Your Hospice Playbook: The Road Map to Success - The ...

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Your Hospice Playbook: The Road Map for Success

Sylvia Singleton, RN, CHCCorporate Compliance Officer, Caris Healthcare

& Marisette Hasan, RN, BSN,

Vice President, South Carolina Operations,The Carolinas Center, Columbia, SC

Innovation and Excellence in Advanced Illness at End of Life 41st Annual Hospice & Palliative Care Conference – September 2017 – Asheville, NC

Goals and Objectives

Ensuring quality patient care and regulatory compliance

Understanding requirements under the Medicare Hospice Benefit

Review and discuss actual case studies with problem solving

Provide references and tips for success

Innovation and Excellence in Advanced Illness at End of Life The Carolinas Center’s 41st Annual Hospice & Palliative Care Conference – September 2017 – Asheville, ,NC

Regulations Impact Patient Care

• Regulations define how patient care is to be delivered & how quality is measured.

• Regulations define how hospice is paid & what hospice services are covered by this reimbursement.

• Direct Care Staff form the foundation for compliance with regulations.

Innovation and Excellence in Advanced Illness at End of Life

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The Medicare Hospice Benefit

The Requirements:

Patient Eligibility

Election of the Medicare Hospice Benefit

Physician certifying/recertifying that the patient has a life limiting illness

Establishment of a benefit period

Face to Face (F2F) visit for 3rd benefit or greater

Plan of Care (POC)

Interdisciplinary Team or Group (IDT / IDG)


Eligibility Requirements

• Entitled to Medicare Part A

• Terminally ill as determined by a physician

• A signed Physician Certification as being terminally ill with a prognosis of six months or less IF the illness takes it’s normal course

• Medicaid (MCD) has a hospice benefit as well, administered via each state’s MCD program policies


Supporting Eligibility

• Terminal Prognosis vs. Terminal Diagnosis

• Related conditions – Caused by or a result of the terminal illness or the treatment of the terminal illness– Examples: pulmonary effusion, pulmonary

embolism, DVT, seizure, constipation, bowel obstruction, falls, etc.

• All diagnoses combined determine patient’s prognosis and eligibility for hospice.


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Primary Diagnosis: Local Coverage Determination (LCDs)

Developed by Palmetto GBA, the Medicare Administrative Contractor (MAC)

• Neurological Conditions

• Liver Disease

• Cardiopulmonary Conditions

• Renal Care

• HIV Disease

• Alzheimer’s Disease & Related Disorders

• Adult Failure to Thrive Syndrome


Secondary Diagnoses

• Defined as “all conditions that coexisted at the time the plan of care was established, or which developed subsequently, or affect the treatment or care.”

– Examples: pain, anxiety, depression, cough, FTT, pleural effusion, encephalopathy


Co-Morbidities

• The presence of co-morbidities may hasten the patient’s clinical progression and must be identified.

• The presence of a disease such as these is likely to contribute to a limited life expectancy and must be considered in determining hospice eligibility. – Examples: COPD, CHF, diabetes, renal failure,

dementia, liver disease, neoplasia, AIDS, etc.


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NHPCO General GuidelinesProgression of 1º disease as listed in disease-specific criteria, documented by serial MD assessment and other studies

• Multiple ER or inpatient hospitalizations over the past 6 months• Home health nursing assessment

and/or• Karnofsky Performance Scale of < 50%,

and/or• Dependence in at least 3/6 ADLs, and/or• Recent impaired nutritional status

– Unintentional progressive weight loss of> 10% in 6 months

– Serum albumin < 2.5 gm/dl


Other Diagnostic Tools for Assessment

• NY Heart Classification for Heart Failure



• Palliative Performance Scale


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The Hospice Election Statement


The Hospice Election Statement

• The hospice must have the Medicare patient complete an election statement before the first Medicare Hospice Benefit (MHB) period can begin.

• Must be signed on or before the first day of Medicare Hospice coverage.

• The initial nursing assessment must be completed with 48 hours of election, but best practice is Day 1.


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The Hospice ElectionStatement (2)

• Must also be signed if the patient is reelecting their MHB after a revocation, or a discharge due to no longer meeting the eligibility criteria.

• Signature and date of the patient or their authorized representative - can be prior to or on election date, but not after.


The Hospice ElectionStatement (3)

• When a Medicare beneficiary/patient elects hospice services, the hospice must complete the election statement with the beneficiary and file a notice of election (NOE) with Medicare.

• Starting October 1, 2014, Medicare implemented the requirement that hospices must file a NOE within 5 calendar days after the date of the hospice election statement (this is a billing function). (Effective Jan 2018-EDI versus DDE)


Elements Included on the Hospice Election Statement

• The name of the Hospice that will provide services• The patient/representative acknowledgement that

they have a full understanding of hospice care, particularly the palliative rather than the curative nature of treatment

• The Patient (or rep) acknowledgement that certain Medicare services are waived

• Effective date of election• Pt (or rep) signature on the form/date• The name of the attending physician and NPI number if

available.


