Hospice bridge programs raise serious questions

Pre-hospice may be problematic under regulations

As federal and state regulatory forces zero in on hospice admission practices and patients’ terminal prognoses, many providers are looking for ways to support seriously ill patients who don’t quite fit a strict interpretation of the Medicare regulations. For a growing number of hospices, bridge or pre-hospice programs offer counseling and various other components of hospice as transitional care for patients who are not yet ready for hospice but may eventually qualify. However, even if these services are provided for free, they may raise unanticipated questions with regulators.

The Arlington, VA-based National Hospice Organization (NHO) recently surveyed hospices about their bridge programs. More than 200 agencies responded, describing a variety of programs offering different mixes of services funded in the following ways:
- home health benefits (66%);
- donated funds (63%);
- commercial insurance (13%);
- grants (10%);
- patient self-pay (13%).

Joan Richardson, MEd, MSW, section manager for NHO’s National Council of Hospice Professionals, tells Hospice Management Advisor she designed the survey in response to a growing number of telephone requests for technical assistance. Although the survey results are not research-quality data, they shed light on what’s happening in this uncharted territory. "In some ways the survey raised more questions than it clarified, but there are a lot of unanswered questions in this area," she says.

Dually licensed hospices often use home health care benefits to cover some of their transitional or bridge services. But if so, they must be careful to meet all of Medicare’s home health requirements, such as the need for skilled care and homebound status. Medicare hospice definitions and conditions of participation raise additional questions. "You also need to look at state licensing and practice acts and explore liability issues with your insurance carrier — especially if the bridge program is a new business component," Richardson says.

"Everybody in this state is trying to get a home health license, at a time when running a home health agency is harder than ever, as a desperate attempt to improve length of stay in hospice," reports Bernice Wilson, RN, MS, executive director of the Ohio Hospice Organization in Columbus. "But they don’t want to be home health agencies. They’re grumbling about the requirements of the home health cost report. I’ll be interested to see if these programs actually get people on the hospice benefit sooner. Hospices have been sold on the idea that bridge programs will solve the problem, but it’s too early to tell," Wilson says.

In California, Operation Restore Trust surveys of hospices have put the brakes on bridge program development, at least until more definitive rulings are provided by HCFA. In response to the confusion, the California State Hospice Association (CSHA) is now seeking to identify a hospice program willing to submit to a mock survey of its separation of hospice and home health components, to be conducted by HCFA Region 9 hospice and home health surveyors, with CSHA and NHO representatives as observers.

"We hope this will help us more clearly understand how to keep hospice and home health patients separated," says CSHA executive director Margaret Clausen, CAE. The issue of providing free bridge program services remains an open question, "but if it turns out that it can’t be done, some hospices will be very disappointed."

"There are regulatory issues that are not very well understood but have to be understood and applied relative to calling these programs hospices or hospice care," concludes NHO president John J. Mahoney. "You can run into problems with the Medicare hospice conditions of participation, and you can run into problems if you’re also certified as a home health agency and providing services under the home health benefit. Medicare does not recognize bridge programs; that is quite correct," he says.

Providing free services is another muddy issue. "One hospice program providing free services may be in compliance while another providing the same services might not be. It goes back to purpose. If you are providing free services with the idea of inducement or that it might lead to a paid client in the future, or else providing free services in the facility of another provider with the idea of a relationship or future financial benefit, these are the kinds of questions that have to be asked," Mahoney says.

"Certainly the services provided have to be scrutinized but also the intent. It’s not enough to say ‘our interest is to provide access to hospice care.’ You have to go beyond that," he adds. Clearer interpretations have been requested from HCFA and from NHO’s legal counsel, "but people need to understand that there are no cut-and-dried guidelines that will apply across the board. These are fairly complex questions."