Coordinated Care for Coordinated Care for Hospice Patients in a Hospice Patients in a

Nursing Home SettingNursing Home Setting

Presented by:Presented by:

Karen Anthony, RN, MA, LLPKaren Anthony, RN, MA, LLP

Howard Schaefer, MSW, LCSWHoward Schaefer, MSW, LCSW

Learning Learning ObjectivesObjectives

• Identify CMS policy on hospice care for Identify CMS policy on hospice care for nursing home residentsnursing home residents

• Identify the responsibilities of each provider Identify the responsibilities of each provider caring for the resident who elects hospice caring for the resident who elects hospice

• Explain the importance of a coordinated plan Explain the importance of a coordinated plan of care (POC) in the nursing home setting.of care (POC) in the nursing home setting.

• Identify methods for optimizing the relationship Identify methods for optimizing the relationship between hospice and the nursing facility.between hospice and the nursing facility.

All nursing homes should All nursing homes should provide or make available provide or make available

to residents end of life to residents end of life alternatives.alternatives.

The federal regulations offer guidance under The federal regulations offer guidance under F-Tag 309:F-Tag 309:• The Hospice provider The Hospice provider

and the Nursing and the Nursing Home must Home must communicate.communicate.

• The Hospice and The Hospice and Nursing Home must Nursing Home must establish a establish a coordinated Plan of coordinated Plan of Care for both Care for both providers.providers.

The Plan of Care is based The Plan of Care is based on the resident’s on the resident’s

assessment.assessment.• The Plan of Care must The Plan of Care must

include how to manage include how to manage pain and other care pain and other care needs and be updated to needs and be updated to reflect the resident’s reflect the resident’s current condition.current condition.

• The POC must designate The POC must designate which services the which services the facility and the Hospice facility and the Hospice will provide in meeting will provide in meeting the needs of the resident the needs of the resident in hospice care.in hospice care.

The Survey Process will The Survey Process will evaluate:evaluate:

• Does the POC reflect participation of the hospice, Does the POC reflect participation of the hospice, facility and patient to the extent possible.facility and patient to the extent possible.

• Are directives for managing pain revised and Are directives for managing pain revised and updated as needed in consultation with the updated as needed in consultation with the resident and/or resident advocate and hospice resident and/or resident advocate and hospice staff.staff.

• Does the resident have the necessary drugs and Does the resident have the necessary drugs and medical supplies needed for palliation in medical supplies needed for palliation in managing the terminal illness and related managing the terminal illness and related conditions. Primarily responsibility of hospice conditions. Primarily responsibility of hospice agency but in consultation with resident and agency but in consultation with resident and facility staff.facility staff.

• Reference F-309 (Guidance for Hospice)Reference F-309 (Guidance for Hospice)

Survey process Survey process continued:continued:

• Are the hospice and Are the hospice and facility facility communicating when communicating when changes are indicated changes are indicated in the POC.in the POC.

• Does the hospice and Does the hospice and facility know the facility know the other’s other’s responsibilities responsibilities related to resident related to resident care as identified in care as identified in the POC.the POC.

Survey Process continuedSurvey Process continued

• Are the SNF/NF Are the SNF/NF services or personal services or personal care being delivered as care being delivered as needed to the hospice needed to the hospice resident.resident.

• Does the SNF/NF offer Does the SNF/NF offer the same services to the same services to residents who have residents who have chosen hospice as it chosen hospice as it offers to residents who offers to residents who have not chosen have not chosen hospice.hospice.

SO WHAT DO WE LOOK SO WHAT DO WE LOOK FOR?FOR?

• ■■ Is Hospice Offered? If not, the facility Is Hospice Offered? If not, the facility still has still has some responsibility to provide end some responsibility to provide end of life of life intervention. Informed consent.intervention. Informed consent.

• ■■ Are end of life needs being met? Are end of life needs being met? (Clinical Process Guidelines)(Clinical Process Guidelines)

• ■■ What is the ongoing system of What is the ongoing system of communication?communication?

•What is the facility staff’s What is the facility staff’s understanding of how they understanding of how they and the hospice staff should and the hospice staff should coordinate and provide coordinate and provide specific care needs.specific care needs.