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Waiver of Other Benefits

For the duration of an election of hospice care, the individual waives all rights to Medicare payments for the following services:

• Hospice care provided by another hospice except under arrangement made by the designated hospice,

• Any Medicare services that are related to the treatment of the terminal illness or a related condition except those….


Waiver of Benefits (2)

• Provided by the individual’s attending MD if the MD is NOT an employee of the hospice or receiving compensation from the hospice for those services.


Hospice Benefit Periods

• To Be Used Consecutively

90 Day Period

90 Day Period

Unlimited 60 Day Periods

• Revocation or Discharge during a benefit period results in loss of remaining days in benefit period


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Physician Certification & Recertifications


• Certification is a required statement from the physician(s) to certify that the patient has a medical prognosis that his/her life expectancy is six (6) months or less IF the terminal illness runs its normal course.

• In addition, the certification includes a written physician narrative stating why (in as much detail as possible) patient is terminal.

Physician Certification & Recertification (cont.)

• Subsequent certifications (Recertification) can be signed and dated by either the medical director OR another hospice physician.

• Certification and Recertification MUST identify the benefit period the patient is entering.


Physician Certification &

Recertification (cont.)

IF no verbal certification:– Certifications MUST be signed and dated no later than

two calendar days following the date of the initial election

– Recertifications MUST be signed and dated no later than two calendar days after the first day of each benefit period

As a reminder, a signed written certification / recertification statement identifying the benefit period dates MUST be in the patient’s medical record prior to submission of a claim.


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F2F Requirements


F2F & Recertifications (2)

• The Affordable Care Act (ACA) requires that a hospice physician or nurse practitioner (NP) must have a face-to-face encounter with every hospice patient to determine the continued eligibility of that patient prior to the 180th day recertification (3rd benefit period).

• And prior to each subsequent recertification.

• The provision became effective January 1, 2011.


F2F: Recertification

• The Medicare Payment Advisory Commission (MedPAC) recommended that Congress enact this provision to ensure appropriate use of the benefit.

• F2F encounter is not a separately billable service.

• F2F must be conducted by contracted hospice physician, or by a hospice nurse practitioner who is employed by the hospice.


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Hospice Admissions

• The hospice admits a patient on the recommendation of the medical director in consultation with, or with input from, the patient’s attending physician

• The physician(s) must consider at least the following information:– Terminal diagnosis/prognosis– Other health conditions, whether related or not

related– Current clinically relevant information supporting the

diagnoses


Which Staff Member Can Begin the Admission Process?

• Anyone trained to explain what “electing the hospice benefit” means, and that can explain what services the hospice provides.

• But, the RN is the first discipline that can do an assessment of the patient per CoP 418.54(a).


The Assessment(s)

• Patient Rights

• Initial Assessment

• Comprehensive Assessment

• Patient Outcomes

• Update of Comprehensive Assessment


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Patient Rights Overview

• Advance Directives• Exercise of rights & respect for property and person• Grievance procedure• Right to effective pain management and symptom control for

conditions r/t the terminal illness.• Right to be involved in plan of care.• Right to refuse care or treatment.• Right to choose attending physician.• Right to confidential clinical record.• Right to be free of mistreatment, neglect, or abuse.• Right to receive information about hospice services.• Right to receive information about scope of services & specific

limitations of services.


The Initial Assessment

• The hospice registered nurse must complete an initial assessment within 48 hours after the election of hospice care unless the MD, patient, or representative requests that the assessment be completed sooner.

• Purpose – to gather critical information necessary to meet the patient/family immediate needs and to begin the Plan of Care


The Comprehensive Assessment

• The IDG, in consultation with the attending and/or MD, must complete no later than 5 calendar days after election of the hospice benefit.

• Identify the physical, psychosocial, emotional, and spiritual needs r/t the terminal illness that must be addressed in order to promote the patient’s well-being, comfort, and dignity throughout the dying process.


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Updating the ComprehensiveAssessment (CA)

• As frequently as the patient’s condition

requires, but no less often than every 15 days.

• Any change that has taken place since last CA.

• Includes patient’s progress toward desired outcomes.

• Required to document if there have been no changes.

• All members of IDG are involved in this process.


Patient Outcomes

• The comprehensive assessment MUST include data elements that allow for the measurementof outcomes.

– Pain assessment & control

– Dyspnea assessment & management

– Bowel protocol in place with opioid use

– Treatment preferences

– Beliefs & values


The Plan of Care


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The Plan of Care

• Plan of Care (POC) should include services which are reasonable and necessary for the palliation and management of the patient’s terminal illness and related condition(s).

