Collaborative Care: Improving the Hospice- C A L I FOR N I A H EALTH C ARE Nursing Home Relationship F OU NDATION Introduction only receive the Patient’s Bill of Rights but also As the nation’s population ages, care received have the right to hospice care specifically noted by patients at the end of life is becoming more and explained.2 extensive, and choice among options more Issue Brief important. Much media attention has been paid The potential benefits of hospices bringing to the importance of end-of-life care choices, but their services into nursing homes are significant. there has been little focus on nursing homes as a Nursing homes receive the hospices’ expertise site where people receive end-of-life care. Nursing in pain and symptom management, access to homes have become a significant provider of care enhanced patient benefits such as pharmaceuticals delivery at the end of life, particularly for frail and bereavement support, and access to training Medicare beneficiaries. For these patients, hospice resources. Hospices gain access to alternative bed care can significantly improve their quality of life. arrangements for inpatient care, round-the-clock Consequently, a relationship between a hospice support and supervision, and dietary services. and a nursing home that facilitates access to Perhaps most importantly, hospices and nursing hospice care delivery is a crucial element of high homes working well together create a synergy that quality end-of-life care. is better able to meet the end-of-life care needs of nursing home residents than either could provide Although California hospices are widely known on its own. as pioneers in the development of hospice care in the United States, California has been slower in How beneficial the relationship is in any particular moving hospice care into nursing homes compared facility, however, depends heavily on how well to the country as a whole. In 2006, for example, the hospice and the nursing home are able to approximately 17 percent of all hospice admissions cooperate. Despite the significant benefits that and 18 percent of all hospice deaths in California might accrue to all parties involved, creating occurred in nursing homes, compared to 22 and a strong relationship between a hospice and a 23 percent, respectively, in the United States.1 nursing home is not always easy. Although the reasons for this disparity have not been thoroughly analyzed, the greater number of To better understand how hospices and nursing for-profit and larger nonprofit hospice providers homes work together, the California HealthCare in other states may influence patterns of nursing Foundation commissioned The Corridor home use by hospices there. Additionally, some Group, Inc. (TCG) to conduct research on these other states may have more flexible reimbursement relationships in California: benefits and risks or regulatory policies that encourage hospices to for each entity; types of collaboration; perceived collaborate closely with nursing homes. In Rhode quality of care by each provider type; and Island, for example, state law requires that on opportunities for improvement in care delivery, S eptember admission to a nursing home, each patient not resource allocation, and cooperation. 2008 In undertaking the project, TCG conducted telephone home. (See Appendix: California Hospice Payment and or online surveys with 138 industry stakeholders and Benefit Structures.) representatives of hospices and nursing homes throughout California. (Although the goal was to obtain a cross- Whenever hospice care is provided in a nursing section of information and opinions from each of these home — whether to a long term resident or to a patient sectors, it should be noted that far more survey responses the hospice moves to a nursing home for short term were obtained from hospices than from nursing homes care — the hospice and nursing home must enter into a or other industry stakeholders.) This issue brief explores contractual agreement that reflects standards established the survey findings, and recommends a call to action in by 42 C.F.R. 418 (§§418.108, 418.110, 418.112). These response to certain challenges observed in the relationship standards set out the roles and responsibilities of the between hospices and nursing homes, with the goal hospice and the nursing home with regard to staffing, of improving end-of-life care delivery and access in physical environment, safety management, eligibility, and California nursing homes. professional management. Background With the increased use of nursing homes by hospice Since 1983, Medicare has provided coverage of hospice patients, significant interest has been generated services at four levels of care.3 Most care under the concerning the quality of end-of-life care in nursing Medicare Hospice Benefit is provided in the patient’s homes, the level of pain and symptom management place of residence. Typically, this is in the patient’s private provided there, the types of relationships that exist home, but in recent years hospice care delivery has between hospices and nursing homes, and models of increased in nursing homes as patients’ nursing home collaboration to enhance these relationships—subjects stays have lengthened, with the nursing home