Written agreements set clear delineation of duties

Meet regulations with upfront discussions

One of the challenges to providing hospice care in a nursing home is identifying all of the regulations that govern each organization and, in some cases, might conflict with each other.

A written contract with a nursing home in which a hospice provides care is a requirement of the Conditions of Participation (CoPs) for Hospice, points out David Simpson, president and CEO, Hospice of the Western Reserve in Cleveland.

"We use a standard agreement with all of our nursing homes that identifies each organization's responsibilities and makes sure that we meet the regulatory requirements we must meet," Simpson says. "We also create a profile of the nursing home that gives our staff information such as how to enter the nursing home at different times of the day, where to document, where medications are kept, with whom to communicate when in the nursing home, and any other tips that will make their patient visits go more smoothly."

All of the information is communicated to the clinical teams assigned to that facility, and it is also easily accessible on the hospice's intranet, he adds.

Occasionally, Simpson's hospice encounters a nursing home that is prohibited by the company's headquarter policies to enter into a facilitywide agreement with a hospice. "In these cases, we will sign an agreement for an individual patient rather than the facility," he says. If the nursing home does not want to sign an individual agreement, the hospice cannot provide services unless the patient transfers to another facility, Simpson adds.

CoPs also call for a coordinated plan of care that includes the nursing home but reflects the hospice facility and focuses on the individual patient's needs. Bridget Montana, MS, APRN, MBA, chief operating officer for Hospice of the Western Reserve, says, "Sometimes the nursing home wants to use us as a resource to provide what they want to patient to have, vs. what the patient needs. We might choose to use different medications than they use because it is better for the patient's situation, but the nursing home staff might want to stay with the medications they know." Because the patient is a hospice patient, it's important to focus on what they need, Montana adds.

Throughout the agreement, the plan of care, and subsequent patient care, make sure hospice staff members strictly follow Medicare regulations, says Simpson. "The Medicare hospice benefit is a substitute benefit to the nursing home benefit, so there should not be any 'double-dipping' for duplicate services," he says. "That is why the initial agreement is important."

The hospice and nursing home regulations can be very complex so both organizations have to be diligent about certifications for hospice, recertifications, and discharges, says Linda Todd, RN, executive director of Hospice of Siouxland in Sioux City, IA. "We are all under increased Medicare scrutiny, especially as the number of hospice patients served in nursing homes increases," Todd says. "Medicare sees the potential for fraud and will be watching closely."