– The hospice physician must decide what is related or unrelated and what is palliative or curative

• POC must detail the scope and frequency of services to meet the patient’s and family’s need.

• Customized POC versus Cookie Cutter POC


The Plan of Care (cont.)

• The Initial POC must be established beforeservices are rendered.

• The interdisciplinary team (IDT) member who assesses the patient (nurse/physician) MUST consult with at least one other core member of the IDG.

• All IDG members and the attending physician MUST review the POC and provide input


The Review of the POC

• The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) must review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days.

• A revised plan of care must include information from the patient's updated comprehensive assessment and must note the patient's progress toward outcomes and goals specified in the POC.


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The IDT / IDG Collaborative Care Planning Process

The Interdisciplinary Team or Group

• What discipline has the best skill to meet the patient/family need?

• How can other team members assist (if needed)?


Covered Services Under the MHB


Covered Services Under the MHB (cont.)


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Core Services

• The Hospice Agency must ensure that substantially all of the core services are routinely provided directly by hospice employees:

– Nursing Services

– Medical Social Worker Services

– Physician Services

– Counseling Services (Chaplain, Bereavement, Dietary)


Non-Core Services

• Hospice Agency can provide directly or under arrangement

– Physical Therapy

– Occupational Therapy

– Speech Therapy

– Hospice nurse aides (normally provided directly)


Summary of Covered Services by the Hospice Benefit

• Core Services– Nursing– Physician– Medical Social Services– Counseling (dietary & spiritual, bereavement)

• DME• Drugs, biologicals, medical supplies• Hospice Aide Services• PT, OT, ST• Volunteers• Bereavement Care


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How Does The Hospice Provider Determine What Is Covered?

Determining Relatedness

• The majority of diagnoses are related to the hospice prognosis. The CMS perspective is:– Hospice providers are required to provide virtually all

the care that is needed by the patient.

– There must be “clear evidence” that a condition is unrelated.

– In “extremely rare instances” where the hospice MD determines a condition is unrelated to the terminal prognosis, it is the “responsibility of the hospice physician” to document the rationale for this decision.


Drug Coverage & Medicare Part D

Related – Not Covered

• Some related drugs will be discontinued after determined no longer effective or causing negative symptoms.

• Must discuss with patient and family.

• Would not be covered by Medicare Hospice Benefit due to not being reasonable and necessary for the palliation of pain and/or symptom management.

• Not covered by Part D as coverage waived.

• Patient liable and hospice must inform them.


Drug Coverage & Medicare Part D

Related – May or May Not Be Covered

• Patient requests a drug for terminal illness or related conditions that is not on the hospice formulary and refuses to try a formulary equivalent first; or Hospice determines the drug is unreasonable or unnecessary for the palliation of pain or symptom management.

• No payment by Part D.

• Patient may opt to assume financial responsibility for the drug.

• CMS expects hospice to provide non-formulary drugs when necessary to meet patient’s needs and desired outcomes.

• If patient/family does not agree with POC and refuses to accept meds prescribed, then hospice must document this in the clinical record.

• Hospice must inform patient of financial liability.


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Non Related Medications

• A drug is for treatment of a condition that is completely unrelated to the terminal condition(s) or related conditions, may be paid by Part D.

• CMS expects drugs covered under Part D for hospice beneficiaries will be extremely rare.

• Part D plan sponsors should place beneficiary -level Prior Approval requirements on all drugs for hospice beneficiaries to determine whether the drugs are coverable under Part D.


Patient Liability

If a patient opts to continue a medication that will not be covered by hospice or Part D, they must be informed of the liability.• No ABN is needed if hospice is not providing

the medication.• If hospice is providing medication, but will

charge the patient, an ABN must be given.• The patient can file a claim form with CMS if

they think CMS should pay.• The patient can appeal any denials.


Case Study

Primary diagnosis – brain tumorSecondary diagnoses – diabetes, osteoarthritis, hip fracture

Covered or not covered?• PT for balance training & safe transfers• Dexamethasone• Insulin – sliding scale• NSAID• Seizure medication• Hospitalization for hip fx


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Case Study

Dx – lung cancer w/ mets

• Other Dx – heart failure, depression, osteoarthritis

• Multiple ER visits

Covered or not covered?

• Oxycodone

• Nexium

• Celebrex

• Zoloft

• Coumadin

• Thoracentesis

• ER visit


Case Study

Diagnosis-Debility

• Alzheimer's Dementia

• CHF

• Recent hip fx

• Multiple decubiti

What additional information do you need to help determine the terminal diagnosis/prognosis?

Is debility primary or secondary?


