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Carefully select long-term care partners
Look at reputation, reg compliance
Any contract with another organization requires careful attention to details, regulations, and legal issues, but hospice agencies need to pay special attention when contracting with a long-term care facility to provide services, says Meg S.L. Pekarske, JD, an attorney with Reinhart Boerner in Madison, WI.
"There are many advantages to a relationship between a long-term care facility and a hospice agency, but because each organization is governed by different regulations and has a different focus on patient care, a contract needs to address the differences," explains Pekarske. The contract can specify which services are provided by each organization so that regulatory requirements are met, she adds.
Before establishing a contracted relationship, hospice managers need to understand the potential risks of collaboration, says Pekarske. "The hospice is responsible for compliance issues, so it is important that contracts and protocols reinforce the need for nursing home personnel to report a change of condition to the hospice," she says. A hospice visit to the patient due to a change in condition can reduce hospitalizations or trips to the emergency department, Pekarske says. This service is important because most hospice patients don't want to go back to the hospital, she adds.
Because nursing homes have RNs and LPNs on staff, there is someone to observe the patient and report a change, Pekarske says. "It is more of a challenge in assisted living facilities because there are different levels of assisted level care with different regulations, and there is not always a nurse on site," she explains. With assisted living facilities, the hospice and the assisted living provider need to work out a protocol to address this issue, Pekarske says.
Liability insurance is another key point to address in a contract, says Pekarske. "Assisted living facilities are typically small providers who may not carry the level of insurance coverage required for hospice care," she says. With the level set at $1 million per incident and $3 million aggregate, small assisted living facilities won't buy the coverage, Pekarske adds. "In this case, the hospice manager needs to make a business decision as to whether or not the agency will enter into an agreement with the facility," she says. "The risk is that if there is an incident, the hospice becomes the deep pocket for any lawsuit related to the patient."
The insurance coverage may be an issue for some nursing homes as well, she adds.
Be aware of fraud, kickback potential
Hospice agency managers also need to look out for any kickback or fraud issues, suggests Pekarske.
"Nursing homes don't deal with fraud statutes as much as hospice agencies do, so they don't recognize the potential for fraud in many cases," she says.
Be careful not to guarantee a certain number of certified nursing assistant days for all hospice patients, she points out. Guaranteeing a number of days without producing an individual care plan and documenting appropriateness of service will raise a red flag, she says.
Although hospice agencies can purchase services from nursing homes or assisted living facilities that are related to the hospice care of the patient, these services must be priced at fair market value, points out Pekarske. "A hospice cannot pay a nursing home for services that are covered by the nursing home's room and board rate because a facility cannot be paid twice for the same service," she adds. "Be sure to check your state's laws as well as federal laws to make sure that you understand what is allowed."
Hospice agencies need to select their relationships carefully, suggests Pekarske. Look at the reputation of the provider in the community, study Nursing Home Compare, ask the provider how they have addressed any compliance issues identified in their surveys, ask about the acuity of their population to see if they have potential hospice patients, and evaluate the staffing of the facility, she says. (Editor's note: To access Nursing Home Compare, go to www.medicare.gov, then under "Search Tools," select "Compare nursing homes in your area.") You want to make sure the long-term care facility is staffed appropriately to handle day-to-day care of all patients and is not looking for a hospice to supplement staff to handle nonhospice duties, Pekarske explains. Be sure to choose a partner that provides the same quality of care that your organization provides, she adds.
Agencies also should plan their entry in long-term care partnerships carefully as well, warns Pekarske. "There are many problems with establishing as many contracts as possible when you start a long-term care program," she says. A lot of contracts may generate a lot of referrals, but if you are not prepared for the extra patients at a large number of facilities, you won't provide good service and you won't help your own reputation, she explains. "It is better to contract with a few facilities at first as you develop the infrastructure to handle growth," she suggests.
The issue of long-term care and hospice partnerships is an extremely important issue that will only become more important in the future, says Pekarske. "We have an increasing geriatric population with no easy answers as to how to best provide care, but partnerships between long-term care and hospice will grow because it is one way to provide care to patients and their families in a setting of their choice," she says.