Barriers* to Providing Hospice Care in the Skilled Nursing Facility

1. Barriers* to Providing Hospice Care in the Skilled Nursing Facility *(PC = “Challenges or Opportunities”) Ronald S Duemler MD, MS, CMD

2. Three Main Categories of Challenge • 1. Clinical – both staff and patient issues • 2. Financial – both facility and patient issues • 3. Regulatory – Mostly facility issues

3. Clinical Issues • 1. Symptom Presentation • 2. Patient Social and Cultural factors • 3. Staff Cultural and Educational factors

4. Symptom Presentation • 1. Co-morbid Conditions • Dementia, Delirium, and Depression (the big Ds) • Sensory Impairment • 2. Terminology: Two people separated by a common language. • Provider: “Do you have any difficulty breathing?” • Patient: “No, but I am short of breath.” • 3. Atypical Presentations (ask staff) • functional change – cornerstone of Geriatrics • pain presentations

5. Nonspecific Signs and Symptoms that may Suggest the Presence of Pain (from AMDA CPG Pain Management in the LTC Setting) • Bracing, guarding, rubbing, frowning, grimacing, fearful facial expressions, grinding teeth, fidgeting • Changes in behavior: restlessness, agitation, striking out, decreased activity participation • Changes in function including ambulation, eating, sleeping • Changes in Cooperation with Personal Care such as moving extremities, position changes, dressing, bathing, toileting, transfers, feeding

6. Patient Social and Cultural Factors • 1. Communication dilemmas • more axes of communication/miscommunication: • doctor/patient, doctor/staff(x2), doctor/family • patient/staff(x2), patient/family, family/staff • staff(x2)/staff(x2), family/family • 2. Ethnic Overlays/Language Barriers • gender roles, religious issues, symptom identification • 3. Beliefs about symptoms or diseases.

7. Common Misconceptions among both Patients and Caregivers about Pain(from AMDA CPG Pain Management in the LTC Setting) • Pain is an inevitable part of aging and nothing can be done about it. • Elderly patients, especially the cognitively impaired have high pain tolerances. • Patients say they are in pain to get attention. • Patients that “don’t look like” they are in pain probably aren’t. • If the vital signs are normal, the pain can’t be significant. • People who use pain medicines are likely to become addicted. • Admitting pain is a sign of character weakness/bearing pain is a sign of character strength. • Pain is a punishment and may mean death is near. • Pain always means there is a serious disease. • Admitting pain may mean loss of independence and possibly invasive tests • Narcotics are the only way of treating pain. (italics mine)

8. Staff Social and Cultural Factors • Staff Education about symptom management • frequency of assessmet/expectation of treatments • available tools (see regulatory section as well) • which medicine to use when • Staff Beliefs about symptom management • “I don’t want to think I killed my patient” • Facility Subculture/lore – Crucially Important • Credit and Recognition for Care

9. Financial Challenges • 1. Facility Perspective • Best Payer Source • 2. Patient Perspective • Best Coverage

10. Mini-Diversion: Medicare Part A,B,&D • What pays for what, where, and how long • Part A Benefits • Acute care • Post Acute Care (Acute Rehab and Subacute Rehab) • Skilled Homecare • Hospice • Part B Benefits • Rehab • Doctor’s fees • Part D Benefits: Drugs (Not in Hospice)

11. Mini-Diversion II: DRGs, MDS, RUGs, OASIS • 1. DRG – Diagnostic Related Group • Hospital Reimbursement • 2. RUG – Resource Utilization Group • SNF Reimbursement based on subset of MDS • 3. OASIS – Homecare Reimbursement • conceptual blend of diagnosis and function

12. Facility Perspective • 1. First Choice/Best Reimbursement • Part A Post acute Rehab • 2. Second Choice/ Next Best Reimbursement • Private Pay (usually where Hospice patients fall) • 3. Better than an empty bed (usually) • Medicaid (sometimes where Hospice patients fall) • Hospice can equal higher risk of defaulting. • Especially when going from Rehab to Hospice

