Hospice Care in The Nursing
Home
Perspectives of a Medical Director Carole Baraldi, M.D.
Evolution of Nursing Facilities
• Alms houses began over 1000 years ago • Historically serve older people who can no longer work to earn enough to pay rent • Often maintained by a charity or the trustees of a bequest1935 New Deal Program
•
Eliminated poor houses
•
Social Security
SSA Amendments of 1965
• Compromise rather than national health care plan • Health Insurance for over 65 ‐ Title XVIII • Medicaid ‐ Title XIX – Health insurance for “Aged ,Blind and Disabled poor”Current Setting
• 25% Americans die in NH • Expected to rise to >40% by 2030 (3 million people) • 30% people admitted to NH die within one year • Of all NH admissions – 25% short stays <90 days – 50% > 1 year Principles of Geriatric Medicine &Gerontology. Fifth Edition. Medina‐Walpole‐Katz. Chapter 17 Nursing Home Care.Spectrum of NH residents
• “Transitional Care” and Post‐Acute Care • Emphasis on limiting LOS in hospitals • Spectrum – One extreme‐short stay between tx, very healthy baseline – Other extreme‐actively dying • Trend toward more short‐term, temporary patients – 1985 15% pts d/c to community – 2001 30% pts d/c to communityAll NH Residents
Short stayers “Long Stayers”
(1-6 months) (> 6 months) Terminally ill Short-term rehab Medically unstable or subacutely ill Primarily cognitively impaired Both cognitively and Physically impaired Primarily Physically impaired
100 Years of Change
1900 2000
Life Expectancy 47 years 75 years
Usual place of Death Home Hospital, Nursing Homes Most Medical Expenses Paid by Family Paid by Medicare
Care Givers Family Hired
Hospice in Nursing Homes
• 1986 – Medicare Hospice extended to NHs; expanded in 1989 • 2000 – 75% of NHs have a Hospice contract • Hospice use in NHs is increasing – 1995‐97: 5% of NH deaths with Hospice (13‐17% of Hospice enrollees) – 2000‐12: 16‐18% of NH deaths with Hospice (22% of Hospice enrollees) • Wide variation use by nursing home http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts_and_figures.pdfLocation of Death for Hospice Patients
Location of Death 2007 2008 2012 Patient’s Place of Residence 70.3% 68.8% 66.0% Private Residence 42.0% 40.7% 41.5% Nursing Home 22.8% 22.0% 17.2% Residential Facility 5.5% 6.1% 7.3%Hospice Inpatient Facility 19.2% 21.0% 27.4%
Acute Care Hospital 10.5% 10.1% 6.6%
NHPCO Facts and Figures: Hospice Care in America, Alexandria, VA: National Hospice and Palliative Care Organization, Accessed June 2014.
Growth of Hospice in NH
• Rates of NH use more than doubled from 1999 to 2006 • Mean LOS also doubled from 46 to 93 days • Proportion of non‐cancer dx increased • MedPAC concerns Miller SC et al. JAGS 2010Primary Hospice Dx over 10‐yr Period
0 10 20 30 40 50 60 70Cancer dementia failure to thrive heart disease lung disease 1999 2008 % Tschantz Unroe, K et al. JAMDA 2013
Conditions for Participation for
Hospice
• Pt care planning and coordination by a hospice interdisciplinary group • The Hospice provides care to the residents of the NH • Written agreement • Hospice Plan of Care • Coordination of services • Orientation and training of NH staff REF Medicare and Medicaid Programs: Hospice Conditions of Participation; Final Rule. June 2008.“New” Conditions of Participation for
Hospice
• Effective December 2, 2008 • Focus on patient‐centered, outcome‐oriented, and transparent process that promotes quality patient care for every patient every time • Other Core requirements – Patient rights – Comprehensive assessment – Patient care planning and coordination by a hospice interdisciplinary group (IDG)Medicare and Medicaid Programs: Hospice Conditions of Participation; Final Rule. June 2008.
