Hospice Services and the Nursing Home: Collaborating to Care for Residents at the End of Life

Providing High Levels of Care

The number of seriously ill nursing home residents eligible for end-of-life care is increasing. It is projected that by 2030 there will be 3 million nursing home residents, and half of them will age—and die—in the nursing home.

In light of healthcare reform and the Accountable Care Act, every nursing home must provide high levels of care. Hospitals have a mandate to limit readmissions. Quality and performance scores differentiate nursing homes in a sea of competition.

The Centers for Medicare & Medicaid Services (CMS) added language for surveyors reviewing the care of nursing home residents at the end of life. The regulatory language defines the following steps facility staff should take:

• Identify the resident’s prognosis and initiate discussions with the nursing home interdisciplinary team.
• Recognize and advise the resident and/or legal representative when the resident is approaching end of life. Provide education about palliative care options, including hospice.
• Provide and review a plan of care that supports the resident’s choices; manages pain and other symptoms; strives to meet physical, mental, psychosocial and spiritual needs.

Win-Win

A hospice provider working in partnership with a nursing home can improve quality of care at the end of life. Studies have shown that a strong presence of hospice in nursing homes increases palliative care for all residents and improves nursing home staff competencies. Hospices and nursing homes are a win-win partnership.

Listed below are some of the benefits of a hospice/nursing home partnership, at no increase in care costs for long-stay nursing home residents.¹

• Reduced hospital readmissions
• Increased performance scores
• Improved staff end-of-life competencies
• Facilitated conversations between residents and their families regarding treatment decisions

An interdisciplinary hospice team addresses the physical, emotional and spiritual needs of hospice-appropriate residents and their families. The hospice team assumes responsibility for the professional management of all care related to the terminal illness, including equipment, medications and supplies. Nursing home staff continue to offer those residents the same routine daily “home” care they have been providing.

Hospice staff also help families address emotional end-of-life options. With a better understanding of what to expect as the illness progresses, residents and their families are more likely to forgo futile treatments, trips to the emergency room and hospitalization.

Who is eligible?

To be eligible to receive hospice services under the Medicare hospice benefit, a nursing home resident must:

• Be eligible for Medicare Part A
• Agree that they want to receive palliative care rather than curative care
• Waive all other Medicare Part A benefits for care related to the terminal illness
• Have a prognosis of a life expectancy of six months or less if the illness runs its normal course

What to look for?

When a resident triggers multiple quality indicators, nursing home staff should consider a referral to hospice. Quality indicators of decline:

• Excessive weight loss
• New/worsened pressure ulcers
• Moderate to severe pain
• Depressive symptoms
• Increased need for help with ADLs (risk-adjusted for hospice)
• Long-stay residents whose ability to move independently worsened (risk adjusted for hospice & six-month prognosis)
• Long-stay residents who received an antianxiety or hypnotic medication (risk adjusted for hospice & six-month prognosis)

The hospice team caring for a resident in a nursing home fulfills the same role it would if the patient were living in a private home. That includes providing any necessary medical services the hospice would normally furnish to patients in their homes. Hospice services must be provided by the hospice staff and cannot be delegated to the facility. Hospice care may involve nursing facility personnel only to the extent that the hospice would routinely utilize the services of a patient’s family/caregiver.

Hospice staff must also orient facility staff in the hospice philosophy, including hospice policies and procedures regarding methods of comfort, pain control, symptom management, principles of death and dying, individual responses to death, patient rights, appropriate forms and record-keeping requirements.

Hospice staff can help answer surveyor questions regarding residents under care. They can assist in preparation for survey by providing your nursing home with documents supporting the terminality of residents, including:

• Hospice election form
• Physician’s written six-month prognosis statement with re-certifications at 90, 90 and every 60 days thereafter
• Advance directives
• Palliative care plan

Hospice can help

Death is a process, not an event. Appropriate care requires ongoing recognition, assessment and response. Clinical hospice staff are experts in controlling symptoms, such as pain, without invasive procedures. Hospice social workers and chaplains can assist in funeral arrangements; bereavement specialists offer support and resources to family and nursing home staff who are grieving.

Hospice can add to a nursing home resident’s end-of-life goals and to its staff’s end-of-life expertise.

Source: ¹ Kathleen Unroe, MD, MHA, et. al., “Impact of Hospice Use on Costs of Care for Long Stay Nursing Home Decedents,” May 5, 2016, published online ahead of print in the Journal of the American Geriatrics Association.