Hospice Inpatient Care - California State Hospice Association

9/23/2010
2010 CHAPCA Annual
Conference
Session 3C: Hospice Inpatient Care –
Options in Today’s Market
Presenters
Facilitators:
• Holly Swiger, RN, MPH, PhD & VP
VITAS Healthcare Corporation
• Brenda Klütz, Senior Consultant
Health Management Associates
Panelists:
• Vanessa Bengston, RN, CPHQ & Executive Director
Hospice of the Foothills (Grass Valley)
• Audrey Flower, Executive Director
Madrone Hospice (Yreka)
• Sharon O’Mary, Executive Director of Patient Care Services
San Diego Hospice
Session Goals:
• Learn how inpatient care fits into the
continuum of hospice care
• Learn of federal certification and state
licensing options for providing inpatient care
• Learn of creative options and alternatives for
providing inpatient care
• Learn from the experience of other hospice
providers who operate hospice homes and
provide both residential and inpatient care
• Questions and Comments
1

9/23/2010
Portability of Hospice Care
• The portability of hospice services is a
strength, but it can also become
complicated
• The type of care that is provided
• The place in which the care can be
provided
Types of Hospice Services
• Routine Care
• Continuous Care
• Short-term General Inpatient (symptom
management & pain control)
• Inpatient Respite Care
Where Hospice Services can be
Provided: Routine Care
• Home
• Residential Care
• Health Facility
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Where Hospice Services can be
Provided: Continuous Care
• Home
• Residential Facility
• Health Facility (excluding a hospital)
Where Hospice Services can be
Provided: Short-term Inpatient
• 42 CFR § 418.108 – COP: Short-term
inpatient care.
• Must be provided in a Medicare or
Medicaid facility
Where Hospice Services can be
Provided: Short-term Inpatient
Inpatient care for symptom management and pain control –
must be provided in one of the following:
• A Medicare-certified hospice that meets the CoP for
providing inpatient care directly (§418.110)
r
• A Medicare-certified hospital or skilled nursing facility
that also meets §418.110(b) & (e) regarding 24-hour
nursing services and patient areas
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Where Hospice Services can be
Provided: Short-term Inpatient
Inpatient care for respite must be provided in one of the following:
• A Medicare-certified hospice that meets the CoP for providing
inpatient care directly (§418.110)
• A Medicare-certified hospital or skilled nursing facility that also
meets §418.110(b) 110(b) & (e) regarding 24-hour nursing services and
patient areas
• A Medicare or Medicaid-certified nursing facility that also meets
§418.110(e)
Federal Certification Requirements:
Condition of Participation (COP)
• 42 CFR § 418.110: COP: Hospices that
provide inpatient care directly.
• In its own facility
State Licensing Options for Providing
Inpatient Care
• Hospital
• Skilled Nursing Facility
• Intermediate Care Facility
• Congregate Living Health Facility
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Challenges to Providing Inpatient
Care Directly
Hospice providers must ensure that their
facility meet state requirements:
• Health facility licensing requirements
• Building standards
• Retail Food Act standards (unless food is
being prepared offsite)
Challenges to Providing Inpatient
Care Directly
Hospice providers must ensure that their facility
meet certification requirements:
• For category of facility (hospital, SNF, ICF,
CLHF)
• For hospice CoPs such as Life Safety Code
and other standards under §418.110
Challenges to Providing Inpatient
Care Directly
Hospice providers may also choose to be
accredited by an accrediting organization
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Challenges to Providing Inpatient
Care Directly
State Oversight requires that the facility be
surveyed for:
• Compliance with state licensing
requirements
• Compliance with federal certification
requirements, including a life safety code
survey
Inpatient Care in a Hospital
• In a hospital with services provided by the
hospital, under arrangement/contract with a
hospice
• In a hospital with services provided directly by
the hospice, under arrangement/contract
• A hospice provider can provide inpatient care
directly by being licensed as a hospital
• One such hospital in California
Inpatient Care in a SNF
• In a SNF with services provided by the SNF,
under arrangement/contract with a hospice
• In a SNF with services provided by a hospice,
under arrangement/contract
• A hospice provider can provide inpatient care
directly by being licensed as a SNF
• One such SNF in California that has been
formally identified
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Inpatient Care in an ICF
• In an ICF with services (except GIP) provided by the ICF,
under arrangement/contract with a hospice
• In a ICF with services provided directly by a hospice,
under arrangement/contract
• A hospice provider can provide inpatient care directly by
being licensed as an ICF
No ICF has been formally identified as providing inpatient care
directly in CA
Inpatient Care in a CLHF
• A hospice provider can provide inpatient care
directly by being licensed as an congregate
living health facility (CLHF)
• While there are 13 CLHFs licensed to hospice
providers, not all provide inpatient level of
care
Providing GIP “inside” another
health facility
Federal CoPs clearly acknowledge that a
hospice can lease space from a
healthcare facility and operate their own
hospice facility
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9/23/2010
Providing GIP “inside” another
health facility
• If a health facility allows the hospice to use
space under an Outside Resources Contract,
those beds remain licensed to the host facility
• The hospice must meet all of the licensing
requirements for the host facility as well as
those for the hospice
Providing GIP “inside” another
health facility
A hospice cannot have an Outside
Resources Contract for a portion of the
beds in a CLHF
CLHFs must be free-standing by state law
Inpatient Care in Residential Care
Facilities?
• The federal CoPs state that a hospice must provide
inpatient care directly in its own facility.
• The CoPs do not specify that the facility needs to be a
health facility
• There have been no residential facilities that have been
formally identified as providing inpatient care directly.
Stay Tuned!
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Questions or Comments?
9