13. Patient Perspective • Common Misconceptions: (75%/50%) Standard Medicare • “I get 100 days of Medicare coverage after a hospital stay (no matter what) at full coverage.” • Reality: Medicare Rules: Coverage Requires meeting criteria and amount covered declines (i.e. copay increases) at intervals and 100 days is the yearly total. • If you had a qualifying hospital stay and continue to improve or require complex medical management (i.e. meet criteria) • 100% first 20 days, the 80/20 rest of 80 days • When applicable, comfort care on Part A still financially better for patients than Hospice since room and board is covered in skilled Part A benefit and not under Hospice benefit • Medicare HMO and Advantage Plans: Whole Different Story

14. Medicare Reality • Part A Qualification rapidly ends for stable comfort care patients. • With some Part A plans (HMO and Advantage Plans) medications can be subject to the plans authorization.

15. Regulatory Challenges (from AMDA Synopsis of Federal Regulations in the Nursing Facility ) • Large, Complex Issue • Background: 1987 Omnibus Budget Reconciliation Act • Refined slightly 1990 Omnibus Budget Reconciliation Act • Published in Code of Federal Regulations. • Interpretation of these Guidelines and applications for surveyors are found in the State Operations Manual. • Federal Reimbursement is tied to compliance. • Over 500 regulations making it as highly regulated as the nuclear industry and perhaps the most highly regulated industry. • State Regulations overlay the Federal Regulations • Enforced with annual surveys and complaint investigations • CMS contracts with state to survey both sets of regulations

16. Facility Survey Process • Annual Survey has roughly a 3 month window • Fire marshal and State surveyors come together. • sometimes a Federal team is also surveying the State team doing their survey and that makes everybody very tense • Deliberately designed to be surprise surveys • Deliberately designed to be adversarial and punitive • Multiple requests to make process collaborative and constructive – similar to JACHO - have been declined. • Complaint surveys equally random and can have just as broad a scope as the annual survey

17. Overall Regulatory Principles (from AMDA Synopsis of Federal Regulations in the Nursing Facility*) • Regulations require facilities to meet “the highest practicable physical, medical and psychological well-being” of every resident* • Any decline in the resident’s well-being must be demonstrably unavoidable.* (italics mine) • Facilities are expected to only admit residents for whom they are able to safely care and meet their needs.

18. Facility Care Structure • Minimum Data Set (MDS) Structures Care • 400 item classification which results in multi-domain risk assessments and care plans. • Any providers participating in care must have care plans that are integrated with the facility care plans • Sentinel Events – Uniquely defined for SNF • Always mean a qualitative failure of nursing care • 3 events and only one risk stratified • fecal impaction • dehydration • Pressure sore in a low risk patient

19. More on Sentinel Events • Being terminally ill is no excuse for having a sentinel event. (remember overall principles) • Corollaries: • Hard stool in the rectum should never be described as an impaction unless it is causing an obstruction syndrome. • Dehydration in the SNF is defined as Output exceeding Input so quit measuring I&O. • End of life patients should always be described as high risk for pressure sore and if they occur should be charted as unavoidable (presuming this is accurate)

20. Common Areas of Dissonance • Designated Decision-makers • Advanced Directives • Psychoactive medications • Communication • Communication • Communication

21. Decision making and Advanced Directives • Typically facilities have more rigid documentation needs for this. • “Full Code” on Hospice very difficult for SNF based on regulatory issue of meeting needs – appears inherently contradictory to care plan

22. Medication Usage • Psychoactive Medication Use – even for nontraditional and off-label uses needs extensive (usually formal) risk-benefit documentation. • “PRN” meds need specific instructions – which symptoms, how often and in this setting are expected to be truly patient initiated. • if you don’t expect the patient to be able to ask for the med – consider scheduling it.

23. Communication • Working relationships develop over time but they have to start well. • Offering to attend the care plan meetings with facility staff, patients, and patients’ families build enormous good will (Care plan meetings are a formal regular activity for facilities) • Providing staff education can be an extremely valuable bridge for better collaboration.

24. Final Thoughts • The importance of understanding the care environment lies in being able to give the patient the best care, while helping assure the facility is able participate in that best care and stay compliant with their regulatory framework.