Levels of Care

Reimbursement rates are based on the level of care being rendered to the patient:

• Routine Home Care

• Continuous Home Care

• Inpatient Respite Care

• General Inpatient Care


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Routine Home Care

• Patient is considered to be at the Routine Home Care (RHC) level each day the patient is under the care of the hospice and not receiving one of the other levels of care.

• RHC is reimbursed at the a higher rate for the first 60 days of service. (1/2-Tier Payment)

• RHC is reimbursed at a lower rate from the 61st day to the last 7 days of life. (2/2 Tier Payment)


Routine Home Care

• Patient is also considered to be at the routine level of care when the patient enters a hospital for a condition not related to the terminal illness

• Patient’s medical record should include daily/weekly/monthly progress notes indicating services provided to patient.


Service Intensity Add-On (SIA)

Effective for hospice services with dates of service on and after January 1, 2016, a hospice claim will be eligible for an end of life Service Intensity Add-On (SIA) payment if the following criteria are met:

– The day is a RHC level of care day.

– The day occurs during the last seven days of life (and the beneficiary is discharged dead).

– Service is provided by a registered nurse or social worker that day for at least 15 minutes and up to 4 hours total.

– The service is not provided by a social worker via telephone.


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Service Intensity Add-On (SIA) (cont.)

• The SIA payment amount shall be equal:

– The number of hours (in 15 minute increments) of service provided by an RN or social worker during the last seven days of life for a minimum of 15 minutes and up to 4 hours total per day.

• CMS would expect that at end of life the needs of the patient and family would need to be frequently assessed and thus the skills of an RN are required.

• And the needs of the patient and family related to unique stressors would need to be frequently assessed by the social worker.


Continuous Home Care (cont.)

• Requirements of Continuous Home Care once a “Period of Crisis” has been determined: – MINIMUM of 8 hours in a 24 hour day beginning

and ending at midnight.– Care need not be “continuous”.– Nursing care (RN/LPN) must be provided for more

than half of the period of care.– Hospice aides may supplement the nursing care in

the total continuous care hours.– All hours must be counted (aide hours cannot be

discounted).


Continuous Home Care (cont.)

• Documentation should clearly indicate– The nature of the medical “period of crisis” and the

need for skilled intervention.

– Services and staffing that were provided during the medical “period of crisis”. Hour by Hour with signature/title after each hour, and Day by Day beginning and ending at midnight.

• Continuous Home Care is billed by the hour, once the minimum of 8 hours is met, any part of an hour is billable.


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Inpatient Respite Care

• Provided when families or caregivers need respite or relief.

• Must be provided in a hospice inpatient unit, in a hospital, Nursing Facility (NF) or Skilled Nursing Facility (SNF) under contract.

• The facility providing respite care must provide 24-hour nursing services that meet the nursing needs of all patients and are furnished in accordance with each patient's plan of care.

• No more than 5 consecutive days at a time.


Inpatient Respite Care(cont.)

• The Hospice Agency remains the professional manager of the patient’s care regardless of the physical location of the patient.

• Services provided in the facility must conform to the patient’s POC.

• Patients can receive more than one respite episode per billing period.


Inpatient Respite Care (cont.)

• Documentation should clearly indicate:

– Name of Facility where patient is receiving inpatient respite care.

– Why the inpatient respite level of care was necessary.

– If an additional inpatient respite level of care is necessary within the same billing period, the reason must be clearly documented.


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General Inpatient Care (GIP)

• Provided when the patient requires pain control or symptom management which cannot feasibly be managed in other settings.

• Must be provided in a hospice inpatient unit or in a hospital, Nursing Facility (NF) or Skilled Nursing Facility (SNF) under contract

• Must have an RN on site twenty-four hours a day providing direct patient care.


General Inpatient Care (cont.)

• General Inpatient Care (GIP) is a short-term level of care and is not intended to be a permanent solution to a negligent or absent caregiver.

• GIP is NOT the same as the inpatient level of care under the regular Medicare hospital benefit.

• The hospice agency retains the professional management of the patient’s care regardless of the physical location.


General Inpatient Care(cont.)

• Examples of situations appropriate for short term GIP: – Skilled nursing care may be needed by a family whose

home support has broken down and the breakdown makes it unfeasible for the skilled care to be provided in the home

– Pain Control – Medication adjustment – Observation for a short time– Stabilizing treatment and symptom control– Patient whose family is unwilling to permit the

needed skilled care in the home


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General Inpatient Care (cont.)

• Documentation should clearly indicate– The name of the facility in which the patient is

receiving this level of care.– Reason for the admission to GIP – precipitating

event– Patient’s condition and care provided during the

stay, including plans for discharge.

• Documentation should include, at the minimum:– Physician’s discharge summary – IDT notes during the patient’s stay in the facility


Recertification

Benefit Periods = 90 days, 90 days, 60 days . .