Contracting for Inpatient Care
Holly Swiger, RN, MPH, PhD
VP of Public Affairs
VITAS Healthcare Corporation
CHAPCA Regulatory Committee Chair
Holly.Swiger@VITAS.com
1
What Level of Hospice Care Can Be Provided
in What Inpatient Setting?
License Type GIP Respite Continuous
Care
Routine
Hospital C/O C/O No C/O
Special Hospital: Hospice C/O C/O No C/O
Skilled Nursing Facility (SNF) C/O C/O C/O C/O
Intermediate Care Facility (ICF) O C/O C/O C/O
Congregate Living Health Facility
(CLHF)
Residential Care Facility for the
Chronically Ill (RCFCI)
O O C/O C/O
No No C/O C/O
Residential Care Facility for the
Elderly (RCFE)
No No C C
Adult Residential Facility (ARF) No No C C
C = Contracted O = Operated
If IPU is operated by the Hospice, it can do GIP or CC, but not both.
2
Who needs a contract?
• Anytime your hospice enters a relationship
where there is a need to clarify the
expectations of the relationship.
• This is done with either a contract or written
agreement:
– Patient Election
– Hospital/SNF Contract for GIP/Respite
– Nursing Home contract for routine care
– Assisted living facilities for routine care
– Hospice unit in a host facility
3
1

Types of Contracts for Inpatient Beds
4
Scatter Beds
• Hospice contracts with a facility to provide
care in whatever beds are available and
where the host facility chooses to place the
patient.
– General Inpatient Care scatter beds
• The hospital, skilled nursing facility or hospice (licensed
as either of these or as a congregate living health
facility)
– Respite scatter beds
• The hospital, nursing facility, intermediate care facility or
hospice (licensed as one of the above or a congregate
living health facility)
5
Scatter Beds
• Easiest to contract.
• Most difficult to keep host facility staff
educated.
• Difficult to obtain, in under bedded areas.
• Hospice GIP & Respite reimbursement is
far below hospital reimbursement.
• Hospice Respite reimbursement is below
SNF Medicaid reimbursement in some
areas.
6
2

