The Centers for Medicare and Medicaid Services has published its final rule governing hospice services under Medicare, a massive overhaul of standards for patient rights, comprehensive assessment of patients, care planning, and relationships between hospice programs and nursing homes. The rule, Medicare and Medicaid Programs: Hospice Conditions of Participation, will take effect Dec. 2.
The regulations echo those of the OBRA '87, which governs nursing homes, said Daniel Swagerty, MD, CMD, a past president of AMDA, of the University of Kansas center on aging in Kansas City. “The performance-improvement projects and quality-assurance provisions of the new Conditions of Participation [mirror] the progress of the quality of care that has been required in nursing facilities,” said Dr. Swagerty, who cochaired the AMDA working group that wrote the 2007 “White Paper on Palliative Care and Hospice in Long-Term Care.”
The new regulation is the first to set out a detailed list of rights for hospice patients. Specifically, patients deserve participation in their treatment plans, effective pain management and symptom control, and the right to choose their own attending physicians and to refuse treatment.
The final rule also prescribes the stages of each patient's care as follows:
▸ Initial assessment. A registered nurse will, within 48 hours after the patient elects hospice care, assess physical, psychosocial, and emotional status related to the patient's terminal illness and related conditions in order to provide immediate care.
▸ Comprehensive assessment. The hospice must complete the comprehensive assessment within 5 days of the patient formally electing hospice. This process is to be based on the hospice's policies and procedures as well as on the information gathered in the initial assessment.
▸ Plan of Care. A hospice interdisciplinary team, in collaboration with the patient's attending physician, must develop an individualized plan of care in accord with the information gathered in the comprehensive assessment.
▸ Update of the Comprehensive Assessment. The hospice should update each patient's comprehensive assessment no less frequently than every 15 days.
The rule also addresses the relationship between hospices and nursing facilities, requiring that they develop written agreements that specify how hospice services will be provided in a facility and that ensure communication between providers.
Elements of the agreement include written documentation of the patient's or a representative's desire for hospice services, identification of the services that the hospice and the facility would provide, the manner in which the facility and the hospice would communicate to meet the needs of the patient, a statement that the hospice assumes responsibility for determining and changing the appropriate course and level of care, and a provision that the hospice could use the facility's nursing personnel, as permitted by law.
When the hospice rule was first proposed in 2005, AMDA asked CMS to strengthen the role of the nursing facility and its medical director in the relationship with a hospice and hospice medical director. “The nursing facility medical director or attending physician has the responsibility of oversight of the patient's plan of care contingent on the advice, counsel, and agreement of the hospice medical director,” wrote AMDA.
While the CMS agreed that designated long-term care facility staff should actively participate in a patient's hospice interdisciplinary group, the new rule states that it's the hospice's responsibility to decide what care is provided, based on the information gathered during the patient assessments. But hospices are not permitted to delegate their responsibilities to the long-term care facility medical director and staff.
AMDA President Charles Crecelius, MD, PhD, CMD, said the new regulations give hospices specific guidance on working in the long-term care environment. “While the nursing facility medical director cannot unilaterally mandate services,” said Dr. Crecelius, he or she should “ensure services rendered are appropriate and thorough, and discuss concerns with the hospice medical director.”
William Smucker, MD, CMD, a hospice medical director in Westfield Center, Ohio, commented that, “LTC caregivers have the professional responsibility to contribute their unique knowledge and insights about patients and families to the creation of the hospice care plan.”
He added that the new rule's requirements for quality improvement activities “provide an excellent opportunity for both hospices and LTC facilities to work together on initiatives that recognize the unique challenges of shared care for frail elders living in long-term care.”
Other provisions of the new hospice rule include:
▸ A requirement that each patient receive a full drug assessment that examines issues ranging from the effectiveness of current therapies to potential drug interactions and side effects. A treatment team must consult with a qualified individual, such as a pharmacist, to ensure that drugs meet the needs of every hospice patient.
▸ Permission for Medicare-certified hospices to contract with each other for nursing, medical social services, and counseling services under extraordinary or other nonroutine circumstances, including travel of a patient outside of a hospice's service area.
▸ Removal of the requirement that an inpatient facility providing only respite care have a registered nurse on duty 24 hours a day. The patient's needs, acuity, and plan of care will drive the nursing and staffing requirements.
▸ A requirement that hospices have an infection control policy and procedure.
▸ Implementation of a mandatory quality assessment-performance improvement program in each hospice to continually boost responsiveness to the needs, desires, and satisfaction levels of patients and their families. Physicians are expected to be involved in the assessment and improvement process but are not required to direct it.
Judi Lund Person, MPH, a regulatory affairs specialist with the National Hospice and Palliative Care Organization, said her organization is pleased with the rule's clarification of the hospice-nursing home relationship.
She added that even more specifics should come in another rule now in the works. “It is CMS’ intention to issue a companion rule for nursing homes, so that both hospices and nursing homes would have complementary rules for the relationship,” said Ms. Lund Person.
The final regulations issued so far can be viewed in the Federal Register on CMS' Web site (www.cms.hhs.gov/CFCsandcops/05_hospice.asp).
Kathleen Wilson, PhD, is director of government affairs for AMDA.
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