• Is the patient still terminally ill with a prognosis (as of this date) of six months or less?

• What data/observations support this determination?

• Repeat initial certification process (by hospice MD only)


Recertification Pointers

Timeliness• Use as much data as possible• Be rationale, not emotional• Document carefully & consistently across

disciplines• 3rd benefit period (& beyond) F2F visit

(Medicare & NC Medicaid)• 5th benefit period → pre-authorization (NC

Medicaid)• Follow agency guidelines for long-term patients


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Case Study 2Mrs. Fox, 72 y/o with diagnosis of failure to thrive, dementia, depression, Type 2 Diabetes, hypertension, osteoarthritis and recurrent UTIs. She was admitted to hospice 6 mos ago. She was independent in the year prior to admission, though her MD noted she had increased forgetfulness and decreased appetite. In the 60 days prior to admission her weight dropped from 111# to 95#.

She is 5’5” tall. She lost 2# more in her first month of hospice care. Over the next 4 months, Mrs. Fox has been sleeping more, complains of fatigue and has lost interest in her usual activities. She is eating less and less, some day eating nothing, despite attempts to feed her.


Case Study 2Two months ago, Mrs. Fox moved to an SLF. The next day she fell resulting in mild bruising and a skin tear. She was also noted to have foul-smelling urine and monitored for a UTI. Over the past month, Mrs. Fox began settling into her new home. The suspected UTI issue resolved and she began eating more. She has gained 2#. Visits by the hospice chaplain and volunteer are well-received by the patient and she has begun socializing at mealtime in the dining room.

• What is the primary dx? Can FTT be used as a primary dx? • Was this patient eligible for hospice at admission?• Throughout the course of care?• Should the team re-cert into the 3rd benefit period? Why?• What additional information would help you make a decision?


Case Study 3

David is a 43 y/o male with a diagnosis of CHF. He was admitted to MCD hospice 3mos ago. He has smokes 4 PPD for 25 years and drinks 12 beers/day. At 5’8” he weighs 425# and rarely leaves his house. Co-morbidities include: hypertension, bipolar disorder, depression, and early cirrhosis of the liver.

He had a heart attack 5 years ago and is not being treated with ACE inhibitors and diuretics. He is non-compliant with advice to improve his diet, stop smoking, or to quit drinking. He has no support system or caregiver. He relies on the hospice volunteer to shop for basic items and Meals on Wheels for his meals.


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Case Study 3Labs obtained prior to admission show an Ejection Fraction of 25% and bilirubin levels higher than normal limits. David spends most of his time on the couch due to difficulty with activity and uses a urinal rather than walking to the bathroom. He is able to get around the house with great effort and becomes easily short of breath with any exertion. After ambulating 15 ft. he must stop and rest. When advised that his habits and non-compliance will kill him, he replies, “I am ready to die. I don’t care.”• Was David eligible for hospice at the time of admission?• Should the team re-certify David for the 2nd benefit

period?– Why or why not?

• How do you know? Is there additional information that would be helpful?


Supporting the Diagnosis& Prognosis

Use the appropriate LCD, Assessment Tools (i.e. PPS, Karnofsky, FAST, NY Heart Classification, etc.)

• Include information r/t co-morbidities

• Are secondary conditions contributing to decline? Document Impaired physical functioning in measurable terms.

• Malnutrition, weight loss, infections, MAC measurements, lab work, x-rays, etc.

• Depression/decreasing socialization.


Physician Narrative

The physician narrative is not just a restatement of the medical record facts.

• Explains the physician’s rationale as to how the facts justify the prognosis.

• The intent is for the physician to support his/her prognosis, rather than to simply sign a form.


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ProfessionalPhysician Services

• A professional service is the actual procedure performed by the physician as designated by the appropriate CPT code.

• Professional services are the ONLY physician services which are separately billable to Medicare Part A.

• Technical services such as labs or drugs provided in the MD office are covered by the hospice per diem


Administrative Physician Services(Medical Director)

• Participates in establishing, reviewing and updating the plan of care.

• Attend all IDT meetings.

• Supervises care and services.

• Evaluates therapies.

• Assesses the need for treatment changes.

• Should be actively involved in the QAPI activities.


Physician Types

• There are three types of physicians that may interact with Medicare Hospice patients:

– Attending physician / Nurse Practitioner (serving as attending)

– Hospice Medical Director

– Consulting physician


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Physician Types (cont.)

• Attending Physician

– Designated by the patient as the physician primarily responsible for his/her care while under the Medicare Hospice Benefit.

– Primary Physician will be indicated on the election statement and on the Notice of Election to Medicare Part A as the patient’s attending physician and whether an employee or non employee of the hospice.


Physician Types (cont.)

• Consulting Physician– Any physician other than the attending physician

that the patient might see for consultation or treatment of his/her terminal illness.

