’s right to access hospice
  services if the resident qualifies for that
    Eligibility/Admission Process,
                    LTC Staff
•   Identify potential hospice patients.
•   Review legal paperwork, identify legal
    representative who can make decisions.
•   Obtain a physician’s order for hospice
    evaluation and potential admission.
•   Educate resident/legal surrogate regarding
    treatment alternatives.
  Eligibility/Admission Process,
               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.
    Eligibility/Admission Process,
                    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.
  Eligibility/Admission Process,
                 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
    Eligibility/Admission Process,
               Hospice Staff, cont.
•   Verify hospice order for admission.
•   Explain hospice services, conduct the intake
    process, and obtain a signed election
•   Verify patient financial status and educate
    patient and family about financial issues.
•   Notify LTC of hospice election.
  Eligibility/Admission Process,
        LTC/Hospice Staff Collaboration
• Hospice and nursing facility must have a mutually
  agreed on contract before services can be
• Review LMRP guidelines in appendix, or at:
• Modify the Plan of Care to reflect the change in
        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
• Hospice plans address pain, symptom
  management, preparation for death and
  bereavement, and end-of-life tasks.
Integrated Plan of Care, cont.

Hospice service retains overall
professional management of the plan of
care related to the terminal illness.
     Integrated Plan of Care, cont.
                       LTC Staff
•   Provides relevant physician’s 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.
   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.
    Integrated Plan of Care, cont.
                   Hospice Staff
•   Provides initial hospice nurse assessment.
•   Completes guidelines for hospice
•   Medication list indicating payor source
•   Physician’s orders certifying 6-month
•   Hospice plan of care.
    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
    patient’s terminal condition.
   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
     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
•   Determine patient’s DME, medication and
    treatment needs
•   Designate discipline responsible for care.
•   Identify payor source of items/treatments.
  Integrated Plan of Care, cont.
 LTC Staff and Hospice Staff Collaborate,
• 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.
             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 physician’s 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.
        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.
        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.
        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 resident’s terminal diagnoses and make
  recommendations to the physicians related to
• 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.
  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
• Confidentiality of records maintained.
• Written authorization to share information.
  Medical Record Management,
                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.
  Medical Record Management,
• 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.
    Medical Record Management,
            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.
 Utilization of Therapy Services
• Ancillary therapies, including tube feedings, IV’s;
  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 resident’s
  palliative care needs.
• The hospice IDT and the attending physician must
  make prior authorization for therapy services.
 Utilization of Therapy Services
                  LTC Staff
• May recommend therapies to the hospice
• 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.
    Utilization of Therapy Services,
•   Obtain orders and make arrangements for therapy
•   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.
 Utilization of Therapy Services,
      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.
       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 family’s 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.
  Loss and Grief Services, cont.
• LTC and hospice formulate a joint care plan
  addressing bereavement needs.
• LTC staff provides grief support LTC staff and
• 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.
Responsibilities at the Time of
Collaboration is critical during this time!

Determine in advance who is responsible
for notifying the physician, pharmacy,
mortuary, and coroner (per county
    At the time of Death, cont.
                  LTC Staff
• Calls hospice to inform them of imminent
• Provides support for pt, family, staff and
• Determine who will contact family to report
  imminent death.
     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
• Notifies LTC facility staff and resident of
  death and funeral arrangements.
      At the Time of Death, cont.
•   Makes visit to dying resident as needed.
•   Provides counseling, spiritual, and volunteer
    support for family.
•   Offers visit at time of death and assists with
•   Manages extreme psychosocial response of family
    by involving hospice counselors and chaplains.
•   Notifies hospice IDT of death and funeral
      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
•   Attend visitation/funeral as desired.
•   Provide ongoing support to LTC staff and
 Hospitalization and Emergency
• Consistent with the patient’s 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
    Hospitalization and Emergency Care,
                         LTC Staff
•   Determine a need for emergent care.
•   Contacts hospice for relationship to terminal
•   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.
     Hospitalization and Emergency Care
                   Hospice Staff, cont.
•   Respond to LTC and determines necessary
•   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.
    Hospitalization and Emergency Care,
         LTC Staff and Hospice Collaboration
•   Develop protocols in advance-both staffs
    coordinate with each other on transfers.
•   LTC and hospice will know the resident’s
    resuscitation status and abide by the resident’s
•   LTC and hospice will predetermine which entity
    will be responsible for receiving updates and
•   LTC and hospice will change the plan of care to
    reflect changes in condition.

• Resident’s right to discontinue or transfer hospice
  services at any time.
• Resident/surrogate may revoke the hospice
• If resident no longer meets the criteria, the hospice
  may discontinue hospice services or decertify the
• The resident may transfer his care to another
  hospice if he moves or prefers a different hospice.
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.
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
• Hospice and LTC staff develop integrated plan of
      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.
  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.
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
  individual’s needs and unique living situation in
  the facility.”
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.”
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.”
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
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 other’s
• Facilities services are consistent with the
  plan of care developed in coordination with
  the hospice.
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 it’s
  residents who have elected the hospice benefit as
  it furnishes to it’s resident who have not elected
  the hospice benefit.
        Long-Term Care Regulations and
        Expectations of Hospice Services
            CMS Identified Problem Areas
            Four Major Areas of Concern
1.   Care and services do not reflect the hospice
2.   Coordination, delivery, and review of the care
3.   Ineffective systems to monitor effectiveness of
     the plan of care for pain management and
     symptom control.
4.   Poor communication between hospice and
     facility staff.
  In Summary


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