March 01, 2011

As the scope of end-of-life diagnoses has broadened to people with dementia and adult failure to thrive, more residents of group homes, assisted living, and skilled nursing facilities are receiving hospice care.

This has always led to questions about which care tasks are the responsibility of the nursing facility versus the hospice, but Medicare has laid out some rules. The hospice provides and is reimbursed by Medicare for all treatments, medications, and durable medical equipment related to the terminal diagnosis – but not treatments, medications, or equipment not traceable to that diagnosis. The nursing home resident, through private insurance or Medicaid coverage, remains responsible for the costs of room, board, and medications unrelated to the terminal diagnosis.

In many frail elders, it can be difficult to parse which issue or problem is caused by which diagnosis. Issues of responsibility occur regularly. This tension became clear in the care of “Mrs. Brown,” an 87-year-old resident of our skilled facility. A longtime resident, Mrs. Brown had advanced Alzheimer's disease, congestive heart failure, seizure disorder, and peripheral vascular disease. When her dementia became severe enough that she could no longer verbalize her needs, the facility's unit nurse recommended her for hospice referral. Her attending physician agreed and the referral was made.

Although in nursing home medicine we typically work in interdisciplinary “teams” of professionals, in the jargon of hospice, the body coordinating a patient's care is an interdisciplinary “group” (IDG).

According to Medicare requirements for hospice certification, the IDG is required to discuss the condition and needs of each hospice-enrolled patient no less than every 15 days. And this rule is quite firm – there is no flexibility for Midwestern blizzards or staff illness.

The IDG must include a physician. According to Medicare rules, “The attending physician may be either a doctor of medicine or osteopathy or a nurse practitioner. This person is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual's medical care.”

The patient care coordinator (“Nurse” in the dialogues below) is a key IDG member who presents the case of each hospice patient – one at a time – at a group meeting. She or he reports the patient's medical status, any change in condition since the last IDG discussion, and whether the patient has had a fall, wound, infection, or medication change.

The IDG pharmacist reviews medications. The social worker reports on the psychosocial status of the patient, his or her family, and caregivers.

The chaplain reports on any spiritual issues that need to be addressed. The volunteer coordinator and bereavement coordinator chime in with their expertise. The patient-care manager, also a registered nurse, records everyone's issues and concerns and reviews recommendations from the last group meeting.

Initial IDG Meeting

Patient Care Manager: Mrs. Brown's Palliative Performance Scale is 40%. This means that she can't do any physical exertion, is mainly in bed, and requires assistance for most self-care. Her weight has dropped 15 pounds in the past 3 months and now her body mass index is 24 kg/m

She requires oxygen occasionally and is New York Heart Association functional class III. Both her caregivers at the nursing home and her physician feel she is hospice appropriate, with a prognosis of less than 6 months. Doctor, I need your decision as to which terminal diagnosis best fits Mrs. Brown's situation.

Medical Director: Mrs. Brown clearly meets criteria for hospice enrollment, but looking at her values, I think she fits best under dementia as the terminal diagnosis. You report that the medical record says she has Alzheimer's disease.

Pharmacist: Is there anything in the record to suggest that she has vascular dementia?

Patient Care Manager: No. She has never had a stroke or hypertension. She does have coronary heart failure and peripheral vascular disease, however.

Medical Director: Let's go with “dementia.”

Pharmacist (reviewing medication list): Dementia it is. We [the hospice] will be responsible for memantine, quetiapine, acetaminophen, and hydrocodone. Her other prescriptions remain the responsibility of the patient or the facility.

Two Weeks Later

Nurse: Mrs. Brown's condition has deteriorated. She now no longer gets out of bed and has to rely on caregivers for all her activities of daily living. She remains able to feed herself with assistance. A new problem has emerged: a stage II ulcer in the bunion on her right foot. We received an order from the attending and have started using a topical treatment on it. She has had tremors, but no definitive seizures. She has had no falls, no infections, and no wounds other than on the bunion.

Pharmacist: Please make note that the topical treatment for the bunion ulcer is a noncovered medication.

Nurse: Noted.

Eight Weeks After Enrollment

Nurse: The staff report that they have been consistent in repositioning Mrs. Brown every 2 hours. However, the patient continues to have the stage II ulcer on her bunion and now has a blister on her coccyx but not an open wound. Otherwise, she has not had a fall or an infection during the past 2 weeks. Shall I begin treatment for the coccyx?

Medical Director: I would recommend it. Please contact the attending and get the official order.

Four Weeks Later

Nurse: Mrs. Brown's bunion ulcer now cultures positive for drug-resistant MRSA. The facility contacted the attending, and he ordered a course of oral vancomycin. She now also has a stage II ulcer on her right hip, and the coccyx ulcer has progressed to a stage III. We have begun topical treatments for each of the wounds. I would like to order a specialized air mattress.

Medical Director: Agreed.

Social Worker: Mrs. Brown's family has a realistic outlook on her illness. They have made funeral arrangements and there appear to be no conflicts.

Chaplain: I visit Mrs. Brown every 2 weeks. She is Christian and was active in her church. Although she never speaks to me when I am there, she does mouth the words to the Lord's Prayer when I recite it. Her family seems to be at peace.

Recertification Meeting

Nurse: Mrs. Brown, an 87-year-old patient at the skilled nursing facility is on hospice with a terminal diagnosis of Alzheimer's disease. She has a Palliative Performance Scale of 30%, her FAST is 7C, and she has lost 11 pounds since starting hospice. She is now no longer feeding herself. She has multiple wounds: on her right bunion, coccyx, and both trochanters. She is on a specialized air mattress. She requires hydrocodone three times a day for pain. Here is her current medication list. (Hands list to pharmacist.)

Pharmacist: I agree that we are responsible for all of the medications with the exception of the vancomycin and the other treatments for the bunion wound. The infected bunion is unrelated to her terminal diagnosis.

Nurse: But aren't we covering the treatment for the other three ulcers? Do we cover the topical treatments for three ulcers yet tell the nursing facility that it's responsible for the same ointment when it's used on the fourth ulcer, the one on her bunion? How do I explain that one to the facility's director of nursing?

Patient Care Manager: There is an argument that can be made that each of the ulcers on her bottom are directly related to her advancing dementia, but the bunion was preexisting and unrelated to the dementia. We agree to cover the pressure-relief boots, we will agree to cover the topical ointments because it is just easier than trying to determine what proportion of the ointment is used for which wound. But I do not want us to be held financially responsible for the vancomycin, which is a fairly expensive drug.

Pharmacist: I concur. Technically, we are not responsible for any treatment of the bunion.

Looking Back at the Case

And so it goes. Medicare's hospice benefit was designed to give palliative care to a patient in the last days of life and to ease the burden on the caregiver, but it sometimes has a paradoxical effect.

Medicare requires that both a hospice and a skilled nursing professional produce and record written care plans that are consistent with one another, as well as progress reports for each intervention and a complete set of physician orders and medication lists.

Both the hospice and the nursing facility are responsible for having face-to-face physician visits with the patient, but these are on different schedules and usually are done by different physicians. Of a skilled nursing facility, Medicare requires visits by an attending physician or nurse practitioner at 30, 60, and 90 days after admission and every 60 days thereafter. The hospice requirement is a face-to face visit by 180 days after admission and every 60 days thereafter – to be performed by a hospice physician or a hospice-employed nurse practitioner.

In the attempt to better care for dying patients, we have found ourselves in a situation of many unintended consequences.

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