Medicare Hospice Benefits and More

Presented by: XXXXX

Introductions

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Objectives• Overview of the TRUE project• Explore triggering events for a hospice

referral• Explore strategies for communication with

primary physician about a hospice referral• Describe the Medicare hospice benefit and

services

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Stratis Project Team

Stratis Health Staff• Janelle Shearer, RN, MA, CPHQ, Program

Manager• Laura Grangaard, MPH, Research Analyst

Subject Matter Experts• Barry Baines, MD• Lores Vlaminck, RN, BSN, MA, CHPN

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Local Project Hospice Lead(s)• Insert from Speaker Notes

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Targeting Resource Use Effectively (TRUE)

Goal: Optimize hospice use– Increase appropriate referrals to hospice– Increase the length of stay of hospice

patients (days of care)

How: By forming multidisciplinary community based teams to implement strategies to address barriers to optimal hospice use in the XXXXX community

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What is the Reality?

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The Medicare Hospice Benefit is Widely Underutilized• The median (50th percentile) length of stay in

hospice was 18.7 days in 2012• 30% of all Medicare Beneficiaries enrolled in

hospice died within three days or less• 35-40% of patients enrolled in hospice died in

seven days or less– NHPCO 2012 Data

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Triggering Events for a Hospice Referral

Triggering Events for Hospice Referral• Recurrent infections

• Recurrent hospitalizations/clinic visits

• Repeated home care admissions

• Declining health

• Weight loss

• Decrease in independence in ADL’s

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Triggering Events for Hospice Referral cont’d• Increase in pain/interventions

• Unexplained weight loss

• Patient/family request

• Change in goals of care

• Provider referral

• Other

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Opportunities for Conversation• Expressions of spiritual/social distress

affecting daily life• Quality of life/patient stated goals for

care/interventions in conflict• Expressed desire for advance care planning

or revision of current plan• Lack in clarity of goals• Conflict among family members

and/or patient

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Communicating with Physicians & Providers

Suggestions…

• Gather the facts– Assessments

• (Demonstrating comparison and contrasts)

– Observations of client• Recount expressed feelings, behavior, emotions

– Patient complaints• Pain, fatigue, weight loss, depression, etc

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Suggestions… cont’d

– History of ER visits, clinic visits, home care readmissions

– Patient/family stated questions/comments (if any)

– Caregiver observations– Advance Care Directives– Other

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Phrasing….• Frame the conversation:

– I am calling you about ______________.– During the past _________(time) I have

noted the following of our mutual patient.• Share your assessments/observations• Patient/family quotes• Concerns

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Shared Decision-Making

Between Physician and Patient:• Physician’s Responsibility:

– Inform and recommend best treatment option(s)

• Patient’s Responsibility: – To choose or refuse treatment option(s)

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Hospice and the Hospice Medicare Benefit

Hospice

• Definition-philosophy and services

• Benefits

• Eligibility

• Guidelines

• Level of Care/Reimbursement

• Transfers/Revocation/Discharge

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Hospice PhilosophyHospice is based on a Philosophy which embraces six significant concepts:

• Death is a natural part of life. When death is inevitable, hospice will neither seek to hasten or postpone it.

• Hospice care establishes pain and symptom control as an appropriate clinical goal.

• Hospice recognizes death as a spiritual and emotional as well as physical experience.

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Hospice Philosophy• Patients and their families are a unit of care.

• Bereavement care is critical to supporting family members and their friends.

• Hospice care is made available by most hospices regardless of the ability to pay.

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Hospice Today

• Over 5300 hospice programs nationwide

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Holistic Needs-Holistic Care

• Physical

• Spiritual

• Emotional

• Psychological

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Hospice Team Members

• Medical Director/Attending Physician• Nurses (RN on-call 24/7)• Social Worker• Chaplain/Counselor• Volunteers (Active and Bereavement)• Hospice Aide• Therapies (PT/OT/ST)• Registered Dietician• Pharmacist

– Pet Therapy– Massage/Music– Other

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Who Qualifies for Hospice Care?• Terminally ill persons whose life

expectancy is six months or less given the current progression of their disease process (any age-any diagnosis)– Minnesota Medical Assistance ≤ 12 months

• Patient is seeking palliative care rather than curative treatment

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Local Coverage Determination Guidelines for Hospice• CMS Provides guidelines for hospice admission

– Alzheimer's and related dementia– Cardiac disease– Lung disease– Liver disease– Acute and chronic renal disease– Stroke and coma– AIDs– ALS– Cancer– General decline in status

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Primary Hospice Diagnosis 2012

• Cancer 36.9% • Non-Cancer Diagnoses 63.1%

– Debility Unspecified 14.2% – Dementia 12.8% – Heart Disease 11.2% – Lung Disease 8.2% – Other 5.2% – Stroke or Coma 4.3% – Kidney Disease (ESRD) 2.7% – Liver Disease 2.1% – Non-ALS Motor Neuron 1.6%– (ALS) 0.4% – HIV / AIDS 0.2%

NHPCO published 2013

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Levels of Care

• In-home

• Respite

• Continuous Care

• General Inpatient

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Medical Supplies

• Per diem includes all supplies to terminal illness and related conditions

• Wheelchair• Walker• Oxygen• Wound care• Incontinent products• Dressings• Ostomy supplies• Other

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Medications

• Per diem includes all medications related to the “terminal and related conditions

• Hospice may charge $5.00 co-pay for medications

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Palliative Care Treatment Measures

• This may include: Chemotherapy Radiation Blood products Enteral feedings IV fluids Dialysis Surgery Other

“Palliative” care

measures as

approved

by the IDG team

related to the

alleviation of pain

and suffering

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Transportation

• Emergency transportation by ambulance is covered by hospice if approved by Hospice Team and deemed the mode of transportation needed for transfer

• Non-emergency transport not mandatory-individual agency decision

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Who Pays for Hospice Care?

• Medicare• Medical Assistance• Most Insurance

Plans• Private Pay• Long Term Care

Insurance

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Revocation

• Patient and/or family initiated

• Requests revocation of the hospice

• No penalty to patient to re-enroll

• Patient signs statement of revocation on effective date

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Discharge

• Hospice provider may initiate if:– Patient moves out of service area– Patient is no longer deemed terminally ill– Chooses facility in which hospice does not

have a contract– Behavior is disruptive, abusive, or is

uncooperative

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The Reality Again – Expressed by Patient and Family

• “I wish I had enrolled in hospice sooner”

• “I didn’t realize all the support hospice offered”

• “Why didn’t my doctor tell me about hospice?”

• “Why didn’t I know about hospice?”

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Average Length of Stay in Hospice in Days

• 2012 - 35.5% died/discharged in ≤ 7 days

• 2012 - 71.8 average length of stay

• 2012 - 18.7 median length of stay

NHPCO Data 2013

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Questions

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Contact Information

XXXXXXX

XXXXXX

www.stratishealth.org

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Stratis Health is a nonprofit organization based in Minnesota that leads collaboration and innovation in health care quality and safety, and serves as a

trusted expert in facilitating improvement for people and communities. 

This templatewas prepared by Stratis Health, the Quality Improvement Organization for Minnesota, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the US Department of

Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-MN-SIP TRUE HOSPICE-14-68 050214