Hospice in ECF Handout - Home Care Information Network

HOSPICE EDUCATION NETWORKProviding Hospice in Extended Care Facilities by Carla BravemanProviding Hospice Servicesfor Residents of ExtendedCare FacilitiesCarla Braveman, RN, M.Ed, CHCEBig Bend Hospice, Tallahassee FLCopyright © 2007Download Handouts Remember to download the handouts Click the LINKS button Handouts are in PDF Format You can print them out for use duringthe program Let’s beginCopyright © 2007OBJECTIVES Explain how hospices use the Center forMedicare and Medicaid Services (CMS)Best Practices letter of 2002 to support theirwork in extended care facilities (ECF) List two reasons why hospice programsmay choose not to serve patients in ECF Describe two tips related to communicationand relationship building for ECFCopyright © 2007HEN Copyright 2007www.hospiceonline.com1

HOSPICE EDUCATION NETWORKProviding Hospice in Extended Care Facilities by Carla BravemanHISTORY Omnibus Budget Reconciliation Actsof 1985 & 1989 allowed Hospice carein facilities as home care day rate Census today ranges 0% - 60% AARP projects 7 out of 10 will spendsome time in NH’s after age 65Copyright © 2007CONCERNS Operation Restore Trust (ORT) 1997 Fear of double dipping Fear of 488’s - AdditionalDevelopment Requests (ADR) Fear of fraud and abuse Staff did not like it anywayCopyright © 2007Quality of Life IssuesGAO study 1999-2000Hospice Patients vs. other NH patients: Better pain assessment and treatment – 2times more likely to get narcotics for daily pain Less likely to be hospitalized More likely to have dyspnea treated More likely to have depression/anxiety treated Less likely to be restrained, receive tube orparenteral feedings, IM or IV Meds, therapyCopyright © 2007HEN Copyright 2007www.hospiceonline.com2

HOSPICE EDUCATION NETWORKProviding Hospice in Extended Care Facilities by Carla BravemanTIME TO RECONSIDER Improved quality of life for resident/family Patients have a right to accessservices Impact on CensusCopyright © 2007CMS Best Practices Letter May 10, 2002 Promising Practices for Implementingthe Medicare Hospice Benefit forNursing home Residents Sent to State Survey Directors andRegional OfficesCopyright © 2007LET’S LOOK AT Contract Education Care Plan Management Relationship building MD orders Written Communication PI or QA activities Compliance PlanCopyright © 2007HEN Copyright 2007www.hospiceonline.com3

HOSPICE EDUCATION NETWORKProviding Hospice in Extended Care Facilities by Carla BravemanContracts Initiates the relationship Specify responsibilities: Hospice Facility Shared Specify payment structure/ timelines/ $ Specify term Must be signed prior to providing careCopyright © 2007Responsibilities: Facility 24/7 Room and Board Comply with life safety codes Show respect for the patient and carefor them w/ dignity 24/7 visiting hours including kids Provide meal services Allow personal belongingsCopyright © 2007Responsibilities: Facility, cont. Participate in the development of thecare plan Notify Hospice of change in condition Provide medications, medicalequipment, supplies, and otherservices for non-hospice diagnosis(based on payer)Copyright © 2007HEN Copyright 2007www.hospiceonline.com4

HOSPICE EDUCATION NETWORKProviding Hospice in Extended Care Facilities by Carla BravemanResponsibilities: Hospice Professional care management Development of the plan of care RN oversight for the planimplementation Admit and discharge decisions Orientation / education for facility staff 24/7 core services availableCopyright © 2007Respnsibilities: Hospice cont. All medications, supplies, equipment,inpatient days and outpatient services,related to the terminal diagnosis andincluded in the hospice plan of care(based on payer) Ensure that pts are eligible for admitand recertificationCopyright © 2007Joint Responsibilities Care of patient and family Resident rights and confidentiality Employer responsibilities Liability, insurance, risk management Clinical documentation Communication Marketing/ PRCopyright © 2007HEN Copyright 2007www.hospiceonline.com5

HOSPICE EDUCATION NETWORKProviding Hospice in Extended Care Facilities by Carla BravemanPurchasing Services Non Core Services can be purchased fromNH – specify in contract Must not be customarily included in R&B Therapy services, Medications, Oxygen, etc Must be at fair market value Hospice must authorize in advance and bein the Plan of CareCopyright © 2007Financial Responsibilities Must be clearly stated Complex -depends on the paymentsources Who pays for what- room and board,medications, supplies, equipment,therapy services, etcCopyright © 2007Dually eligible beneficiaries Medicare and Medicaid 36+ states have Medicaid Hospice Benefit Room/Board is paid by Medicaid Hospice is paid by Medicare Pass through billing for most states Not more than 95%-100% of what theywould have been paid (Office of InspectorGeneral)Copyright © 2007HEN Copyright 2007www.hospiceonline.com6

HOSPICE EDUCATION NETWORKProviding Hospice in Extended Care Facilities by Carla BravemanOther Payment Scenario’s Medicaid for both NH and Hospice Medicare for Hospice, Private pay forNH Medicare for Hospice, Privateinsurance for NH Never Medicare for NH and Hospiceunless unrelated condition Contract must address eachCopyright © 2007Details Required For each payment arrangement, youmust specify in the contract: how to bill, time requirements for billing and paying amount of payment for dually eligiblebeneficiariesCopyright © 2007Education Hospice is responsible for orientationand continuing education - examples Pain and symptom management What is hospice Ethical considerations Role of the nurses aides Care plan coordination Death and dyingCopyright © 2007HEN Copyright 2007www.hospiceonline.com7