New Hospice CoP
• Hospices provide care to residents of NH • Resident eligibility, election, and duration of benefits • Written agreement • Hospice plan of care • Coordination of services • Orientation and training of NH staffMedicare and Medicaid Programs: Hospice Conditions of Participation; Final Rule. June 2008
Updates – Effective August 2013
• June 2013 companion rule to CoP,
• Previously CoP focused on the hospice obligations
• Now NH is required to have a written agreement with hospice providers in place • NH MUST notify hospice regarding need to transfer a patient for ANY condition, not just the terminal condition • NH must appoint a liaison • Must be capable of performing clinical assessments (or have a someone in facility who can do that and then report the findings to the liaison) = RN • No new requirements or responsibilities for hospice
Hospice Liaison
• IDT team member with responsibilities • Collaborate with hospice staff • Most recent hospice plan of care • Hospice election form • Physician cert/re‐cert • Names/contact info for hospice team members involved in care of resident • Instructions on 24‐hour on‐call system of hospice • Hospice and attending MD ordersComparisons of Regs
Hospice CoP (for Hospices)418.112 Subpart B (NEW for LTC facilities) 483.75
Hospice Services can be provided by EITHER ‐facility arranges for hospice svc through agreement with one or more Medicare certified hospices OR ‐not arrange for hospice care, but assist in transfer of pt to a facility that does when resident requests transfer
New Regs Summary
• NF and hospice now hav equal amount of responsibility and obligation to provide care • NF have to have hospice providers under contract OR transfer resident out who wants hospice • NF have to clearly designate liaisonBenefits to Hospice in the Nursing
Home
What Do Patients with Serious Illness
Want?
• Pain and symptom control • Avoid inappropriate prolongation of the dying process • Achieve a sense of control • Relieve burdens on family • Strengthen relationships with loved ones D. Meier AAHPM 2010Considering Hospice in the NH
Hospice vs Non‐hospice •Feeding tube 7 vs 11% •DNR 87 vs 63% •DNH 11 vs 3% •Hospitalized in last month 13 vs 41% •Daily pain WITH analgesic at least 2x/day 57% vs 39% Miller SC, JPSM 2003; Miller SC, AJM 2001Considering Hospice in the NH
• Advanced dementia – Fewer meds and injections – Fewer feeding tubes – Better pain and dyspnea tx – Lower likelihood of hospital death • Hospice with or after SNF care – Favored hospice after rather than with Miller SC et al. JAGS 2012, Kiely DK et al. JAGS 2010Increasing hospice in NH – a model
• Intervention to promote communication about hospice care • Simple, easy • Faxing info to MD if patient “appropriate for hospice” Casarett, David et al – JAMA 2005Increasing hospice in NH – a model
• Greater referral to hospice • Fewer acute care admissions and less hosp LOS • Perception of better end‐of‐life care • No difference in 6‐mo mortality or being on hospice at time of death • More important as concept of patient‐ centered care and patient satisfaction grows!. Casarett, David et al – JAMA 2005Barriers in the Nursing Home
• Lack of care provider knowledge about palliative care • Care provider attitudes/beliefs about death and dying • Staffing levels/lack of available time for dying residents • Lack of physician support • Lack of privacy for residents and families • Families' expectations regarding residents' care • Hospitalization of dying residents. REF Int J Palliat Nurs. 2007 Jul;13(7):345‐50.OIG – Medicare Hospice in NH
• Objective: to determine the extent to which hospice
claims for beneficiaries in nursing facilities in 2006 met Medicare coverage requirements
OIG, "Medicare Hospice Care for Beneficiaries in Nursing Facilities: Compliance with Medicare Coverage Requirements,: OEI-02-06-00221, September 2009.
Reality Check – OIG report 2006
• 82% of hospice claims for beneficiaries in NH did not meet at least 1 Medicare coverage requirement •33% of claims did not meet election requirements •63% of claims did not meet plan of care requirements •31% of claims, hospices provided fewer services than outlined in POC •4% of claims did not meet certification of terminal illness requirements OIG, "Medicare Hospice Care for Beneficiaries in Nursing Facilities: Compliance with Medicare Coverage Requirements,: OEI‐02‐06‐00221, Sept 2009.OIG – Medicare Hospice in NH
• Recommendations – Educate hospices about coverage requirements – Provide tools and guidance to hospices – Strengthen monitoring practices • Response from CMS – Concurred with recommendationsOIG, "Medicare Hospice Care for Beneficiaries in Nursing Facilities: Compliance with Medicare Coverage Requirements,: OEI-02-06-00221, September 2009.
