What is hospice

1
What is hospice?

• Questions and Answers for Family Physicians

2
Background

• Hospice is a multidisciplinary, patient-centered
  approach to palliative care
• Most dying patients want was hospice has to offer
  - home-based,comfort care
• Most dont know about hospice
• 50 die in hospital, 25 in NH, 25 home
• About ¼ of Americans receive hospice care

3
What is hospice?

• Hospice care is guided by an individualized plan
  developed and implemented by a multidisciplinary
  team including attending physician, medical
  director, nurse care manager, social worker,
  chaplain
• Care plan consistent with preferences of the
  patient, including pain and symptom management,
  family and spiritual support

4
What are the services provided?

• RNs provide direct care and case management
  visits as needed, 24 hr call
• Social worker assesses and provides support
• Chaplain provides pastoral care
• Medical director supplies oversight and
  consultation to team and physician

• Trained volunteers offer companionship
• Home health and homemaker services
• Bereavement care provided for one year
• Therapies as needed
• Physician and other consultations as needed

5
What about drugs and equipment?

• These are provided as needed to address the
  hospice related condition
• Patient responsible for 5 co pay, not to exceed
  5
• Durable medical equipment such as commode chairs,
  walkers, hospital beds, oxygen supplied without
  charge

6
Who is eligible for hospice?

• Anyone who is dying
• Medicare, Medicaid, and most insurers have
  hospice benefit paid as capitation
• Generally intended for those with life expectancy
  fewer than 6 months
• In 2000, 60 had cancer diagnosis, 80 Medicare
  recipients
• Guidelines developed for general conditions and
  specific diseases

7
Do I give up care for my patients?

• The attending physician remains in charge of her
  or his patient while working cooperatively with
  the multidisciplinary team
• Important to collaborate based on goals of care
  as defined by patient, surrogate, and team
• FPs might get patients after subspecialty disease
  oriented care no longer beneficial
• Patients can be referred to other parts of care
  can be delegated

8
How will hospice help me care for my patient?

• Dying patients and their family members need more
  help and attention
• First contact is hospice nurse, who is available
  or on call nurse is at all times
• SW and chaplain assessment and visits
• Regular team meetings review care plan and
  communicate with attending physician
• Services intensified at end, person to call,
  bereavement support

9
How is hospice different from good home health?

• Share some of the same goals maintaining
  function and helping patient stay at home
• Home care patients are expected to stabilize and
  improve, and terminate when patient no longer
  merits nursing or rehab services
• Hospice does not require patient to be homebound
• Most hospice does not provide long term inpatient
  care (e.g. hospice house or hospital unit)

10
If my patient is in hospice, does that mean I
cant treat pneumonia?

• No, but we need to compare every decision with
  the patients goals of care
• Goals shift from disease oriented to comfort and
  improving quality of life
• If treating pneumonia helps these, then ok
• May be terminal event that means patient should
  be supported with antipyretics, oxygen, and
  morphine

11
What if my patient doesnt die within 6 months?

• This fear causes reluctance to refer patients
• Average length of stay in hospice was 48 days,
  median was 25 days
• 33 die within 7 days of referral making it hard
  to implement patients plan
• Patient reviewed at 3 mos and every 2 mos after
  for continuing eligibility
• No limit on length in hospice no risk of fraud
  for attending physician

12
What if my patient wants to opt out, recovers or
doesnt need hospice anymore?

• Any patient can change goals of care and opt out
  at any time and then reenroll
• Hospice graduates are not uncommon patients
  who improve when disease oriented therapies are
  terminated

13
What is things can be taken care of at home?

• Respite care can be provided for overwhelmed care
  givers
• Patients can be admitted for intensive management
  of symptoms
• Both are usually unnecessary

14
What do we do in the hospital before hospice?

• Initiate discussions of goals of care
• Use the Comfort Pathway (look for these documents
  in Launch Applications in Power chart)
• Allow people do die in comfort in the hospital
• For those who do not need the hospital, involve
  hospice prior to discharge to enable smooth
  transition to home or nursing home

15
What about hospice in the nursing home?

• 28 of deaths in Missouri occur in nursing homes
• No patient can receive Medicare sponsored SNF
  care and hospice (both Part A)
• Hospice can provide care in nursing homes
• Nursing home/ hospice must have contract
• Must share care planning
• New program to facilitate Guidelines for End of
  Life Care in Nursing Facilities (Missouri End of
  Life Coalition)

16
How do I bill for hospice patient?

• Attending physicians bill same either office
  based or home codes adding GV modifier
• If unrelated to hospice dx use GW modifier
• Consulting physicians bill the hospice itself

17
How to learn more?

• Perspectives of hospice nurse and attending
  physician
• Care for patients in hospice
• Participate in EPEC training
• Pocket manuals for symptom management
• Ask residency leadership for more talks!