Coordinated Care for Hospice Patients in a Nursing Home Setting

1. Coordinated Care for Hospice Patients in a Nursing Home Setting Presented by: Karen Anthony, RN, MA, LLP Howard Schaefer, MSW, LCSW

2. Learning Objectives • Identify CMS policy on hospice care for nursing home residents • Identify the responsibilities of each provider caring for the resident who elects hospice • Explain the importance of a coordinated plan of care (POC) in the nursing home setting. • Identify methods for optimizing the relationship between hospice and the nursing facility.

3. All nursing homes should provide or make available to residents end of life alternatives.The federal regulations offer guidance under F-Tag 309: • The Hospice provider and the Nursing Home must communicate. • The Hospice and Nursing Home must establish a coordinated Plan of Care for both providers.

4. The Plan of Care is based on the resident’s assessment. • The Plan of Care must include how to manage pain and other care needs and be updated to reflect the resident’s current condition. • The POC must designate which services the facility and the Hospice will provide in meeting the needs of the resident in hospice care.

5. The Survey Process will evaluate: • Does the POC reflect participation of the hospice, facility and patient to the extent possible. • Are directives for managing pain revised and updated as needed in consultation with the resident and/or resident advocate and hospice staff. • Does the resident have the necessary drugs and medical supplies needed for palliation in managing the terminal illness and related conditions. Primarily responsibility of hospice agency but in consultation with resident and facility staff. • Reference F-309 (Guidance for Hospice)

6. Survey process continued: • Are the hospice and facility communicating when changes are indicated in the POC. • Does the hospice and facility know the other’s responsibilities related to resident care as identified in the POC.

7. Survey Process continued • Are the SNF/NF services or personal care being delivered as needed to the hospice resident. • Does the SNF/NF offer the same services to residents who have chosen hospice as it offers to residents who have not chosen hospice.

8. SO WHAT DO WE LOOK FOR? • ■ Is Hospice Offered? If not, the facility still has some responsibility to provide end of life intervention. Informed consent. • ■ Are end of life needs being met? (Clinical Process Guidelines) • ■ What is the ongoing system of communication?

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

10. What guidance/direction is in place to ensure that caregivers know WHO does WHAT? • How is hands-on care being communicated between facility and hospice caregivers (i.e.; ADL’s). • Are facility and hospice staff aware of where to access information regarding resident care.

11. INTERVENTIONS: • Are they appropriate? • Are they being implemented? • Consistently?

12. 42 CFR 418.112 Hospice Condition of Participation: • New CoP’s for Hospices became effective in December of 2008 • 418.112 defines the standards that a hospice providing hospice care to patients of a SNF / NF must abide by.

13. In future, new F Tags and/or guidance related to hospice patients residing in a nursing home: • New F tags/guidance being written at present by a CMS work group to address the special situation of “hospice in a nursing home”…… • --companion requirements and/or process for LTC to correspond with the hospice requirements • --expected roll-out unclear at this time • Both the facility and hospice must comply with their own regulations.

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

15. The written agreement must include, but is not limited to the following: • A provision that it is the hospice’s responsibility to provide services at the same level and to the same extent as if the patient were in his or her own home. • A provision that it is the facility’s responsibility to continue to furnish 24 hour room and board care, meeting the personal care and nursing needs that would have been provided by the primary caregiver at home. • A delineation of the hospice’s responsibilities, some examples of which are: medical management related to the terminal diagnosis, nursing, counseling, social work, provision of medical supplies, DME equipment and drugs

16. Contract Provisions (continued) • A provision that hospice core services must be routinely provided by the hospice, and cannot be delegated to the facility. Hospice may use the facility nursing personnel to assist in the implementing the plan of care only to the extent that the hospice would routinely use the services of a hospice patient’s family. • Core services include: • Physician services • Nursing services • Medical social services • Counseling services • Hospice may not contract with the nursing home to provide core services.

17. In addition, the hospice and nursing facility should define in the written agreement: • How communication between hospice and facility staff will occur: • The manner in which the hospice and facility are to communicate with each other to ensure the patient’s needs are met 24 hours a day. • A provision that the facility immediately communicate with the hospice if a significant change in patient condition occurs. • How documentation in the clinical record will occur. • How development of a coordinated plan of care will occur.

18. After the written agreement is established the process may proceed… Patient resides in a nursing home facility…… The patient / resident meets eligibility requirements and elects the Hospice benefit…….. The patient is admitted to the hospice…… The hospice then assumes full responsibility for “professional management” of the individual’s hospice care in accordance with the hospice CoP’s.

19. What is Professional Management ? • The term “professional management” for a hospice patient who resides in a facility has the same meaning that it has if the hospice patient were living in his / her own home. • The hospice assumes the “professional management” duties of assessing, planning, monitoring, directing and evaluating the patient’s hospice care across all settings. • The facility staff, from the viewpoint of the hospice, assume the role of the patient’s primary caregiver… or in other words “family.”

20. Responsibilities of the Hospice • Ongoing patient assessment. • Monitoring, care planning and coordination by the interdisciplinary group. • Coordinating the plan of care with the nursing home facility. • Coordination by the hospice RN of the implementation of the plan of care. • Consultation about the patient’s care with facility staff. • Determining the appropriate level of care to be given the patient. • Coordination and provision of any needed general inpatient or continuous care. • Financial responsibility for, and provision of (in a timely manner), all medical supplies, appliances and medications related to the terminal illness.