Scatter Beds
• For GIP, the Host facility must provide
RN 24/7 and levels of staffing equivalent
to meet the needs of patients in crisis.
• This level of care and intervention must
be clearly l documented.
d
• Hospice staff must visit every day to
assure management of care and
documentation.
7
Dedicated Hospice Beds Under Contract
• Contracted General Inpatient Care or Respite
dedicated beds in a host facility.
• Could be a couple of rooms or a wing.
• Hospice guarantees payment per day (holds
the bed for only hospice patients).
• Hospice pays for ancillary services based on
days of care (dietary, linen, housekeeping,
etc.).
• Contracted with the same facilities as float
beds.
8
Dedicated Hospice Beds Under Contract
• Hospice can create a more home like
environment.
• Dedicated host facility staff creates greater
ease of training.
• Dedicated and educated staff may require less
oversight.
• Better overall experience for patient/family.
• Guaranteed income for the Host facilities.
• If beds are not utilized, it is costly for the
hospice.
9
3

Hospice Operated Unit in a Host Facility
• Hospice operates a unit in a host facility
under an Outside Resources Contract.
• The beds remain licensed to the host facility.
• Hospice gets it added to its program license
(COP §418.108 and 418.110)
• Hospice operates the unit.
• Hospice may contract for staffing from the
host facility.
10
Hospice Operated Unit in a Host Facility
• No bricks and mortar investment.
• Decorate it to suit patient/family needs.
• Staff are hospice trained.
• May contract with facility for staffing.
• Less need for daily hospice visits.
• Must keep unit occupied to break even.
11
Hospice Operated Unit in a Host Facility
• Steady income for host facility.
• Potential referrals from host facility.
• Must keep unit occupied to break even.
• Survey risk and potential fines for the
host facility.
• More difficult to find a host facility
willing to enter this contractual
arrangement in CA.
12
4

Hospice Operated Units/Facilities
• San Diego Hospice – Sharon O’Mary
– Special Hospital: Hospice
– Contracted Hospice Unit in a SNF
• Madrone Hospice – Audrey Flower
– CLHF (Residential Care)
• Hospice of the Foothills – Vanessa Bengston
– Congregate Living Health Facility
13
Questions?
14 Selected Statistics 4-2010
5

Sharon O’Mary
(619) 278-6286
somary@sdhospice.org
Inpatient Unit Comparison
ICC and GlenBrook Care Centers
SDHIPM has two inpatient care centers, staffed entirely by its own employees. SDHIPM MDs and
NPs provide daily visits. Skilled pain and symptom management is provided on either unit with
access to infusions, medications, and other therapies.
License/Beds
Levels of Care
Staffing Matrix
Challenges
Positive
Outcomes
Pharmacy
Inpatient Care Center
4311 Third Avenue
San Diego, CA 92103
Special Acute Care Hospital
24 beds
Primary teaching site for Institute for
Palliative Medicine
General Inpatient – Hospice
DRG Admission – Palliative Care
Adheres to RN staffing ratios required
for acute care hospital.
75 staff
Manager + Charge RN (patient free)
Unit Medical Director + 2 Attending
physicians + NP
RN 1:4
CNA 1:6
MSW 1:12
SPC 0.8:12
Unit clerk 1:12
Licensing – Permanent Pilot Acute
Hospital and ongoing adherence to
regulatory requirements
Organized Medical Staff
Cost
Internal competition for limited beds
Quality.
Total control of palliative setting,
treatment protocols & integrative
therapies, operations, staffing,
expenses.
Certified palliative physicians.
Academic setting for all disciplines.
Physical identity for hospice in San
Diego. .
On Site. Pharmacist consultation on
daily rounds.
GlenBrook Care Center
1950 Calle Barcelona
Carlsbad, CA 92009
Skilled Nursing Facility
12 beds, leased
General Inpatient - Hospice,
Respite - Hospice.
2 licensed nurses all shifts,
regardless of census
Charge Nurse (patient assignment)
24 staff
Attending physician + NP
RN 1:6
CNA 1.6
MSW 0.5:12
SPC 0.4:12
Unit clerk 1:12
Licensing – SNF regulations &
culture (Medication, age,
documentation and care planning,
removal of body, consent process,
MDS completion)
Semi-private rooms – beds limited by
isolation precautions, gender
Space for private conversation
Short stay “residents” (ALOS 8 days)
DHS consent for automated
medication dispensing system
(Pyxis)
Cost - Staffing for fluctuating census
Quality.
Control of palliative setting, treatment
protocols, operations, staffing
Partnership with premiere Continuing
Care Community in north county.
Certified palliative physicians.
Pyxis – managed by SDHIPM
Pharmacy. Pharmacist consultation.

