Making the Decision for Hospice Care

This episode of Passages deals with End of Life Issues.  It highlights the impact hospice care has had on a patient and includes a discussion of a panel of experts on how to help families make difficult choices regarding care for persons with advanced illness.

Chapter 5: Living life fully- hospice care

The heading of this chapter may at first seem strange. “Living life fully” is not a phrase that the average person calls to mind when thinking about hospice care. Typically, hospice is thought of as a place to die. In reality, this couldn’t be further from the truth. In fact, it is inaccurate on two fronts.

First, hospice is not a place. It is a philosophy and program of care. The majority of hospice care is provided in the person’s home. That home may be in a traditional house or apartment, or it may be in a residence such as an assisted living facility or nursing home. Hospice patients may also be treated in an in-patient setting when they have severe symptoms that need aggressive medical and nursing management, or if they caregivers need a respite, or break, for a few days. That in-patient setting may be freestanding, or part of a hospital or nursing home.

Second, the focus of hospice is not on helping someone die. It is about helping a person live to their fullest, even when they are in the end stage of an advanced illness. This means very aggressive approaches to controlling their symptoms so that they can enjoy the company of family and friends and have meaningful conversations and activities with them. There is lots of support of a variety of professionals, para-professionals, and volunteers. The team addresses the physical, emotional, and spiritual needs of both the patient and their caregivers. These interventions may include life review, facilitating conversations with family members, helping the patient engage in a long desired activity or unfinished business, etc. The goal of care is to reduce symptoms of pain or discomfort, while at the same time helping the patient to remain engaged and interactive to the greatest degree possible.

The support of the caregivers often makes the difference between a patient being able to remain in the comfort or familiarity of their home or not. I never ceased to be amazed at the demonstrations of love and care that I see family members and friends show to the hospice patient. The hospice team supplies these caregivers with the knowledge and support that makes this possible. And that support continues long after the patient dies, as hospice continues to meet with caregivers and family for bereavement support. A period of individual counseling is provided after the death of a patient to family and friends, and support groups and memorial services are provided by hospice throughout the year. For children who are dying, or for children of patients who are dying, hospice care-givers help them through play therapy and other age appropriate ways to process their thoughts and feelings.

The decision for hospice care is often a difficult one for families, caregivers, and even doctors. It is often less difficult for the patient themselves. Why is this? People are often afraid to suggest hospice as an option because they think that they are telling the patient that there is no longer any hope and that they are going to die. Physicians are often afraid to discuss the topic because they may feel that it represents a failure on their part, or that it means that they must end their relationship with the patient. From my experience, these fears are often more real to those caring for the patient then they are for the patient themselves. Most patients in the end stage of an advanced illness know the reality of their situation. In having the conversation about hospice, we are not calling their attention to their hopelessness or dying. We are acknowledging that we understand it too, and that we want to support them, be with them, and give them what they need to enjoy what time is left.

Even when a patient is beyond alertness or ability to comprehend these critical conversations about hospice, caregivers and family benefit from coming together with a mutual understanding of the situation and how they can best come together to meet not only the patient’s needs, but each other’s needs as well.

When is a patient appropriate for hospice care? The reimbursement criteria for hospice are that the patient have a serious, life threatening illness with a life expectancy of six months or less, and for which additional aggressive treatment is futile. It is important to understand that this does not mean that the patient must die within six months. It just means that it seems likely to be the case. If a hospice patient lives longer than the six months, they can be re-certified for another period, or a determination may be made that they have improved and are no longer hospice eligible.

There are four different levels of hospice care. The routine level covers services at home, including medical and nursing visits, physical therapy if needed, social work and pastoral care too. Medications related to the primary illness and symptom control are provided, as are medical equipment and supplies. A home health aide is provided to supplement the care given by family and friends. If caregivers need a break from their daily duties to re-charge themselves or to meet the needs of another family member, the second level, respite care is provided. The patient is moved to an in-patient setting for these days and receives care from the hospice team. When the caregivers are ready to resume their duties, the patient is returned home. Sometimes the care needs intensify during an acute episode, or in the very final stages of decline. During this time, the hospice team is able to provide aide and nursing care for extended hours in the home. This is called continuous care. Finally, there may be needs for symptom control and clinical management that exceed what can be reasonably provided in the home. In this case the patient is provided in-patient level of care by hospice professionals around the clock in a freestanding hospice unit, or in a hospital unit or scattered bed.