21. Hospice must: • (L777) …designate an IDG member responsible for coordination of hospice care with representatives of the nursing home • --may be an RN, social worker, counselor • --this role is aimed at broader coordination and troubleshooting

22. Examples of areas coordinator might focus on: • --are each providers’ plans and goals complementary and reflective of hospice intent • --does documentation show coordination? Is documentation easy to access? • --are physician orders obtained and implemented according to plan of care and written agreement? • --do aspects of the written agreement need to be reviewed between the parties?

23. More examples: • Is a discussion of potential hotspots, such as use of anti-psychotics by the hospice, part of written agreement negotiations? • Is written agreement updated to anticipate and clarify hotspots? • Do medical directors communicate? Can this be facilitated to clarify aspects of the written agreement?

24. Overall Goal of the Designated Hospice IDG member is to: • …coordinate approaches of the hospice and the nursing home • …to ensure effective communication about patients • …and to ensure that outcomes are monitored and evaluated

25. Responsibility of the Facility To provide services by qualified staff, consistent with professional standards of practice. These services include: • Personal care services • Supervision / Assistance with ADL’s • Administering medications • Social activities • Room cleanliness • Assistance with durable medical equipment use andprescribed therapies more…….

26. The facility responsibilities also include: • Ongoing assessment of the patient. • Notifying hospice when the patient has a change in condition. • Notifying the attending physician and family when the patient has a change in condition. • Notifying hospice when the patient needs are not being met (i.e. spiritual, psychosocial) • Coordinating the plan of care with the hospice. • Orienting hospice staff to the facility. • Requesting orientation of new facility staff by the hospice. • Maintaining RAI / MDS. Regulations for completion and submission of RAI / MDS data do not change when the patient / resident elects the hospice benefit.

27. Joint Responsibilities • Patient rights & responsibilities • Confidentiality • Ongoing assessment • Quality assurance • Clinical documentation • Coordinated care of patient and family…… This is accomplished and demonstrated by

28. A Coordinated Plan of Care !! • The hospice and nursing home must jointly coordinate, establish and agree upon a plan of care to be used by both providers. • The providers may develop one common care plan to be utilized by both providers, or two care plans following the documentation policies for each provider.

29. If there are two care plans, when compared, each care plan should reflect identification of the following points….

30. The Coordinated Plan of Care Must Reflect: • A common problem list • Palliative interventions • Palliative goals / desired outcomes in measurable terms • Responsible provider • Schedule and frequency of actions • The POC must include the individual’s current medical, physical, psychosocial, family and spiritual needs.

31. A Coordinated Plan of CareRequires that : • The hospice and the facility staff members communicate with each other when any changes are indicated to the plan of care. • Each provider must be aware of the other’s responsibilities in implementing the plan of care. • The hospice must approve any changes to the plan of care proposed by the facility staff prior to implementation. • Assumes extra efforts. Use common sense approach. Ensure interdisciplinary team is involved and updated.

32. Coordinated Plan of CareRequirements (continued) • Evidence of this coordinated plan of care must be present in the clinical records of both providers. • All aspects of the plan of care should reflect the hospice philosophy. • The care plans are to be implemented, evaluated, and subsequently updated to meet the identified needs of the patient as changes occur.

33. Coordinated Plan of Carealso requires that: • The hospice and the nursing facility coordinate care to assure the patient does not experience a delay in receiving needed drugs and treatment for optimal palliation. • The hospice works with the nursing facility to monitor the effectiveness of treatments related to pain and symptom control.

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

35. More on Documentation… • The patient’s record in the nursing home should be identified as belonging to a hospice patient. • Copies of hospice informed consent and current physician certification should be included in the nursing home record. • It is necessary to ensure that copies of all other hospice documents (previously agreed upon by both providers) are available and accessible to staff caring for the patient. • Both providers may document physician orders……. However, implementation of changes to the plan of care resulting from physician orders received by the facility must have prior hospice approval.

36. Documentation *** Most importantly*** The documentation and plan of care must reflect the patient’s current status – Which means it must be updated !!

37. Another piece of the puzzle…. Assuring effective participation by all levels of staff requires that the hospice provide ongoing education aimed at improving efficiencies and understanding of experienced and new facility staff.

38. Ongoing Education • Hospice is responsible for orientation and continuing education of the facility staff. This should include but is not limited to the following: • Hospice philosophy. • Definition of the hospice benefit and services available.. • Introduction of core team members and their roles. • Role of non-core services if assigned. • Discussion of mutual roles and responsibilities. • Pain and symptom management. • Medication management. • When to notify hospice, including on – call availability • Care plan coordination requirements.

39. Building a Successful Relationship • Optimizing the relationship between the nursing facility and the hospice is dependent on : • A specific, practical written agreement • Ongoing education • Continual communication, via clearly identified channels • Evaluating the success of coordination of services

40. Questions ?

41. Contact Information Howard Schaefer, MSW, LCSW Acting Assistant Division Director Bureau of Health Systems Division of Nursing Home Monitoring 517-334-8413