Sharon O’Mary
(619) 278-6286
somary@sdhospice.org
Consent for
Treatment
Room
Occupancy
Visitors
Patient/DPOA must sign prior to
transfer to unit
Private
Families may stay overnight. Pull-out
couch available in each room.
Patient/DPOA must be available to
sign consents upon arrival on unit.
Verbal consent OK for 24 hours,
followed by signed consent.
Semi-private, 2 beds per room.
Arrangements for private room
($350/day) can be made.
One person may spend night on
recliner in room. Others may sit in
lounge, but are not allowed to sleep
in facility.
Admit adults only. Children welcome
to visit.
Children May admit newborns, adolescents and
young adults.
Pets OK with supervision OK with supervision
Resuscitation Must be DNR DNR not required. 911 called.
Oxygen Oxygen >10L/min Oxygen via concentrator and tanks.
Not available >15L/min
Compassionate Yes
No
Extubation
TB Isolation Yes No. Prior +PPD requires CXR that
rules out TB or 3 negative sputums.
Blood
Yes
No, storage not permitted
Transfusions
Multiple Yes
Evaluate, case by case.
complex
therapies
Behavioral
problems /
Suicide
ideation
Non-SDHIPM
admits
Integrated
Therapies
Palliative psychiatry on site
Non-hospice palliative care admissions
Massage, Acupuncture, Hydrotherapy,
Energy
Aroma, Pet, Music, Art Therapies
Psych consult can be arranged.
Required psych assessment or
transfer to ER for suicide ideations.
North Coast Hospice GIP admits per
contract

Madrone Hospice, Inc.
255 Collier Circle
Yreka, CA 96097
Presenter:
Audrey Flower, MA
Executive Director
(530)842-3160)
Siskiyou County 5 th largest county in CA
Population 45,000
“Frontier”
Yreka‐ County Seat Population 7,000
Madrone Hospice House
Madrone Hospice is a very small community‐based program
ADC – 33
ALOS – 58 days
Serve 60% of all deaths
No competition
Situation in 1999 when we built the Hospice House
3 SNF’s county‐wide, no Assisted Living Facilities
Limited options for hospice patients unable to remain at home
Madrone Hospice House
6 beds (shared baths)
CLHF Licensure
90% occupancy
Room & Board ‐ $145/day
Negotiate reduced rates
Limit stay to 30 day transitional period at “greatly” reduced pay
Levels of Care
Routine Home Care (option for Continuous Care)
No Inpatient Care
Staffing
Director of Patient Services as p/t Hospice House Administrator
LVN ‐ am/pm/NOC
CNA – am/pm/NOC
1/2x cook/housekeeping coordinator
Prepares food, coordinates housekeeping
CNA's provide light housekeeping and laundry
Part‐time activities coordinator (2 hours/wk)
Pharmacist & Dietitian contracts for drug disposal and menu oversight

Hurdles
‐ No reimbursement source/Private pay only @$145/day
‐ Charging a fee for any related services to hospice patients
‐ Plan to supplement income by +/‐ $100,000/yr (hospice shop sales/memorial donations)
‐ Developing appropriate EOL nutrition guidelines
‐ Developing appropriate EOL activity guidelines
‐ Low occupancy due to Room & Board cost
‐ Hesitancy by physicians & D/C planners to make referrals based on ability to pay
Positive outcomes
‐ Increased memorial donations
‐ Improved visibility
‐ Hospice House Care Fund as an opportunity
‐ Community pride
‐ Perfect option for hospice patients and caregivers as needed
‐ Recognized model for a Hospice House

CHALLENGES REWARDS