becoming that this issue brief addresses. their primary residence. The two levels of care provided in the primary residence are referred to as routine home care Key Findings and continuous care. The relationship between a hospice and a nursing home works best where: Hospice providers are also required by Medicare to K There is good and open communication between provide short-term inpatient care, when appropriate, them; in Medicare- or Medicaid-certified facilities. These facilities are typically acute care hospitals and skilled K The nursing home leadership and staff alike nursing facilities (nursing homes). This short-term understand the value of hospice; inpatient care may be provided at either of two levels: K The leadership of both the hospice and the nursing inpatient care for symptom and pain management home are committed to making the relationship (referred to as general inpatient care), and inpatient care work; for the purpose of providing caregiver respite (known as K Both the hospice and nursing home make a inpatient respite care). significant effort to work collaboratively, especially in care planning; and There are separate delivery and reimbursement guidelines for each of these four levels of care. There are additional K The hospice consistently sends the same personnel reimbursement implications to hospices and nursing to a particular nursing home. homes when care is delivered to patients in a nursing 2  |  California HealthCare Foundation The relationship between a hospice and a nursing home Residents, families, and nursing home staff can often flounders, however, where the nursing home receive grief support. After a resident on hospice staff does not understand the overall value of hospice dies, hospice continues to serve the family through its or what its role is, including what specific services it bereavement program for up to a year after the death. provides and how and why it uses certain drugs. The Hospice also can provide grief support, as well as relationship also may not work well if the hospice staff bereavement education and training, to the nursing home does not understand how to function in a nursing home, staff. in particular showing a lack of responsiveness, a lack Nursing homes get the added services of certified of staffing consistency, or poor communication with hospice aides (nursing assistants). Hospice aides the nursing home staff. Not surprisingly, hospice does complement services already provided by the nursing not do well in a nursing home if neither side shows a home and may offer a level of personal care assistance not commitment to building a relationship. All of these often available throughout the nursing home. problems are compounded when there is high turnover of nursing home clinical staff. Non-hospice residents receive secondary benefits. Research has found that non-hospice residents residing Significant Benefits in those nursing homes that have a greater proportion The survey respondents indicated many benefits to both of residents enrolled in hospice are less frequently hospices and nursing homes when a good relationship hospitalized at the end of life and more frequently have develops. The stronger the relationship is, the greater the pain assessment performed.4,5 Also, hospice bereavement benefits to hospice, nursing home, residents, and families. counselors may be available to provide additional grief counseling to residents not in the hospice program. Some Benefits to the Nursing Home and Its Residents hospices have community bereavement programs that The most common benefits accruing to the nursing home are offered as a community service and may be arranged from a good relationship with a hospice include: through the nursing home. Nursing homes get expertise in pain and symptom Hospice staff are expert resources for the nursing management. Many patients require intensive pain home. Hospice staff are experts in end-of-life care and management during the end stages of life. Hospice staff are available to answer questions and provide guidance, are trained in the nuances of pain management and particularly in those relationships where the leadership of often are better able than nursing home staff to titrate both hospice and nursing home understands the overall medications (under the direction of the patient’s physician benefits of hospice care and encourages collaboration. or the hospice medical director) for maximum patient comfort. Benefits to the Hospice and Its Patients The benefits to the hospice provider of a good Residents can receive great value from the hospice relationship with a nursing home include: interdisciplinary team. Most nursing home residents are eligible for the Medicare or Medi-Cal (Medicaid) hospice Hospices are able to meet the end-of-life care needs of benefit. Residents who elect this hospice coverage are more patients. Hospices hope to serve as many patients eligible for extra nursing, hospice aide, social work, and as possible who are at the end stage of life. Since this pharmaceutical benefits, in addition to services already includes many nursing home residents, hospices that provided by the nursing home. work regularly with nursing homes have the opportunity to serve more patients. Collaborative Care: Improving the