In each of these levels of care, the patient’s primary physician can remain the attending physician. He or she is supported by the medical staff of the hospice, who are trained and experienced in controlling pain, nausea, anxiety, and other symptoms that the patient may be experiencing. In some cases, the primary physician elects to turn the management of the patient completely over to the hospice medical team, but this is not required.

Hospice offers a wonderful program to provide comfort, support, and purposeful living in the final stages of illness. The biggest frustration of hospice workers is that often the referral to their program is made too late and they have such little time to accomplish so much with the patient. If hospice care is considered earlier so that patients are on the program for weeks or months, rather than days, both the patient and their loved ones have much to gain. In fact, for some illnesses research has shown that patients live longer on hospice care--and more comfortably-- than they do when receiving aggressive curative treatment that is futile. If you are not sure if hospice is right for you or a loved one, don’t hesitate to call a hospice provider and discuss your situation. They won’t push you to make a decision, and will give you the information you need to decide when the time may be right.

Chapter 4: Care after a Hospitalization

Arranging care for a parent or loved one after a hospitalization can be a maze of options. You may be pressed by the hospital’s care management department to make arrangements quickly, as the day of discharge approaches. At the same time, you feel pressed to find the optimal care setting and to do so with the available financial resources.

Under Medicare or commercial insurance, a patient coming out of the hospital will only get intermittent home care for a few months.  That means a nurse will make home visits a couple of times a week to check and monitor symptoms, medications and progress. These visits may be more frequent if some sort of skilled service such as injection or dressing change is needed. Various rehabilitation therapists may set up an exercise program and also visit several times a week to work toward improved ambulation, transfers, and endurance.  For the months that the nurse or therapists come, the insurance will provide home health aide services about two hours at a time several days a week-- to support the plan with activities, exercise, and bathing. This coverage may not be enough for the patient to be maintained at home without additional private resources.

If the hospitalization was for an advanced illness and the patient meets hospice eligibility criteria, there is more generous aide coverage.  Depending on the patient’s needs, hospice generally will cover daily aide service for up to four hours a day.  What families usually do is arrange for this aide service for hospice and have them do the daily bath and health related care, and then privately hire another aide, or just a sitter (depending on what he needs) for the rest of the day.  Hospice also has volunteers who will come in and visit , but not regularly where you can count on it for coverage.  

If the patient is eligible for Medicaid, then he or she might be able to get additional aide service coverage, but this is getting more and more difficult to get approved.  State requirements for Medicaid vary, and it is best to consult with a hospital or home care social worker or an elder attorney to explore this option.  Medicaid would also give you the option of getting care in a nursing home covered if the patient deteriorates and requires that level of care.

If the patient has Medicare there is another option right after hospitalization. This option is to seek admission into a nursing home for skilled services under Medicare coverage.  That might only last a few weeks up to three months depending on needs and the requirement of skilled services, but it would gain you some time to pursue a more permanent option at home.  It also gives the social workers at the nursing home time to work with you on a Medicaid application for continued care in the nursing home after Medicare runs out, or for extra services at home when the patient leaves the nursing home.  If you want to try this option and the patient has an advanced illness, don’t go on hospice care yet as they wont pay for nursing home care in most cases (Medicare will only allow a patient to be on one Medicare program at a time-- skilled Medicare nursing home placement, or hospice, but not both).  

Making post discharge arrangements is a challenge. The options discussed here may vary depending upon specific insurance coverage, state programs, and availability of services in your community. Most home care programs need to be supplemented by the time of family and friends, and perhaps even privately paid for care. Typically, there is not a one-stop option. You will need to build a quilt of programs, people, and resources to meet your loved ones needs. The care manager or social worker in the hospital can be an important resource. They are experienced with what programs are available in your community that meet the patient’s needs, and they also typically know the coverage limitations of the various insurance plans and government programs.

Health Care Reform Brings Heightened Provider Scrutiny

The proposed House and Senate plans for health care reform vary considerably, but the one common element of both, give or take a few billion, is that they are very expensive. The Office of Management and Budget discusses on their website the various sources of revenue that will be used to finance this expenditure. One category they point to is the billions of dollars that are lost each year to Medicare fraud and abuse. This means that the already active revenue recovery efforts by federal and state agencies will intensify over the coming years.