HOSPICE EDUCATION NETWORKProviding Hospice in Extended Care Facilities by Carla BravemanEducation, Cont Get CEU’s ( RN, SW) or certificates (CNA)for staff to encourage attendance Say why you are there – address thetension from the facility staff that you aregoing in and taking their job Initial and ongoing education plan Gives you opportunity to build relationshipsCopyright © 2007Care Plan Management Hospice IDT and Facility staff do thiswith patient and family Facility and Hospice plans don’t haveto be identical Goals cannot contradict Facility is more detailed day to day Copies in each record Cosign them to show coordinationCopyright © 2007Nursing Home Regulations NH regulations promote rehabilitationand / or maintenance of the patients’current status Hospice promotes quality of life Orders and Care plan can addressthese issues Both NH and hospice regulationsrespect the rights of the patientCopyright © 2007HEN Copyright 2007www.hospiceonline.com8

HOSPICE EDUCATION NETWORKProviding Hospice in Extended Care Facilities by Carla BravemanExample of Orders No hospitalization No IV medications or fluids No monthly weights No routine blood work No antibiotics Patient can stay in bed if desired Offer food, no feedingCopyright © 2007Relationship Building Needs ongoing focus at NH and withhospice team Some NH staff don’t want you On their turf Their day is already too complex Hospice staff don’t like the NH Always new staff Cannot find right person Don’t like the care they provideCopyright © 2007Helpful Tips Assign specific hospice staff to eachfacility Have all staff and volunteers check inwith and report out at nurses station Discipline specific contact at each visit Regular contact with administrator,Nursing Director, SW staff, Admitstaff, pastoral careCopyright © 2007HEN Copyright 2007www.hospiceonline.com9

HOSPICE EDUCATION NETWORKProviding Hospice in Extended Care Facilities by Carla BravemanHelpful Tips Care plan meeting attendance Invite to hospice team Have hospice team at the facility Memorial services at facility Condolence cards Say ‘Thank you’Copyright © 2007Helpful Tips Work with your hospice team EducateVolunteers, Aides, and licensed staff Talk about difficulties at team meeting Have ‘cheat sheet’ per facility How to order meds/ from who How to order oxygen and supplies/from who Numbers, names, layout within the facility How to get into the building after hours, where topark, etcCopyright © 2007MD orders Most facilities will not allow hospiceRN to write MD verbal orders in thefacility record Causes extra work for MD and RN Anticipate progression and haveorders on hand, protocols, etc Sometimes, Hospice will call MD, thenfacility needs to validate order fromMDCopyright © 2007HEN Copyright 2007www.hospiceonline.com10

HOSPICE EDUCATION NETWORKProviding Hospice in Extended Care Facilities by Carla BravemanCommunication Facility has three shifts, with new staff,pool staff, float staff Difficulty with communication of theplan of care, of changes in status, andfor hospice to be professional caremanager Problem areas – supply and paymentof medications, MD orders,hospitalizations, tests, ED trips, etcCopyright © 2007Helpful Tips Sticker on outside of chart ( Hospice) Sticker / card in medication cardex Sticker on name boards, etc Hospice number next to phone Mirror NH’s HMO/ managed careprocess Color coding of notes, stickers, etcCopyright © 2007Performance Improvement (PI) Sit on each others’ PI committee Create Hospice and NH joint PIcommittee NH only PI projects Include NH pts in hospice PI projects Satisfactions survey for NH’s, NHhospice patients/families, MD’s Trend hospitalizations, falls, etcCopyright © 2007HEN Copyright 2007www.hospiceonline.com11

HOSPICE EDUCATION NETWORKProviding Hospice in Extended Care Facilities by Carla BravemanCorporate Compliance Plan Initial and ongoing assessment isdocumented Care plans demonstrate coordination Hospice care plan identifies scope andfrequency of services Care plan is reviewed and updated to meetneeds Contracts are in place prior to care fordually eligible P/P in place for access of non-hospicerecordsCopyright © 2007Compliance Plan Cont No free care, free services, freeconsultation Non-core services purchased at market Don’t buy what is customarily in R&B You can provide non-hospice consultationat market rates Provide same care in facility as at homeCopyright © 2007Bibliography June Gibbs Brown, A-05-96-00023 OIG,DHHS, Enhanced controls needed toassure validity of Medicare HospiceEnrollments, Nov 1997 Jones, Diane. Woods, Karen. The NewHospice Compliance Plan: Defining AndAddressing Risk Areas, Home Health CareConsultant, vol 7 no 1, Jan 2000Copyright © 2007HEN Copyright 2007www.hospiceonline.com12

HOSPICE EDUCATION NETWORKProviding Hospice in Extended Care Facilities by Carla BravemanResources General Accounting Office/ Department ofHealth and Human Services, Outcomes andUtilization for Hospice and Non-HospiceNursing Facility Decedents,http://aspe.os.dhhs.gov/daltcp/reports/oututil.htm Health and Human Services, Center forMedicare and Medicaid Memorandum, Ref:S&C-02-29, Promising Practices forImplementing the Medicare Hospice Benefitfor Nursing Home (NH) ResidentCopyright © 2007Thank YouHospice Education NetworkCopyright © 2007HEN Copyright 2007www.hospiceonline.com13