Hospice/Nursing Home Interface

Guidelines for Care Coordination for Hospice Patients Who Reside in Nursing Homes

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SECTION III - CONTRACT CONSIDERATIONS

The following list of key considerations during hospice/nursing home contract negotiations is meant to assist providers in effectively coordinating provider services to the hospice patient receiving routine home care who resides in a nursing home.  While by no means all-inclusive, these factors reflect many provisions found in the hospice and nursing home regulations and were compiled from comments and guidance distributed by authoritative state (Bureau of Quality Assurance) and federal (Centers for Medicare and Medicaid Services) sources.

The information that follows is specifically pertinent to the routine home care contract.  It is not intended to comprehensively address considerations for inpatient and respite care, which hospices and nursing homes may elect to include as part of the same contract or as separate contracts.  Providers are encouraged to review the following contract considerations, but since the listing is not exhaustive, are cautioned to also review their respective regulations, insurance and liability concerns, financial position and attorney's advice prior to entering into any formal contract.

CONSIDERATIONS FOR THE HOSPICE "ROUTINE HOME CARE" CONTRACT

1. The hospice/nursing home agreement must be in writing.

2. The written agreement must specify that (1) the hospice takes full responsibility for professional management of the patient's hospice cares, and (2) the nursing home provides room and board.

3. Hospice must provide the same services that it would otherwise offer if the patient was in a private residence, including necessary medical services and inpatient care arrangements.

4. The written agreement should identify a dispute resolution mechanism to be utilized in the event of conflict or disagreement.

5. Hospice may not discharge a hospice patient at its discretion, even if care promises to be costly or inconvenient.

6. Statute/regulation prohibits a hospice from discontinuing care to a Medicare beneficiary due to inability of the patient to pay.

7. References to specific government agencies can often be misleading and should be omitted from contract language, refer more generally to "state" (or "federal") regulations, rather than "CMS," "BQA," etc.

8. Admission criteria and requirements must be identical for all individuals regardless of payment.

9. The agreement should specify the exact services, and extent of services, that will be provided individually by the hospice and nursing home.

10. The agreement should specify the exact responsibilities of each provider in the provision, and coordination, of care and services.

11. Substantially all core services must be routinely provided "directly" by hospice employees, and must not be delegated. . (Interpretation of "directly" is that the person providing the service for the hospice is a hospice "employee." "Employee" includes paid staff and volunteers under the jurisdiction of the hospice (see 42CFR 418.3 (exit DHFS).

12. Hospice must provide the following core services through its own employees:

• Physician services (DSL-BQA-99-039, Variance of 
  HFS 133.43 (2) (a) 1)

• Nursing services

• Medical social services

• Counseling services

13. Hospice may not contract with the nursing home to provide core services.

14. The nursing home may provide non-core services based on the contract. Hospice MUST assume the overall professional management responsibility for the services and assures that these services are performed in accordance with hospice policy and the hospice plan of care.

15. Routine room and board services to be provided by the nursing home including:

• Personal care services

• Assistance with activities of daily living (ADLs)

• Administration of medications

• Social activities

• Room cleanliness

• Supervision/assistance with DME use and prescribed therapies

16. Hospice must include the patient's attending physician in the care planning process.

17. Hospice certification and licensure requirements does not require designation of a primary caregiver, although individual hospices can require this as a prerequisite to admission.

18. Identify the terms and procedure for formal review and renewal of the hospice/nursing home relationship on a regular basis.

1. At the time each hospice patient/resident is admitted to the facility, the nursing home must have physician (attending and/or hospice medical director) orders for the recipient’s immediate care.

2. Both providers must specify who is responsible for obtaining, administering and controlling of medications.  This includes access to emergency medications.  If self-administration is indicated, the contract must delineate the provider responsible to ensure that medications are labeled appropriately and have not expired. (HFS132)

3. Contract must specify that patient confidentiality will be maintained and that hospice staff have access to nursing home records and vice-a-versa.