• What guidance/direction is in What guidance/direction is in place to ensure that caregivers place to ensure that caregivers know WHO does WHAT?know WHO does WHAT?

• How is hands-on care being How is hands-on care being communicated between facility communicated between facility and hospice caregivers (i.e.; and hospice caregivers (i.e.; ADL’s).ADL’s).

• Are facility and hospice staff aware Are facility and hospice staff aware of where to access information of where to access information regarding resident care.regarding resident care.

• INTERVENTIONS:INTERVENTIONS:

• Are they appropriate?Are they appropriate?

• Are they being implemented?Are they being implemented?

• Consistently?Consistently?

42 CFR 418.112 Hospice 42 CFR 418.112 Hospice Condition of Participation:Condition of Participation:

• New CoP’s for Hospices became New CoP’s for Hospices became effective in December of 2008effective in December of 2008

• 418.112 defines the standards that a 418.112 defines the standards that a hospice providing hospice care to hospice providing hospice care to patients of a SNF / NF must abide patients of a SNF / NF must abide by.by.

In future, new F Tags In future, new F Tags and/or guidance related to and/or guidance related to

hospice patients residing in hospice patients residing in a nursing home:a nursing home:

• New F tags/guidance being written at present New F tags/guidance being written at present by a CMS work group to address the special by a CMS work group to address the special situation of “hospice in a nursing home”……situation of “hospice in a nursing home”……

• --companion requirements and/or process for --companion requirements and/or process for LTC to correspond with the hospice LTC to correspond with the hospice requirementsrequirements

• --expected roll-out unclear at this time--expected roll-out unclear at this time

• Both the facility and hospice mustBoth the facility and hospice must

comply with their own regulationscomply with their own regulations. .

Before beginning….Before beginning….

• The hospice and facility are required The hospice and facility are required to have a written agreement to have a written agreement outlining key elements in the outlining key elements in the relationship before the hospice relationship before the hospice provides care to the resident(s). provides care to the resident(s).

The written agreement The written agreement must include, but is not must include, but is not limited to the following:limited to the following:

– A provision that it is the hospice’s responsibility to A provision that it is the hospice’s responsibility to provide services at the same level and to the same provide services at the same level and to the same extent extent as if the patient were in his or her own home.as if the patient were in his or her own home.

– A provision that it is the facility’s responsibility to A provision that it is the facility’s responsibility to continue to furnish 24 hour room and board care, continue to furnish 24 hour room and board care, meeting the personal care and nursing needs that meeting the personal care and nursing needs that would have been provided by the primary caregiver would have been provided by the primary caregiver at home.at home.

– A delineation of the hospice’s responsibilities, some A delineation of the hospice’s responsibilities, some examples of which are: medical management examples of which are: medical management related to the terminal diagnosis, nursing, related to the terminal diagnosis, nursing, counseling, social work, provision of medical counseling, social work, provision of medical supplies, DME equipment and drugssupplies, DME equipment and drugs

Contract Provisions Contract Provisions (continued)(continued)

• A provision that hospice core services must be routinely A provision that hospice core services must be routinely provided by the hospice, and cannot be delegated to the provided by the hospice, and cannot be delegated to the facility. Hospice may use the facility nursing personnel facility. Hospice may use the facility nursing personnel to assist in the implementing the plan of care only to the to assist in the implementing the plan of care only to the extent that the hospice would routinely use the services extent that the hospice would routinely use the services of a hospice patient’s family.of a hospice patient’s family.

• Core services include:Core services include:1.1. Physician servicesPhysician services2.2. Nursing servicesNursing services3.3. Medical social servicesMedical social services4.4. Counseling servicesCounseling services

• Hospice Hospice may notmay not contract with the nursing home to contract with the nursing home to provide core services.provide core services.

In addition, the hospice and In addition, the hospice and nursing facility should define in nursing facility should define in

the written agreement:the written agreement:• How communication between hospice and How communication between hospice and

facility staff will occur:facility staff will occur:– The manner in which the hospice and facility are to The manner in which the hospice and facility are to

communicate with each other to ensure the patient’s communicate with each other to ensure the patient’s needs are met 24 hours a day. needs are met 24 hours a day.

– A provision that the facility immediately A provision that the facility immediately communicate with the hospice if a significant communicate with the hospice if a significant change in patient condition occurs. change in patient condition occurs.