– Physician must be contracted with the hospice in order to be reimbursed for his professional services.

– Should be approved by the hospice prior to visit and if approved, becomes part of the plan of care.


Types of Discharges


• Patient Dies (RN can pronounce if allowed in states if allowed)

• Patient Revokes (Revocation) – No longer wants hospice services

• Moves out of service area

• Enters non-contracted facility

• Discharge for Cause:

– Safety; Non-compliance

• Change Hospices - Transfer

• Condition improves – No longer considered in the terminal phase of illness

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Revocation

• Patient may revoke his/her benefits at any time during the benefit period.

• Revocation must be in writing.

• Verbal Revocations are not acceptable.

• Revocation must be signed and dated on day of revocation by patient/authorized representative – retroactive revocation is not allowed.


Revocation (cont.)

• Forfeits coverage for remaining days of benefit period

• Patient resumes Medicare coverage of the benefits waived when hospice care was elected

Note: A patient may elect to receive hospice coverage at anytime, even after having revoked previously


Discharge

• Moves out of Service Area– If patient moves without notifying the hospice,

the hospice may discharge

– If patient notifies hospice of the move, hospice would offer to transfer the patient to another hospice in location patient moving to or

– If patient refuses transfer or there isn’t a hospice in area, hospice may discharge


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Discharge for Cause

• Extraordinary Circumstances – Safety of patient

– Safety of hospice staff

– Hospice must make every effort to resolve the problem before it considers discharge as an option Detailed documentation and physician order present

on clinical record.

Notification to Medicare Administrative Contractor (MAC) [done through submission of claim] and State Medicaid Agency [done via notification to DHSR or DHEC].


Change of Hospice - Transfer

• A patient may change from one hospice to another once a benefit period.

• The patient must file with the hospice he/she is leaving a signed statement that includes the following information:

– Name of Hospice he/she is leaving

– Name of Hospice he/she is changing to

– Date the change is to be effective


Condition Improves/No Longer Terminal

• Hospice will be unable to recertify a patient if their condition improves and is no longer considered terminal.

• Must give patient 2 days notification (Federal guideline) prior to discharge.

• Each state may have additional requirements (know your state).

Note: Patients may re-elect the hospice benefit if condition changes and is considered terminal.


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Case Study 4

• ADMISSION NOTE• 68 year old … referred by NHC HOME CARE and admitted to

hospice with Primary diagnosis of ... ALZHEIMER'S DEMENTIA

• Other significant diseases, conditions and or symptoms affecting patient.....HX OF CHILDHOOD POLIO WITH

• RT LOWER EXTREMITY AFFECTED, SEIZURE DISORDR, HYDROCHEPHALUS, OSTEOPENIA, HYPERLIPIDEMIA, TREMORS

• Patient is now appropriate for hospice services as evidenced by ...DOES NOT RESPOND TO VOICE, TOTAL CARE FOR ADLs BED/CHAIR BOUND, INCONTINENT OF BOWELS AND BLADDER, HAS TO BE FED, CHOKES ON FOOD AND FLUID FREQUENTLY CONTRACTURES OR ABNORMAL POSITION OF LIMBS, BILATERAL FOOT DROP WT LOSS, CACHEXIA,

• Acuity/Disaster Level....2• Primary support system consists of …HUSBAND, 2 CHILDREN• PPS score…20%• FAST score...7E (MAYBE F) PT WAS IN BED• Weight… Percent of weight loss in previous 6 months...PT

HAS NOT BEEN WEIGHED FOR 3 YRS, LAST• KNOWN WT 110 LBS,• BMI... 18.3 3YRS AGO• Arm Circumference R arm...18CM and Left arm...17CM• Ambulation Ability/Use of device...BED BOUND, HUSBAND

USES WHEELCHAIR TO MOVE PT AROUND• IN HOUSE, TAKES 2 PEOPLE TO SHOWER, ONE TO BATHE

AND THE OTHER TO HOLD PT UPRIGHT ON SHOWER BENCH

88Innovation and Excellence in Advanced Illness at End of Life

• Ambulation Distance and Associated Symptoms present...UNABLE

• Hours in bed/geri chair/day...BED 24HRS PER DAY, WOULD LIKE TO TAKE HER OUTSIDE, HAVE REQUESTED GERI-CHAIR

• ADLs/Level of required assistance...TOTAL CARE• Equipment provided by hospice…. HAS OWN BED AND WHEEL

CHAIR• Bladder/Bowel Function...INCONTINENT• Ability to make needs known...NON-VERBAL ONLY BY MOAINING

AND RESTLESSNESS• Decubitus Ulcers (stage, location, measurement)...NONE• Other wounds (location, type, measurement)...NONE• Infections within last 12 months...URI, 2-3 WKS AGO, FREQUENT