4. All information relevant to the patient's care must be shared and contained in the medical records compiled by both the hospice and nursing home.  (Caution: The term "relevant" must be interpreted broadly enough to avoid inadvertently failing to share marginally relevant information.)

5. Except where dictated by state or federal regulations, identify which provider will retain "originals" and which provider will retain "copies" of pertinent documents in the medical record.

6. Specify a procedure for the prompt and orderly communication of general information, MD orders, etc., between the providers.

7. Identify who will be responsible for completing various parts of the MDS document. The hospice provides information about the patient/resident for completing the required Minimum Data Set (MDS) for nursing home resident assessment and care plans. The nursing home is responsible to assure that the MDS is complete and submitted to the state in accordance with the nursing home requirements.

8. The hospice and nursing home must jointly coordinate the development, implementation and evaluation of the comprehensive plan of care. This comprehensive plan of care must be implemented according to accepted professional standards of practice.

9. The comprehensive plan of care must clearly delineate each provider’s responsibility for the patient specific care and services.

10. Aside from hospice responsibilities that are part of the core requirements, include a statement that the comprehensive plan of care must specify the individual responsible for carrying out each intervention.

11. Specify a procedure that clearly outlines the chain of communication between the hospice and nursing home in the event a crisis or emergency develops, a change of condition occurs and/or changes to the plan of care are indicated.  Hospice must authorize all changes to the plan of care prior to the change being made.

12. Each provider must be aware of the other's responsibilities in implementing and updating the plan of care.

13. Hospice must ensure that hospice services are always provided in accordance with the plan of care, in all settings.  The nursing home must ensure that its services are provided in accordance with the plan of care.

14. Hospice may involve nursing home nursing personnel in the administration of prescribed therapies, as they would use the patient's family/caregiver in implementing the plan of care.

15. Hospice is responsible for making all inpatient care arrangements (symptom control and respite).

16. Specify bed hold requirements.

1. A key consideration for both the hospice and nursing home is the extent to which services will be directly provided by hospice with its own staff, since hospice receives the payment.

2. A hospice may use contracted employees for core service only during:

• periods of peak patient load

• extraordinary circumstances

3. For a hospice, "employee" is defined in 42 CFR 418.3 and HFS 131.13 (7).

4. Nursing home employees may be employed by the hospice to serve hospice during non-nursing home employment hours.  Essential requirements for this to occur include :

• accurate time records and wage and hour compliance issues

• clear delineation of responsibilities (intent is to avoid 
  allegations of dual reimbursement) or confusion. For example: nursing home staff might assume that aide or RN providing hospice care is providing nursing home care as well.

5. The hospice and nursing home will ensure that all state and federal employment regulations are met.  Individual employer records will be kept by each entity and shared with the other entity as specified in the contract.

6. Specify orientation and ongoing training development requirements.

1. Specify which entity is responsible for billing the cost of specific services and determining to whom billing is directed.

2. Specify procedure for managing patient's social security liability payment when patient has elected the Medical Assistance hospice benefit.

The following chart briefly summarizes various reimbursement mechanisms for hospice care provided in a nursing home:

* In rare cases, if it can be demonstrated that skilled nursing care as defined by Medicare is needed for care not related to the terminal illness, Medicare Part A will pay for nursing home care under normal Part A Medicare and Hospice services under the Medicare Hospice Benefit.

SAMPLE PROVISIONS FOR INCLUSION IN A HOSPICE/NURSING HOME CONTRACT

Initially developed for the first edition by:

Jan A. Erickson, Former Director of Legal Services, Wisconsin Health Care Association; and Mary H. Michal, Shareholder, Reinhart, Boerner, VanDeuren, Norris & Rieselbach, S.C.

Revised for the second edition by the HOPE of Wisconsin

The following sample contract provisions are provided for use when developing the format of a hospice-nursing home contract. . Since it is essential that the contract process be individualized to best meet the particular circumstances of the contracting parties, these sample provisions are intended for general reference only.