• How documentation in the clinical record will How documentation in the clinical record will occur.occur.

• How development of a coordinated plan of How development of a coordinated plan of care will occur. care will occur.

After the written agreement is After the written agreement is established the process may established the process may proceed…proceed…

Patient resides in a nursing home facility……Patient resides in a nursing home facility……

The patient / resident meets eligibility The patient / resident meets eligibility requirements and elects the Hospice requirements and elects the Hospice benefit……..benefit……..

The patient is admitted to the hospice……The patient is admitted to the hospice……

The The hospicehospice then assumes full responsibility then assumes full responsibility for “for “professional management”professional management” of the of the individual’s hospice care in accordance with individual’s hospice care in accordance with the hospice CoP’s.the hospice CoP’s.

What is Professional What is Professional Management ?Management ?

• The term “professional management” for a The term “professional management” for a hospice patient who resides in a facility hospice patient who resides in a facility has has the same meaning that it has if the hospice the same meaning that it has if the hospice patient were living in his / her own home. patient were living in his / her own home.

• The hospice assumes the “professional The hospice assumes the “professional management” duties of assessing, planning, management” duties of assessing, planning, monitoring, directing and evaluating the monitoring, directing and evaluating the patient’s hospice carepatient’s hospice care across all settings. across all settings.

• The facility staff, from the viewpoint of the The facility staff, from the viewpoint of the hospice, assume the role of the patient’s hospice, assume the role of the patient’s primary caregiver… or in other words “family.” primary caregiver… or in other words “family.”

Responsibilities of the Responsibilities of the HospiceHospice

• Ongoing patient assessment.Ongoing patient assessment.• Monitoring, care planning and coordination by the Monitoring, care planning and coordination by the

interdisciplinary group.interdisciplinary group.• Coordinating the plan of care with the nursing Coordinating the plan of care with the nursing

home facility.home facility.• Coordination by the hospice RN of the implementation of Coordination by the hospice RN of the implementation of

the plan of care.the plan of care.• Consultation about the patient’s care with facility staff. Consultation about the patient’s care with facility staff. • Determining the appropriate level of care to be given the Determining the appropriate level of care to be given the

patient. patient. • Coordination and provision of any needed general Coordination and provision of any needed general

inpatient or continuous care.inpatient or continuous care.• Financial responsibility for, and provision of (in a timely Financial responsibility for, and provision of (in a timely

manner), all medical supplies, appliances and medications manner), all medical supplies, appliances and medications related to the terminal illness.related to the terminal illness.

Hospice must:Hospice must:

• (L777) …designate an IDG member (L777) …designate an IDG member responsible for coordination of responsible for coordination of hospice care with representatives of hospice care with representatives of the nursing homethe nursing home

• --may be an RN, social worker, --may be an RN, social worker, counselorcounselor

• --this role is aimed at broader --this role is aimed at broader coordination and troubleshootingcoordination and troubleshooting

Examples of areas Examples of areas coordinator might focus on:coordinator might focus on:• --are each providers’ plans and goals --are each providers’ plans and goals

complementary and reflective of hospice complementary and reflective of hospice intentintent

• --does documentation show coordination? --does documentation show coordination? Is documentation easy to access?Is documentation easy to access?

• --are physician orders obtained and --are physician orders obtained and implemented according to plan of care implemented according to plan of care and written agreement?and written agreement?

• --do aspects of the written agreement --do aspects of the written agreement need to be reviewed between the parties?need to be reviewed between the parties?

More examples:More examples:

• Is a discussion of potential hotspots, Is a discussion of potential hotspots, such as use of anti-psychotics by the such as use of anti-psychotics by the hospice, part of written agreement hospice, part of written agreement negotiations?negotiations?

• Is written agreement updated to Is written agreement updated to anticipate and clarify hotspots?anticipate and clarify hotspots?

• Do medical directors communicate? Do medical directors communicate? Can this be facilitated to clarify Can this be facilitated to clarify aspects of the written agreement?aspects of the written agreement?