YEAST INFECTIONS• Recent changes in Appetite... FED BY FAMILY USUALLY 3 MEALS

PER DAY,• PRN medication required for(pain, anxiety, dyspnea, etc) - name

and frequency administered... NONE COMFORT KIT TO BE ORDERED

• Psychosocial/Spiritual issues affecting plan of care... ANTICIPATORY GRIEF OF HUSBAND, VERY EMOTIONAL, HAVING DIFFICULTY MAKING DECISIONS ABOUT CPR, FEEDING TUBE ETC, EMOTIONALLY UNABLE TO MAKE FUNERAL ARRANGEMENTS

• Pt/family EOL goals are... COMFORT, AVOID NURSING FACILITY• Symptoms that are adversely affecting patient/family EOL

goals/outcomes are... NONE

Case Study 4

• CURRENT NOTE• Acuity/Disaster Level...3• PPS score…10• FAST score...7f• Weight…unable to obtain• Appetite...pcg literally pours pureed foods and liquids down her throat while she struggles to

breath and swallow• Arm circumference - R arm... 18/19 L arm…18/19• Wound measurements...none• Pain and symptom issues are...roxanol is on her profile but pt not using this med yet• Equipment provided by hospice...in use• Changes in functioning ability are…pt bedridden. she is in a total fetal position. unable to move at

all. when she opens her eyes she has no eye contact. her eyes dart side to side• Significant issues affecting plan of care are…none• Symptoms that are adversely affecting the patient/family's EOL goals/outcomes are... none• Date of next facility care plan meeting....home pt



• Generalized or multiple conditions

• Another disease or condition being treated (if you are aware)

• How is it impacting terminal condition (complaining of …)

• Condition(s) will directly and significantly impact the rate of decline

• No closure, understanding prognosis

Psychosocial and Spiritual Needs

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Chaplains and Social Workers

To identify areas for documentation by Chaplains and Social Workers

Identify opportunities to document changes in patient status

Documenting a patient’s decline

Have a level of comfort in documenting from your discipline’s view point

Develop sensitivity for grief counseling for staff



Social Worker Services

• There is no doubt that social workservices are important in effective end-of-life care. Research has demonstratedthat increased social work involvement issignificantly associated with:


Social Worker Involvement

Lower hospice costs

Lower pain costs

Fewer on-call visits by staff

Fewer hospitalizations of patients

Fewer nights of continuous care

Better team functioning

Fewer visits by home health aides, nurses, and by the agency

Decreased staff turnover

Increased job satisfaction for MDs, nurses, and social workers

Higher client satisfaction and quality of life for patients

Lower severity of problems in the case(combined results from Cherin, 1997; Mahar, Eickman, & Bushfield, 1997; Paquette, 1997; and Reese & Raymer, 2004)

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Bereavement counseling

• Finally, it is important to note that bereavement counseling is now defined by CMS to include “emotional, psychosocial, and spiritual support”.

• It is likely that coordination with the spiritual counselor will be necessary to achieve compliance with bereavement scope of practice.

• “Spiritual counselors” must recognize that their input into the plan of care and participation in coordination and delivery of that care .


Hospice Quality Reporting Program

CAHPS Overview

• Mandatory survey designed to focus on the experience of care.

• CMS completed field test to determine final questions.

• April 1, 2015 – Full implementation.

• Hospices with <50 unduplicated deceased patients in calendar year are exempt – must provide documentation to CMS.


Survey Administration

• Approved vendors administer & collect surveys.

• Vendors submit data to CMS on hospice’s behalf.

• Survey is initiated two months following the month of patient death.

• Submission to the CAHPS Hospice Survey Data Warehouse will occur quarterly.

• Hospices must not influence caregivers in any way about whether or how to answer the survey.


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Survey Eligibility

• The following decedents are eligible:– Patients age 18 and over

– Death at least 48 hours after last admit

– Patients with a caregiver who is someone other than a non-familial legal guardian

– Decedents for whom the caregiver has a U.S. or U.S. Territory home address

• Exclusions:– Caregivers who request that they not be contacted

– Patients who were discharged alive


Hospice Item Set

• Implemented July 1, 2014• Collects standardized patient-level data at

admission & discharge.• Capture information during the admission

assessment process on 7 quality measures.• Data is to be collected on every patient including

non-Medicare patients!• All patients are included regardless of length of

stay – 7-day LOS exclusion is no longer applicable• Must submit timely on 80% of patients in 2017.


