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Hospice Care in the Nursing Home

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LTC must have 24-hour on-site RN coverage in a Medicare/Medicaid certified facility. ... a resident has elected the Medicare hospice benefit, the hospice and ... – PowerPoint PPT presentation

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Title: 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!!!
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