Despite their best intentions, providers can find themselves facing an Office of Inspector General or State Office of Medicaid Inspector General audit, and be surprised to find out that they have been submitting claims for reimbursement that are not supported properly. It may be that the wrong procedure or E&M code was selected; or the right code was selected for what was done, but the documentation doesn't support it; or the visit was not justified medically. Nursing home providers may find that MDS completion was not based on the true condition of a resident,or that the resident experienced quality of care issues while being covered by Medicare. A home care agency may find that the ICD-9 codes they selected for prospective payment were not appropriate for the client's medical diagnoses, or a hospice provider may find that they inadvertently billed for days after a patient died because of a breakdown in communication.

While these types of events are most often not intentional, they can happen very easily from a variety of factors:

1. Staff can become so absorbed in meeting the tremendous needs of patients that they don't pay enough attention to the "paperwork".

2. Interfaces between clinical and financial information systems can have glitches that remain unknown for months.

3. Providers become accustomed to doing things a certain way for years without being told it is not a proper procedure that they assume it is proper.

4. Staff can identify an issue as not being correct, but because of workplace politics, power structures, etc., nothing happens about it, so they stop bringing it up.

So what is a provider to do to prepare for the increased scrutiny of their claim submissions? Every provider organization should have a compliance plan where the principles of revenue integrity are spelled out for all staff to see, and the expectations for how that integrity will be monitored and what a staff member should do if he or she sees something they don't think is right, is laid out. This compliance plan should include ongoing monitoring of revenue cycle processes to make certain that claims submitted are based on proper coding and are supported with the appropriate clinical documentation. Staff who show a pattern of non-compliance should be given feedback and if they do not improve, should be subject to disciplinary action. It also is valuable to have both the compliance plan, as well as a sample of claims submissions for a period of time, reviewed by an outside consultant who will be objective and provide the perspective of external scrutiny.

For more information on this topic, or to discuss how a diagnostic assessment of how effective your organization's compliance and revenue integrity processes are, contact Joseph Tomaino at 212-372-1640, or joseph.tomaino@rsmi.com .

Continuing Care InSite is the blog of Joseph Tomaino, who assists his clients with smart approaches to improving continuing care organizations. He can be reached at jtomaino@continuingcareinsite.info

Health Care Reform Brings Heightened Provider Scrutiny

The proposed House and Senate plans for health care reform vary considerably, but the one common element of both, give or take a few billion, is that they are very expensive. The Office of Management and Budget discusses on their website the various sources of revenue that will be used to finance this expenditure. One category they point to is the billions of dollars that are lost each year to Medicare fraud and abuse. This means that the already active revenue recovery efforts by federal and state agencies will intensify over the coming years.

Despite their best intentions, providers can find themselves facing an Office of Inspector General or State Office of Medicaid Inspector General audit, and be surprised to find out that they have been submitting claims for reimbursement that are not supported properly. It may be that the wrong procedure or E&M code was selected; or the right code was selected for what was done, but the documentation doesn't support it; or the visit was not justified medically. Nursing home providers may find that MDS completion was not based on the true condition of a resident,or that the resident experienced quality of care issues while being covered by Medicare. A home care agency may find that the ICD-9 codes they selected for prospective payment were not appropriate for the client's medical diagnoses, or a hospice provider may find that they inadvertently billed for days after a patient died because of a breakdown in communication.

While these types of events are most often not intentional, they can happen very easily from a variety of factors:
1. Staff can become so absorbed in meeting the tremendous needs of patients that they don't pay enough attention to the "paperwork".
2. Interfaces between clinical and financial information systems can have glitches that remain unknown for months.
3. Providers become accustomed to doing things a certain way for years without being told it is not a proper procedure that they assume it is proper.
4. Staff can identify an issue as not being correct, but because of workplace politics, power structures, etc., nothing happens about it, so they stop bringing it up.

So what is a provider to do to prepare for the increased scrutiny of their claim submissions? Every provider organization should have a compliance plan where the principles of revenue integrity are spelled out for all staff to see, and the expectations for how that integrity will be monitored and what a staff member should do if he or she sees something they don't think is right, is laid out. This compliance plan should include ongoing monitoring of revenue cycle processes to make certain that claims submitted are based on proper coding and are supported with the appropriate clinical documentation. Staff who show a pattern of non-compliance should be given feedback and if they do not improve, should be subject to disciplinary action. It also is valuable to have both the compliance plan, as well as a sample of claims submissions for a period of time, reviewed by an outside consultant who will be objective and provide the perspective of external scrutiny.

For more information on this topic, or to discuss how a diagnostic assessment of how effective your organization's compliance and revenue integrity processes are, contact Joseph Tomaino at 212-372-1640, or joseph.tomaino@rsmi.com .