Measures

• NQF #1617 Patients Treated with an Opioid who are Given a Bowel Regimen

• NQF #1634 Pain Screening

• NQF #1637 Pain Assessment

• NQF #1638 Dyspnea Treatment

• NQF #1639 Dyspnea Screening

• NQF #1641 Treatment Preferences

• NQF #1647 Beliefs/Values Addressed


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2017 HIS Changes

• Two new measures will impact payments in FY2019

• CMS is eliminating the 7-day exclusion so all records will be included

– This will yield more qualifying stays so more hospices will be able to participate

• HIS forms are being revised


New Paired Measure for Visits

• Hospice Visits When Death is Imminent Measure Pair –Will assess visits to patients in last week of life

• Measure 1 – Assess the percentage of patients receiving at least 1 visit from RNs, MDs, NPs or PAs in the last 3 days of life.

• Measure 2 – Assess the percentage of patients receiving at least 2 visits from MSWs, Chaplains, LPNs, or Hospice Aides in the last 7 days of life (includes the 3 days prior to death)– Excludes patients with LOS ≤ 1 day (i.e., died day of admission)


Hospice Visits Paired Measure

• Applies only to Routine Home Care patients admitted on or after April 1, 2017.

• Includes short stay patients due to expectation of high symptom burden.

• Only visits counted – not phone calls.• CMS wants to encourage providers to be

proactive in addressing symptoms.• Expected to enhance quality of life.• Will report level of care and number of visits via

revised Hospice Item Set admission form.


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New – Composite Process Measure

• Hospice and Palliative Care Composite Process Measure – Comprehensive Assessment at Admission

• Will use the HQRP quality measures from HIS to calculate score

– Pain Screening– Pain Assessment– Dyspnea Screening– Dyspnea Treatment– Treatment Preferences – Patients Treated with an Opioid who receive Bowel Regimen– Beliefs/Values Addressed, if desired by patient


Public Reporting is Here!

On August 16, 2017 CMS unveiled the new Hospice Compare website. https://www.medicare.gov/hospicecompare/

“The goal of Hospice Compare is to help consumers compare hospice providers on their performance and assist consumers in making decisions that are right for them.”Providers can start a conversation with their patients and family members about how the new Hospice Compare website impacts them by:

– Explaining that the compare website provides a snapshot of the quality of care a hospice offers;

– Encouraging patients and their family members to review quality ratings; and

– Helping to strengthen patients and family members’ ability to make the best decisions for their care.

• HIS – All 7 measures are reported


Composite Process Measure

The seven (7) National Quality Forum (NQF) - endorsed Hospice Item Set (HIS) quality measures initially displayed on Hospice Compare are:• Hospice and Palliative Care- Treatment Preferences - NQF #1641• Hospice and Palliative Care- Beliefs/Values Addressed- NQF #1647• Hospice and Palliative Care- Pain Screening- NQF #1634• Hospice and Palliative Care- Pain Assessment- NQF #1637• Hospice and Palliative Care- Dyspnea Screening- NQF #1639• Hospice and Palliative Care- Dyspnea Treatment- NQF #1638• Hospice and Palliative Care- Patients treated with opioids who are

given a bowel regimen- NQF #1617The Consumer Assessment of Healthcare Providers & Systems (CAHPS®) Hospice survey information will be displayed during a subsequent quarterly data update in winter 2018.


https://www.medicare.gov/hospicecompare/

https://www.medicare.gov/hospicecompare/

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Federal Regulations

• Medicare Conditions of Participation, 2008 Revised – Federal Regulations http://edocket.access.gpo.gov/2008/pdf/08-1305.pdf

• CoP Interpretive Guidelines & State Operations Manual – Guidance to Surveyors: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_m_hospice.pdf


CMS Resources

• Medicare Benefit Policy Manual – Chapter 9. Retrieved October 2016. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf

• Hospice Quality Reporting Program Website –https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-reporting/


CMS Resources

• Election Statements Article: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1631.pdf

• Certifications/Recertifications Article: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1628.pdf


http://edocket.access.gpo.gov/2008/pdf/08-1305.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_m_hospice.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-reporting/

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1631.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1628.pdf

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CMS Resources

• Hospice CAHPS® Survey web site at: http://www.hospicecahpssurvey.org.

2018 Final Rule Fact Sheet

• https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-08-01.html


Other Resources

NASW Center for Workforce Studies & Social Work Practice

Social Workers in Hospice and Palliative Care• http://workforce.socialworkers.org/studies/profiles/Hospice.pdf


Thank You!

Marisette Hasan, RN, BSN/VP, SC Operations, [email protected]/803-509-1021

Yesha Bell, Education & Events Coordinator, [email protected]/919-459-5382

Sylvia L. Singleton, RN, CHC/CCO, Caris [email protected]


http://www.hospicecahpssurvey.org/

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-08-01.html

http://workforce.socialworkers.org/studies/profiles/Hospice.pdf

mailto:[email protected]/803-509-1021

mailto:[email protected]/919-459-5382

mailto:[email protected]

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