CAPC 2008 Report
• Adv Dir/Code status missing in 87% transfers • Lack of understanding of role in next setting • Understanding essential steps in management of condition • Patient, family or NH staff unable to contact appropriate health care providersCAPC Report 2008 “Improving Palliative Care in Nursing Homes” • One model doesn’t serve all needs • Nursing Home factors – Size – Culture – Staffing – Leadership • Community factors – Availability of palliative care expertise (Hospice, academic centers, outside consultants ) – Relationship with area hospitals – Availability of other NH in area
Models
• Hospice in Nursing Home • Palliative Care Consults
Possible Changes to the
Medicare Hospice Benefit
MedPAC recommendations – Hospice payment reforms – Make payments relatively larger during first and last periods of hospice stay – Make payments relatively smaller during middle period – No recommendations for modifications based on setting or patient case mix.Medicare Payment Advisory Commission. 2009. Medicare Payment and Policy. Washington DC: MedPAC
Patterns of Hospice Use
0 10 20 30 40 50 60 70 80 90 Only NH Home to NH NH to Home Home to NH to Home Tschantz Unroe, K et al. JAMDA 2013 %Clarifying Responsibility
• Question: Who is responsible for patient
management when patient in NH is enrolled in Hospice? (CMS RULES)
Who to call?
• Question: When should the NH nurses call the attending physician or hospice?
Communication
• Question: Must the attending physician notify hospice if investigating or treating an acute sx or illness?
Comorbidities
• Question: Should the NH medical director delegate supervision of wound care, chronic disease care and weight loss to the hospice IDT?
Responsibilities, again
• Question: Is NH medical director still
responsible for events (falls, fecal impaction, infections) for hospice patients?
Recognize When It’s Time….
• IDT meetings
• Care Conferences • MD visits
Summary
• Hospice enrollment is beneficial to NF residents • Changing demographic and fluidity make changes to hospice benefit in NF difficult • New Medicare regulations bring greater responsibility and obligation to the NF for care of hospice patients • Communication and collaboration are always the foundation for successful partnershipsReferences
• Casarett, D et al. Improving the Use of Hospice Services in Nursing Homes. JAMA 2005;294:211‐217. • Miller SC et al. The Growth of Hospice Care in US Nursing Homes. JAGS 2010;58:1481‐1488
• Tschantz Unroe, K et al. Hospice Use Among Nursing Home Patients. JAMDA 2013;14:254‐259. • Halter JB et al. Hazzard’s Geriatric Medicine and Gerontology, 7thed. McGraw‐Hill 2009.
• Kelley AS et al. Palliative Care‐A Shifting Paradigm. NEJM 363:8, 781‐2
• Miller SC et al. Hospice and Palliative care in Nursing Homes. Clin Geriatr Med 20(2004) 717‐34
• Meier DE. Improving Palliative Care in Nursing Homes. Center to Advance Palliative Care Report June 2007 • Hirschman KB et al. Hospice in Long‐Term Care. Annals of Long Term Care Vol 13(10); Oct 1 2005 • Miller SC A Model for Successful Nursing Home‐Hospice Partnerships. J Pall Med 13(5); 525‐33 • Casarett DJ et al. Does Hospice Have a Role in Nursing Home Care at the End of Life? JAGS 49:1493‐8 • Miller SC et al. Does Receipt of Hospice Care in Nursing Homes Improve the Management of Pain at the End of Life? JAGS 50:507‐15 (2002) • Miller SC. Hospice Care in Nursing Homes: Is Site of Care Associated with Visit Volume? JAGS 52:1331‐6 (2004) • AMDA‐NHCPO Working Group. Management of Hospice Patients in LTC. Caring for the Ages (AMDA publication) Aug 2009;22‐23 • Wowchuk SM et al. The challenge of providing palliative care in the nursing home part II: internal factors. Int J Palliat Nurs. 2007 Jul;13(7):345‐50