This document does not purport to be all-inclusive or "model" in nature.  It will likely need to be changed in at least several respects to accurately conform to the intentions of each party.  For example, exact terms used in the "Definitions" section will probably vary among providers, and certain other sections might be more easily addressed in combination under one general topic heading.  In addition, providers may prefer to include additional provisions and section, which are not included among the samples in order to provide greater detail and clarity to their agreement.  Therefore, while providers should feel free to review these sample provisions (as well as others) during preliminary contract negotiations, the format of their actual contract should always reflect the individuality of their specific relationship.

1. Recitals

2. Definitions (particularized to individual needs and terminology)

   Attending Physician Care Manager Covered Services Facility Hospice Hospice Care Hospice Medical Director Hospice Services Routine Home Care Inpatient Respite Care Continuous Care Inpatient Acute Care

   Informed Consent Interdisciplinary Group Non-covered Services Nursing Home Medical Director Patient Care Management Plan of Care Residential Hospice Patient Respite Care Room and Board Services Other Pertinent Definitions as Identified by the Parties Bed hold

3. Eligible Residents (criteria)

• Medicaid Eligible

• Medicare Eligible

• Medicaid/Medicare (dual eligibility)

• Private Insurance or HMO

• Private Pay

• Other Pertinent Sections As Identified by the Parties

• Admission Procedures (general process, written orders, authorizations)

• Patient Care Management (decision process, delegation of responsibility)

• Continuity of Care (transfers between levels of care, actions requiring patient notice)

• Communication Process (detail the process generally and for emergencies)

  • notification of MD (change of condition, death, etc.)

  • notification of hospice

• Interdisciplinary Team Meetings

• Quality Assurance/Performance Improvement

• Drugs and Pharmaceuticals

• Medical Equipment and Medical Supplies

• Transportation and Ambulance

• Family Services and Bereavement Care

• Other Pertinent Sections as Identified by the Parties

• Hospice Services (general coverage under Routine Home Care), Access and Availability

• Provision of Core Services

• Compliance with Law (including licensure, staff qualifications)

• Hospice Patient Care Management

• Management of the Terminal Illness: Plan of Care

• Medical Order: Responsibilities of Attending Physician

• Medical Order Procedures

• Documentation (clarification of respective duties, location of original medical record)

• Confidentiality of Medical Record

• Orientation and Education

• Other Pertinent Sections as Identified by the Parties

• Facility Services (generally, room and board, specific services, plan of care, cooperation with hospice in identified areas, bedhold policy)

• Compliance with Law (including licensure, staff qualifications)

• Availability of Nursing Home Care (hours of care, adequate services, personnel)

• Documentation (clarification of respective duties, location of original medical record)

• Facility Staff Privileges: Hospice Medical Director

• Access to Documents (medical/business records, federal record retention requirements for facility, subcontractors)

• Orientation and Education

• Other Pertinent Sections as Identified by the Parties

• Responsibility of the Hospice

• Responsibility of the Facility

• Reimbursement

  • Medicaid Patients

  • Medicare Patients

  • Medicaid/Medicare Patients

  • Private Pay/Insurance Patients

  • Purchase of Services by the Hospice from the Facility

  • Other Pertinent Sections as Identified by the Parties

8. Insurance and Indemnification

9. Joint Review of Hospice Services (quality, appropriateness)

10. Compliance with Government Regulations (caregiver background checks, nurse aide registry, corporate compliance, etc.)

11. Relationship Between the Parties

12. Conflict Resolution Process

13. Term of the Agreement (length, renewals)

14. Termination of the Agreement (for cause/without cause, events precipitating regulatory implications, resident transfers and single-case continuation agreements, resident notice timeframes)

15. Amendments to the Agreement

16. Notice Requirements (form, method, and delivery)

17. Miscellaneous (Including Non-discrimination Policy)

18. Other Pertinent Sections as Identified by the Parties

19. Appendices (if desired, may include references to provider policies, clinical protocols and procedures; see also: "Clinical Protocols" and "Educational Planning" documents for possible policies and protocols.)

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