Hospice-Nursing Home Relationship  |  3 Hospice patients in nursing homes receive access to for the patient. For example, the hospice must develop additional facility-based services. Hospice patients a plan of care that guides delivery to the hospice patient often need care when regular hospice visiting staff is not of all medical care related to the terminal illness, and the working. The nursing home setting offers round-the-clock hospice is responsible for all decisions related to such care. care and supervision to patients, as well as dietary services. But the nursing home, too, must develop a plan of care This can reduce the need for the hospice staff to visit that guides its delivery of care and services. When nursing outside routine business hours. home staff members do not fully understand these rules, there may be confusion about who is responsible for the Hospices may obtain alternative bed arrangements for plan of care, as well as about individual care decisions. their patients. While most people would prefer to be at home at the end of life, for many this is not possible due Education and training for both staffs about the role of to family circumstances, financial resources, or cultural the hospice care plan can help alleviate this confusion. mores. Additionally, hospice patients may need inpatient care for acute or respite stays. Nursing homes offer a good Hospice as Substitute for Nursing Home Care venue for short term stays of hospice patients who are not A distinct undercurrent was detected from surveyed nursing home residents. hospice providers that some hospices (labeled frequently Hospices may realize a more efficient environment as the “for-profits”) are providing more services to nursing and better flow of patients. Hospices may serve multiple homes then federal law allows. At the same time, some residents in the same nursing home, allowing for one nursing homes may feel they are not receiving a full range team of hospice staff to concentrate on one facility. This of hospice interdisciplinary services, including volunteers is not only cost-effective but also provides an opportunity and spiritual care counselors. These attitudes can lead for stronger nursing home relationships, since the same to confusion by both hospice and nursing home when hospice staff visit frequently and the two staffs thus entering into contractual agreements or care coordination become more familiar with each other. activities. They may also result in a strain on the relationship when some hospice services are requested but Significant Challenges not provided. The survey identified six significant challenges to a good relationship between a hospice and a nursing home. Clear delineation of these responsibilities in a written contract is essential to avoid conflict or confusion about Lack of Understanding the care that is to be delivered by each entity, pursuant to Frequently, a lack of understanding exists on the part the following categories of responsibility: of each staff regarding what is expected from the other: K The hospice is responsible for providing medical what role each has; what services hospice can and should direction and patient management, nursing, provide; how hospice should operate in a nursing home counseling, social work, medical supplies, durable setting; and how narcotics and other medications are to medical equipment, and pharmaceuticals related to be used. the patient’s terminal illness. The hospice may use the nursing home staff to assist with the administration This lack of understanding is due partly to the Hospice of prescribed therapies. Medicare Conditions of Participation, which place the responsibility of professional management on the hospice, though the nursing home remains legally responsible 4  |  California HealthCare Foundation K The nursing home is responsible for providing The high nursing home staff turnover also impacts the 24-hour room and board care, and for meeting the ability of hospice and nursing facility staffs to develop personal care and nursing needs that would have been long term relationships and loyalty to a particular end-of- provided by the primary caregiver at home. life care delivery approach, which may produce subjective and idiosyncratic approaches to care that are not always in Leadership Cooperation Between Hospice and patients’ best interests. Nursing Home Coordination of the plan of care between nursing Lack of Surveyor Understanding home and hospice can be difficult in even the best Nursing homes are visited each year by a team of of relationships between the two staffs. In a poor surveyors from the state, to ensure compliance with state relationship, nursing home staff can present real barriers and federal regulations. A number of hospice providers to some hospice interventions. A clear, coordinated interviewed for this study reported that some surveyors written plan of care developed together by the nursing do not fully understand hospice regulations. Specific home and the hospice can obviate some of these surveyor misunderstandings relate to control of the plan problems. But when the leadership of either entity is not of care, medication management, and resident eligibility invested in the relationship, there may be insufficient for