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.
 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.
 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 benefit.
 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 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.
 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 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.
 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.
 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.
 DETERMINATION OF
HOSPICE ELIGIBILITY,
CONT.
Current guidelines include:
• Lung disease
• Heart disease
• Kidney failure
• HIV
• Stroke and coma
• Dementia
• Liver failure
 DETERMINATION OF
HOSPICE ELIGIBILITY, CONT
• ALS,
• Lung Cancer
• Prostate Cancer
• Breast Cancer
• Decline in Health Status
http://www.iamedicare.com/Provider/policy/
policyhome.htm
 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 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.
 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, CONT.
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, 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.
 RESPONSIBILITIES OF
PROVIDERS, CONT.
Physician Services

Collaborative relationship:
Each provider shall identify lines of communication for medical
care.
 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.
 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 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 benefit.
 ELIGIBILITY/ADMISSION
PROCESS, CONT.
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, 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.
 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.
 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.
 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.
 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.
 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.
 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 appropriateness.
• Medication list indicating payor source
• Physician’s orders certifying 6-month prognoses.
• 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 goals.
 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 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, 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.
 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 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.
 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.
 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.
 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.
 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.
 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 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.
 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.
 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.
 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
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.
 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).
 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.
 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.
 AT THE TIME OF DEATH,
Hospice 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
arrangements.
• Manages extreme psychosocial response of family by
involving hospice counselors and chaplains.
• Notifies hospice IDT of death and funeral
arrangements.
 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.
 HOSPITALIZATION AND
EMERGENCY CARE
• 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 hospice.
 HOSPITALIZATION AND
EMERGENCY
LTC Staff CARE, CONT.
• 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.
 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.
 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 resident’s resuscitation
status and abide by the resident’s 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.
 REVOCATION/DECERTIFICA
TION/TRANSFER
• Resident’s 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.
 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 chart.
• Hospice and LTC staff develop integrated plan of care.
 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
SOM, cont.
SERVICES
“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
SOM, cont.
SERVICES
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.
 LONG-TERM CARE
REGULATIONS AND
EXPECTATIONS OF HOSPICE
Surveyor should evaluate, cont:
SERVICES
• Hospice and facility communicate on changes in pan of care.
• Hospice and facility are aware of the other’s responsibilities.
• 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
CMS Identified Problem AreasSERVICES
Four Major Areas of Concern
1. Care and services do not reflect the hospice
philosophy.
2. Coordination, delivery, and review of the care plan.
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
Communicate!

Communicate!!
Communicate!!!