Federal officials are homing in on the financial relationship between nursing homes and hospice providers, notably when that relationship affects potential Medicare savings and payment inefficiencies for hospice care in such settings.
An Office of the Inspector General (OIG) work plan, announced in July, aims to determine Medicare payments for hospice care provided in a nursing home, and estimate cost savings from reducing the payment to address inefficiencies in payment structure.
OIG also seeks to examine the practices of hospice providers with a high percentage of beneficiaries living in nursing homes.
Meanwhile, nursing home operators, including Journey Skilled Nursing, say the market is flooded with hospice providers at the moment, while past partnerships have put nursing homes in a financial predicament. The OIG work plan may be a step in the right direction to address these issues, they say, but other sector leaders wonder if the work plan is more a shot in the dark rather than drilling down to the root cause of payment inefficiencies.
“There are too many hospice companies,” said Jody O’Mara, chief nursing officer for Journey. “I feel like over the course of a few years, there’s hundreds of different hospice companies; it’s important to find two or three that are in line with you, and then those are the ones that you partner with throughout your organization.”
And, past partners have been “far behind” on payments – hundreds of thousands of dollars behind. So much so that this payment lag was a key in searching for better partners, O’Mara said.
Journey is currently exploring a joint venture with hospice provider Hospice 360 for its Georgia facilities, O’Mara said. The operator is looking for a partner that’s in line with their culture, their goals and policy and procedure, and the JV is set to be finalized by the end of the year.
“We’re on the same team. It’s not hospice against nursing or hospice against therapy. It’s not their patient, our patient. It’s an interdisciplinary approach, and we’re all in it together,” said O’Mara.
Determining root cause, supporting prognosis
One of the main challenges outlined in the OIG report with the skilled nursing-hospice relationship is that the terminal prognosis and level of care was not supported by insurance, mostly due to a lack of proper documentation, said Jessie McGill, senior curriculum development specialist for the American Association for Post-Acute Care Nursing (AAPACN).
“When we have someone on hospice, we have to have the documentation to support that it’s the appropriate level of payment for the resident at this time to ensure that the resident has access to hospice benefit, and it’s not something that gets removed because of poor documentation,” said McGill.
Once the physician determines the prognosis, and orders hospice, coordination of care should focus on ensuring the documentation is in place, especially if there’s a major medication reduction or other changes and the resident regains their health, which McGill says happens often.
“The physician may need to come in and say that because of these changes, the resident no longer meet the terminal illness criteria, and we’re going to graduate them from the program and see if they would benefit from it at a later point,” said McGill.
But McGill is concerned that this OIG report, similar to other reports put out by the agency in the past, won’t get to the root cause of the inefficiencies. Any action should start first with centering decisions on the needs of the resident, and stressing that the physician has to be highly involved in the initial terminal prognoses, and any changes thereafter, she said.
“Is it that we have misbehavior by providers where these residents truly should not have been on hospice, and we’re trying to capture reimbursement where we should not have, or is it a paperwork flaw, poor documentation?” asked McGill, explaining that the intent of any federal action – based on OIG’s work plan – on the involvement of hospices needs to be clarified.
OIG’s work plan and provider partnerships
The OIG work plan doesn’t establish new requirements, but it brings attention to how responsibilities are divided and how services are delivered, said Lauren Stenson, curriculum development specialist with AAPACN. In the meantime, nursing home operators should review their agreements with hospice providers to ensure there’s a clear understanding of which organization is responsible for each aspect of a resident’s care.
“I wouldn’t recommend that facilities make significant workflow changes simply because OIG has announced this review, but I do think it’s an opportunity to evaluate current practices and identify areas where coordination could be improved,” said Stenson.
There have been times where hospice and nursing homes were misaligned and adversarial, O’Mara said. If there’s a high-level tag or a lawsuit, it’s ultimately the responsibility of the nursing home to take care of that patient.
O’Mara puts hospice providers in the same camp as a lab company or pharmacy. Operators need to be partnered with the right hospice provider to align with the nursing home’s vision, goals and culture.
Moving forward, Journey will continue its quarterly meetings with hospice providers to review how many residents they are servicing and all of the key metrics that are important to Journey, including falls, required antibiotics and special equipment used.
“Some metrics may be quality related, some may be safety related, some may be regulatory,” said O’Mara. “We’re making sure that we have a good partnership when we’re discussing things that are important from both sides and then working on improving those systems.”
Making space for hospice
AAPACN has seen a greater recognition of the importance of hospice services in the nursing home setting, especially for residents with increasingly complex conditions and significant end of life needs, said Stenson.
Thinking back to her experience as a director of nursing, Stenson said one of the biggest considerations was how well the hospice team and facility team worked together.
“Hospice brings in specialized expertise in symptom management, end-of-life care and supporting residents and their families,” said Stenson. “But the nursing home staff, they’re the ones providing care around the clock. They’re often the first ones to recognize a change in condition. They identify that increased discomfort. Communication between the two teams is incredibly important.”
The relationship works best when hospice is integrated into the resident’s overall plan of care, added Stenson, instead of treated as a separate service.
For O’Mara too, a deeper partnership with hospice team members is important.
“Make sure they’re invited to your care plan meeting,” said O’Mara. “If you want to have a good partnership, you have to include them in resident-specific care plans, or if you’re going to do a skills fair. Make sure that they’re getting the same messages that you’re giving out to your other stakeholders.”
Clearly defined responsibilities are needed
Stenson would like to see CMS emphasize greater collaboration and communication between the two care settings and also establish clearly defined responsibilities.
One of the biggest inefficiencies stems from a duplication of processes and, in some cases, an unclear division of responsibilities between the hospice provider and nursing home, Stenson said. Both settings have assessment processes; they have documentation requirements and care planning responsibilities, as well as communication expectations.
“Problems arise when the information isn’t shared effectively. A hospice nurse may assess a resident and recommend a change in symptom management. If that information isn’t clearly communicated to the nursing home staff, there can be delays in implementation of that intervention,” said Stenson. “I’ve seen it happen more times than I would like.”
A handwritten note instead of inputting a recommendation into an electronic medical system can result in unnecessary phone calls, delays in treatment and frustration among staff, residents and family, added Stenson.
OIG has an opportunity here to help hospice and nursing homes improve how care plans are coordinated too, since current hospice and nursing home care plans often contradict each other, McGill noted.
“The care plans have to be integrated,” said McGill. “Whenever we have a hospice election, revocation or change in hospice provider, we are required by federal statute to complete a significant change in status assessment.”
The hospice care plan needs to be integrated into the nursing home care plan as part of a significant change in status comprehensive assessment, said McGill.
In addition to care plan integration, data integration is another wish list item for McGill. Currently, there’s a five-star rating system for nursing homes and another for hospice, McGill said. Hospice data is listed on Care Compare too, but it would be hard to integrate quality measure data since quality of care at end of life is so different compared to what nursing homes monitor.
“I really don’t know what metrics would show how beneficial hospice was besides a family survey, saying whether or not they felt that the resident benefited from the hospice services in whichever setting it was received,” said McGill.
O’Mara said data collection between the two care settings can only improve, especially if operators do more JVs like Journey is doing, or others that own their own hospice company – decisions that put everyone on the same page and not pitting care settings against each other.
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