hospice. These misunderstandings tend to trigger incentive for the nursing home care delivery staff various negative outcomes: surveyors misinterpreting to collaborate on the patient’s care plan, to suggest the scope of work that the regulations permit hospice improvements in the plan of care, or to contact the aides to perform in a nursing home; a greater number of hospice staff when the patient’s condition changes, deficiencies issuing from any given survey; and nursing requiring care plan modifications. home reluctance to enter into a hospice relationship because of fear of surveyor citations. The newly revised In stronger relationships, the leadership of both hospice (June 5, 2008) Medicare Hospice Conditions of and nursing home create a culture of collaboration that Participation (CoPs) may improve surveyor understanding allows for and encourages care plan coordination. In this and interpretation of hospices in nursing homes; in this regard, some hospices even develop special teams that regard, however, careful training and attention to the new circulate to various nursing homes to assure that patient CoPs will be important. care delivery is well coordinated with each facility. Lack of Hospice Access to Nursing Homes Nursing Home Staff Turnover Not all nursing homes have a relationship with a hospice. The staff turnover rate in California nursing homes is Some nursing homes feel they do not need hospice 67 percent. To the extent high staff turnover exists in because they believe their staff can provide good end-of- any particular nursing home, building a strong, durable life care without it. Other nursing homes have had such relationship with hospice providers is extremely difficult. negative experiences with individual hospices that they do (Turnover rates of hospice staff are not available, but not see the value of hospice as worth the significant effort anecdotally are perceived to be relatively low.) Since there that would be needed to make the relationship work. are no “standard” plan of care requirements, medication regimens, or other elements of clinical care delivery, the The number of nursing homes without a hospice hospice must provide frequent education to new staff —  relationship is a serious challenge because nursing homes a difficult task when both hospice and nursing home provide end-of-life care to so many patients, particularly staffing resources are limited. frail Medicare beneficiaries. Collaborative Care: Improving the Hospice-Nursing Home Relationship  |  5 Issues for Consideration Critical Education Opportunities This project’s key findings identify a need to develop, Training for Nursing Home Leadership and Staff provide, and fund enhanced education to support the Education programs should be made available for hospice-nursing home relationship. The project’s survey administrators and directors of nursing homes to help identified a number of opportunities to improve the them more fully understand: relationships between hospices and nursing homes, thus enhancing care delivery at the end of life for residents K What, when, and how hospice services can be of nursing homes and for hospice patients who are provided; moved to nursing homes to receive care. There is also an K What specific laws and regulations (particularly opportunity to improve understanding by federal and pertaining to inducement, fraud, and abuse) govern state nursing home surveyors regarding hospice. Also, hospice care in nursing homes; and acting on these opportunities may more broadly impact the care that is provided to non-hospice residents of K What the role is of hospice and nursing home staff, nursing homes. under their respective Medicare Conditions of Participation, in caring for a terminally ill nursing Individual hospices and nursing homes have a home patient. responsibility to collaborate to improve care at the end of life. A strong step in that direction would be for them to These programs should go beyond the minimum participate, and to the extent possible take a leadership education efforts from hospices to nursing homes role, in the programs of education described below. mandated by regulations of the Medicare Hospice Benefit. Nursing homes can collaborate with hospices But this important task should not be left to individual in this education, and trade associations can help providers. State and national trade associations can also standardize training by developing outlines to guide such take a significant role in educating their provider and programs. The National Hospice and Palliative Care consumer membership, as well as influencing policy Organization (NHPCO) has already taken a significant makers to support and fund education of clinical care lead in such training and could serve as a model for these delivery staff and related consumer awareness campaigns. efforts. NHPCO training resources can be found at As the need for hospice services continues to expand and www.nhpco.org (public use may require authorization the terminally ill population shifts increasingly to nursing from NHPCO). homes, trade associations will be in a unique position to inform on, and provide professional and paraprofessional Training for Hospice Leadership and Staff training in, the benefits of hospice care