Overall Goal of the Overall Goal of the Designated Hospice IDG Designated Hospice IDG

member is to:member is to:• ……coordinate approaches of the coordinate approaches of the

hospice and the nursing homehospice and the nursing home• ……to ensure effective communication to ensure effective communication

about patientsabout patients• ……and to ensure that outcomes are and to ensure that outcomes are

monitored and evaluatedmonitored and evaluated

Responsibility of the Responsibility of the FacilityFacility

To provide services by qualified staff, consistent To provide services by qualified staff, consistent with professional standards of practice. with professional standards of practice.

These services include:These services include:– Personal care servicesPersonal care services– Supervision / Assistance with ADL’sSupervision / Assistance with ADL’s– Administering medicationsAdministering medications– Social activitiesSocial activities– Room cleanlinessRoom cleanliness– Assistance with durable medical equipment use andAssistance with durable medical equipment use and

prescribed therapiesprescribed therapies

moremore…….…….

The facility responsibilities The facility responsibilities also also includeinclude::

• Ongoing assessment of the patient.Ongoing assessment of the patient.• Notifying hospice when the patient has a change in condition.Notifying hospice when the patient has a change in condition.• Notifying the attending physician and family when the patient Notifying the attending physician and family when the patient

has a change in condition.has a change in condition.• Notifying hospice when the patient needs are not being met Notifying hospice when the patient needs are not being met

(i.e. spiritual, psychosocial) (i.e. spiritual, psychosocial)• Coordinating the plan of care with the hospiceCoordinating the plan of care with the hospice. . • Orienting hospice staff to the facility.Orienting hospice staff to the facility.• Requesting orientation of new facility staff by the hospice. Requesting orientation of new facility staff by the hospice. • Maintaining RAI / MDS. Regulations for completion and Maintaining RAI / MDS. Regulations for completion and

submission of RAI / MDS data do not change when the patient submission of RAI / MDS data do not change when the patient / resident elects the hospice benefit./ resident elects the hospice benefit.

Joint ResponsibilitiesJoint Responsibilities

• Patient rights & responsibilitiesPatient rights & responsibilities• ConfidentialityConfidentiality• Ongoing assessmentOngoing assessment• Quality assuranceQuality assurance• Clinical documentationClinical documentation• CoordinatedCoordinated care of patient and care of patient and

family……family……

This is accomplished and demonstrated byThis is accomplished and demonstrated by

A Coordinated Plan of A Coordinated Plan of Care !!Care !!

• The hospice and nursing home must The hospice and nursing home must jointly coordinate, establish and jointly coordinate, establish and agreeagree upon a plan of care to be used by upon a plan of care to be used by both providers. both providers.

• The providers may develop one common The providers may develop one common care plan to be utilized by both care plan to be utilized by both providers, or two care plans following the providers, or two care plans following the documentation policies for each provider.documentation policies for each provider.

If there are two care If there are two care plans,plans,

when compared, when compared,

eacheach care plan care plan shouldshould

reflect reflect identificationidentification

of the following of the following points….points….

The The Coordinated Plan of Care Coordinated Plan of Care Must Reflect:Must Reflect:

• A common problem listA common problem list• Palliative interventionsPalliative interventions• Palliative goals / desired outcomes in Palliative goals / desired outcomes in

measurable termsmeasurable terms• Responsible provider Responsible provider • Schedule and frequency of actions Schedule and frequency of actions

• The POC must include the individual’s The POC must include the individual’s current medical, physical, psychosocial, current medical, physical, psychosocial, family and spiritual needs.family and spiritual needs.

A Coordinated Plan of CareA Coordinated Plan of CareRequires Requires thatthat : :

1.1. The hospice and the facility staff members The hospice and the facility staff members communicate with each other when any changes communicate with each other when any changes are indicated to the plan of care.are indicated to the plan of care.

2.2. Each provider must be aware of the other’s Each provider must be aware of the other’s responsibilities in implementing the plan of care.responsibilities in implementing the plan of care.

3.3. The hospice must approve any changes to the The hospice must approve any changes to the plan of care proposed by the facility staff prior to plan of care proposed by the facility staff prior to implementation. implementation.

4.4. Assumes extra efforts. Use common sense Assumes extra efforts. Use common sense approach. Ensure interdisciplinary team is approach. Ensure interdisciplinary team is involved and updated.involved and updated.

Coordinated Plan of CareCoordinated Plan of CareRequirements Requirements (continued)(continued)

• Evidence of this coordinated plan of care Evidence of this coordinated plan of care must be present in the clinical recordsmust be present in the clinical records of both providers. of both providers.

• All aspects of the plan of care should All aspects of the plan of care should reflect the hospice philosophy. reflect the hospice philosophy.

• The care plans are to be implemented, The care plans are to be implemented, evaluated, and subsequently evaluated, and subsequently updatedupdated to to meet the identified needs of the patient as meet the identified needs of the patient as changes occur.changes occur.

Coordinated Plan of CareCoordinated Plan of Carealso requires that:also requires that:

• The hospice and the nursing facility The hospice and the nursing facility coordinate care to assure the patient coordinate care to assure the patient does not experience a delay in receiving does not experience a delay in receiving needed drugs and treatment for optimal needed drugs and treatment for optimal palliation.palliation.

• The hospice works with the nursing The hospice works with the nursing facility to monitor the effectiveness of facility to monitor the effectiveness of treatments related to pain and symptom treatments related to pain and symptom control.control.

DocumentationDocumentation

Should provide Should provide evidence that the evidence that the patients are patients are receiving the receiving the appropriate level of appropriate level of hospice services to hospice services to meet their needs. meet their needs.

More on More on Documentation…Documentation…

• The patient’s record in the nursing home should be The patient’s record in the nursing home should be identified as belonging to a hospice patient. identified as belonging to a hospice patient.

• Copies of hospice informed consent and current physician Copies of hospice informed consent and current physician certification should be included in the nursing home certification should be included in the nursing home record. record.

• It is necessary to ensure that copies of all other hospice It is necessary to ensure that copies of all other hospice documents (previously agreed upon by both providers) are documents (previously agreed upon by both providers) are available and accessible to staff caring for the patient. available and accessible to staff caring for the patient.

• Both providers may document physician orders…….Both providers may document physician orders…….

However, implementation of changes to the plan of care resulting However, implementation of changes to the plan of care resulting from physician orders received by the facility must have prior from physician orders received by the facility must have prior hospice approval.hospice approval.

DocumentationDocumentation

*** Most importantly****** Most importantly***

The documentation and The documentation and plan of care must plan of care must reflect the patient’s reflect the patient’s current current status – status –

Which means it must Which means it must be updated !!be updated !!

Another piece of the Another piece of the puzzle….puzzle….

Assuring effective Assuring effective participation by all participation by all

levels of staff levels of staff requires that the requires that the hospice provide hospice provide

ongoing educationongoing education aimed at improving aimed at improving

efficiencies and efficiencies and understanding of understanding of experienced and experienced and new facility staff. new facility staff.

Ongoing EducationOngoing Education

• Hospice is responsible for orientation Hospice is responsible for orientation andand continuing education of the facility staff. This continuing education of the facility staff. This should include but is not limited to the following:should include but is not limited to the following:

– Hospice philosophy.Hospice philosophy.– Definition of the hospice benefit and services available.. Definition of the hospice benefit and services available.. – Introduction of core team members and their roles.Introduction of core team members and their roles.– Role of non-core services if assigned. Role of non-core services if assigned. – Discussion of Discussion of mutualmutual roles and responsibilities. roles and responsibilities.– Pain and symptom management.Pain and symptom management.– Medication management. Medication management. – When to notify hospice, including on – call availabilityWhen to notify hospice, including on – call availability– Care plan coordination requirements.Care plan coordination requirements.

Building a Successful Building a Successful RelationshipRelationship

• Optimizing the relationship between the Optimizing the relationship between the nursing facility and the hospice is dependent on nursing facility and the hospice is dependent on ::

– A specific, practical written agreementA specific, practical written agreement– Ongoing education Ongoing education – Continual communication, via clearly Continual communication, via clearly

identified channelsidentified channels– Evaluating the success of coordination Evaluating the success of coordination

of servicesof services

QuestionQuestions ?s ?

Contact InformationContact Information

Howard Schaefer, MSW, LCSWHoward Schaefer, MSW, LCSWActing Assistant Division DirectorActing Assistant Division Director

Bureau of Health SystemsBureau of Health SystemsDivision of Nursing Home Division of Nursing Home

MonitoringMonitoring517-334-8413517-334-8413