delivery in nursing Education programs should be made available for hospice homes. leadership and staff to help them better understand nursing homes and more effectively communicate Finally, philanthropic organizations also have a role, and collaborate with nursing home staff. This could to support and fund critical training areas to ensure include efforts to help hospice staff become more improvements in quality and care delivery. familiar with nursing home structures and procedures, facilitate two-way communication, successfully introduce themselves into a new nursing home setting, and address the needs of a nursing home and its staff. Part of such an education program could incorporate reflection 6  |  California HealthCare Foundation by hospice leadership about the role hospice agencies Expert Attention to Staff Turnover themselves play in creating strains on the relationship Factors influencing staff turnover in nursing homes have between hospices and nursing homes. been addressed in a variety of forums, and the relationship between nursing home staff turnover and quality of care is One way to introduce such education would be to make known. Turnover also has a profound effect on end-of-life existing certification programs for hospices and nursing care delivery, and on the often poor relationship between homes, currently provided by private organizations and hospice and nursing homes. As hospice care delivery in state trade associations, a requirement to obtain state nursing homes continues to increase, nursing home staff and federal funding. For example, California regulations turnover will become an even greater barrier to hospice already specify that certain credentials are required to patient care delivery. Implementing practices to reduce be an administrator or director of patient care services. turnover should be a high priority for payers, providers, These could be strengthened by requiring staff training in and consumers. certain fundamentals of hospice care in nursing homes. Clarification of Surveyor Guidelines Training for Consumers In collaboration with key state hospice and nursing home Education programs should be provided to consumers to leaders, state surveyor guidelines should be updated to help them better understand hospice and its value in a clarify: who is an appropriate patient for hospice services nursing home, as well as how to effectively request such in a nursing home; what are the appropriate roles for care. Educational materials need to be developed, to be hospice and the nursing home in caring for the terminally provided to potential hospice patients and their families ill (especially the role of facility nursing assistants and in a nursing home. Trade associations can play a major hospice aides); and what are the expectations for and by role in developing and producing such programs and hospice in a nursing home. State trade associations can materials. and should serve as a driver of such efforts to improve the understanding of surveyors about the specific nature of Coordinated Action Among CMS, Surveyors, care delivery by hospices in nursing homes. Hospices and Nursing Homes Facilitated Meetings Meetings between the Centers for Medicare & Medicaid Services (CMS), state surveyors, hospices and nursing homes would help all parties better understand hospice care in nursing homes. Such meetings should address issues including: how and why different medications and treatments are used by hospice; how to reduce the level of required documentation by a nursing home for hospice patients; and how to develop a single collaborative care plan that can meet both hospice and nursing home regulations for care plan documentation. Collaborative Care: Improving the Hospice-Nursing Home Relationship  |  7 Appendix: California Hospice Payment and Benefit Structures Overview patient is dually eligible for both Medicare and Medi-Cal, For a hospice patient in a nursing home, the hospice the hospice bills the state for 95 percent of the normal is responsible for providing all core hospice services Medi-Cal skilled nursing facility room and board rate. The (nursing, physician care, social work, and counseling), plus hospice then pays the nursing home for room and board, medications, supplies, and durable medical equipment. The the actual amount negotiated between the hospice and the nursing home provides room and board, and care unrelated nursing home. Following written guidance and oversight to the terminal illness. by the DHHS Office of Inspector General, the hospice is not to pay the nursing home at more than the normal room Approximately 86 percent of all hospice patients in and board rate. Because hospice is in a highly competitive California nursing homes are under the Medicare Hospice market, most hospices pay the entire room and board Benefit, with 6 percent more receiving hospice care under payment they receive directly to the nursing home. Medi-Cal.1 Medicare pays the hospice directly, based on which of four levels of care the patient is receiving. Three A small number of nursing home residents on hospice have levels of care are paid on a per diem basis; the fourth, Medi-Cal coverage but not Medicare. In those cases, the continuous care, is paid at an hourly rate. If the patient is hospice provider receives payment from Medi-Cal at rates dually eligible for both Medicare and Medi-Cal, then the set for each level of care, and also receives 95 percent of the state also pays the hospice provider directly for the patient’s nursing home’s Medi-Cal room and board rate, out of which room and board, and the hospice in turn pays the nursing it pays the nursing home. home based on their contractual arrangement. General Inpatient Care From its Medicare payment, the hospice pays the nursing General Inpatient Care (GIP) is provided to a hospice home for the drugs, supplies, and durable medical patient who meets hospice acute care criteria, whether in equipment provided by the nursing home and related to the a hospital or nursing home. At this more intensive level terminal illness. The hospice and the nursing home negotiate of hospice involvement, the patient is visited frequently the rates the hospice will pay the nursing home for the by hospice staff. GIP involves short-term pain control or services, drugs, and supplies provided. From the remaining acute symptom management when care cannot be provided funds, the hospice covers its expenses related to patient care. in another setting. In 2006, an estimated 2 percent of all patient days were GIP.1 The base payment rate for GIP in Medicare and Medi-Cal Hospice Benefits 2008 is $601.02.6 Medicare and Medi-Cal follow the same reimbursement guidelines, with Medicare rates serving as the basis. Inpatient Respite Care Inpatient Respite Care is provided when the family needs There are four levels of care under the Medicare Hospice short term relief to prevent caregiver burnout. It is offered Benefit. For each level, the hospice is paid a per diem for at infrequent intervals of no more than five consecutive each resident day (or an hourly amount for continuous care). days. Because nursing home regulations require significant Actual amounts vary depending on the patient’s geographic paperwork for such a short stay, many nursing homes are location within the state. reluctant to admit hospice patients for respite care. The base Routine Home Care payment rate for inpatient respite care in 2008 is $139.76. Routine Home Care enables hospices to visit patients in Continuous Home Care their home, whether a private residence, a nursing home, Continuous Home Care is provided during brief periods or an assisted living facility. At this care level, the hospice’s of patient crisis. It is comprised predominantly of nursing interdisciplinary team provides intermittent service. In 2006, care for at least eight hours during a 24-hour period. an estimated 97 percent of all patient care days were routine Because of its intensity, many smaller hospices do not home care.1 The per diem base payment rate for routine have the capacity to provide this level of care. For those home care in 2008 is $135.11.6 hospices that are able to provide it, continuous care can be a Room and board can be paid by the resident with private significant competitive advantage. The base payment rate for pay, private insurance, or Medi-Cal (Medicaid). If the continuous home care in 2008 is $788.55 (billed hourly). 8  |  California HealthCare Foundation About the R e s e ar c h P art n e r Endnotes The Corridor Group, Inc. (TCG) of San Francisco, CA and 1. National Hospice and Palliative Care Organization. Overland Park, KS, provides consulting, executive search, December 2007. NHPCO 2006 National Summary of and educational resources to the home care industry. TCG Hospice Care, SUPPLEMENT: State Comparison Report. staff and associates involved in this report were Jeannee 2. R.I. Gen. Laws, Section 23-17.16-1 et seq. Parker Martin, R.N., M.P.H. (president and co-owner of The Corridor Group, Inc.); David English, D.B.A; and Cheryl 3. Federal Register, Part II, Department of Health and Musial, R.N., B.S.N. More information on TCG is available Human Services, Centers for Medicare & Medicaid at www.corridorgroup.com. Services. 42 C.F.R. §418, Medicare and Medicaid Programs: Hospice Conditions of Participation; Final Rule, 73(109), 32204 – 32220, June 5, 2008. About the F o u n d at i o n 4. Miller, S.C., V. Mor, and J. Teno. 2003. “Hospice The California HealthCare Foundation is an independent Enrollment and Pain Assessment and Management philanthropy committed to improving the way health care in Nursing Homes,” Journal of Pain and Symptom is delivered and financed in California. By promoting Management, 26(3), 791 – 799. innovations in care and broader access to information, our goal is to ensure that all Californians can get the care they 5. Miller, S.C., P. Gozalo, and V. Mor. 2001. “Hospice need, when they need it, at a price they can afford. For more Enrollment and Hospitalization of Dying Nursing Home information on CHCF, visit us online at www.chcf.org. Patients,” American Journal of Medicine, 111:38 – 44. 6. CMS-CR 5685, Update to the Hospice Payment Rates, Hospice Cap, Hospice Wage Index and the Hospice Pricer for FY 2008. Issued June 29, 2007. Effective for care provided on or after October 1, 2007, through September 30, 2008. (Note: Proposed hospice wage rates for FY 2009 were issued May 1, 2009 in CMS-1548-P.) Collaborative Care: Improving the Hospice-Nursing Home Relationship  |  9