Barriers* to Providing Hospice Care
in the Skilled Nursing Facility
*(PC = “Challenges or Opportunities”)
Ronald S Duemler MD, MS, CMD
Three Main Categories of Challenge
• 1. Clinical – both staff and patient issues
• 2. Financial – both facility and patient issues
• 3. Regulatory – Mostly facility issues
Clinical Issues
• 1. Symptom Presentation
• 2. Patient Social and Cultural factors
• 3. Staff Cultural and Educational
factors
Symptom Presentation
• 1. Co-morbid Conditions
– Dementia, Delirium, and Depression (the big Ds)
– Sensory Impairment
• 2. Terminology: Two people separated by a
common language.
– Provider: “Do you have any difficulty breathing?”
– Patient: “No, but I am short of breath.”
• 3. Atypical Presentations (ask staff)
– functional change – cornerstone of Geriatrics
– pain presentations
Nonspecific Signs and Symptoms that
may Suggest the Presence of Pain
(from AMDA CPG Pain Management in the LTC Setting)
• Bracing, guarding, rubbing, frowning, grimacing, fearful facial
expressions, grinding teeth, fidgeting
• Changes in behavior: restlessness, agitation, striking out,
decreased activity participation
• Changes in function including ambulation, eating, sleeping
• Changes in Cooperation with Personal Care such as moving
extremities, position changes, dressing, bathing, toileting,
transfers, feeding
Patient Social and Cultural Factors
• 1. Communication dilemmas
– more axes of communication/miscommunication:
• doctor/patient, doctor/staff(x2), doctor/family
• patient/staff(x2), patient/family, family/staff
• staff(x2)/staff(x2), family/family
• 2. Ethnic Overlays/Language Barriers
• gender roles, religious issues, symptom identification
• 3. Beliefs about symptoms or diseases.
Common Misconceptions among both
Patients and Caregivers about Pain
(from AMDA CPG Pain Management in the LTC Setting)
• Pain is an inevitable part of aging and nothing can be done about it.
• Elderly patients, especially the cognitively impaired have high pain
tolerances.
• Patients say they are in pain to get attention.
• Patients that “don’t look like” they are in pain probably aren’t.
• If the vital signs are normal, the pain can’t be significant.
• People who use pain medicines are likely to become addicted.
• Admitting pain is a sign of character weakness/bearing pain is a sign of
character strength.
• Pain is a punishment and may mean death is near.
• Pain always means there is a serious disease.
• Admitting pain may mean loss of independence and possibly invasive tests
• Narcotics are the only way of treating pain.
(italics mine)
Staff Social and Cultural Factors
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Staff Education about symptom management
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Staff Beliefs about symptom management
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frequency of assessmet/expectation of treatments
available tools (see regulatory section as well)
which medicine to use when
“I don’t want to think I killed my patient”
Facility Subculture/lore – Crucially Important
–
Credit and Recognition for Care
Financial Challenges
• 1. Facility Perspective
– Best Payer Source
• 2. Patient Perspective
– Best Coverage
Mini-Diversion: Medicare Part A,B,&D
• What pays for what, where, and how long
– Part A Benefits
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Acute care
Post Acute Care (Acute Rehab and Subacute Rehab)
Skilled Homecare
Hospice
– Part B Benefits
• Rehab
• Doctor’s fees
– Part D Benefits: Drugs (Not in Hospice)
Mini-Diversion II: DRGs, MDS, RUGs,
OASIS
• 1. DRG – Diagnostic Related Group
– Hospital Reimbursement
• 2. RUG – Resource Utilization Group
– SNF Reimbursement based on subset of MDS
• 3. OASIS – Homecare Reimbursement
– conceptual blend of diagnosis and function
Facility Perspective
• 1. First Choice/Best Reimbursement
– Part A Post acute Rehab
• 2. Second Choice/ Next Best Reimbursement
– Private Pay (usually where Hospice patients fall)
• 3. Better than an empty bed (usually)
– Medicaid (sometimes where Hospice patients fall)
• Hospice can equal higher risk of defaulting.
– Especially when going from Rehab to Hospice
Patient Perspective
• Common Misconceptions: (75%/50%) Standard Medicare
– “I get 100 days of Medicare coverage after a hospital stay (no
matter what) at full coverage.”
• Reality: Medicare Rules: Coverage Requires meeting criteria
and amount covered declines (i.e. copay increases) at
intervals and 100 days is the yearly total.
– If you had a qualifying hospital stay and continue to improve or
require complex medical management (i.e. meet criteria)
• 100% first 20 days, the 80/20 rest of 80 days
• When applicable, comfort care on Part A still financially better for
patients than Hospice since room and board is covered in skilled Part
A benefit and not under Hospice benefit
• Medicare HMO and Advantage Plans: Whole Different Story
Medicare Reality
• Part A Qualification rapidly ends for stable
comfort care patients.
• With some Part A plans (HMO and Advantage
Plans) medications can be subject to the plans
authorization.
Regulatory Challenges
(from AMDA Synopsis of Federal Regulations in the Nursing Facility )
• Large, Complex Issue
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Background: 1987 Omnibus Budget Reconciliation Act
Refined slightly 1990 Omnibus Budget Reconciliation Act
Published in Code of Federal Regulations.
Interpretation of these Guidelines and applications for surveyors
are found in the State Operations Manual.
Federal Reimbursement is tied to compliance.
Over 500 regulations making it as highly regulated as the
nuclear industry and perhaps the most highly regulated
industry.
State Regulations overlay the Federal Regulations
Enforced with annual surveys and complaint investigations
CMS contracts with state to survey both sets of regulations
Facility Survey Process
• Annual Survey has roughly a 3 month window
• Fire marshal and State surveyors come together.
–
sometimes a Federal team is also surveying the State team
doing their survey and that makes everybody very tense
• Deliberately designed to be surprise surveys
• Deliberately designed to be adversarial and punitive
• Multiple requests to make process collaborative and
constructive – similar to JACHO - have been declined.
• Complaint surveys equally random and can have just as
broad a scope as the annual survey
Overall Regulatory Principles
(from AMDA Synopsis of Federal Regulations in the Nursing
Facility*)
• Regulations require facilities to meet “the
highest practicable physical, medical and
psychological well-being” of every resident*
• Any decline in the resident’s well-being must
be demonstrably unavoidable.*
(italics mine)
• Facilities are expected to only admit residents
for whom they are able to safely care and
meet their needs.
Facility Care Structure
• Minimum Data Set (MDS) Structures Care
– 400 item classification which results in multidomain risk assessments and care plans.
• Any providers participating in care must have care plans
that are integrated with the facility care plans
• Sentinel Events – Uniquely defined for SNF
– Always mean a qualitative failure of nursing care
– 3 events and only one risk stratified
• fecal impaction
• dehydration
• Pressure sore in a low risk patient
More on Sentinel Events
• Being terminally ill is no excuse for having a
sentinel event. (remember overall principles)
– Corollaries:
• Hard stool in the rectum should never be described as
an impaction unless it is causing an obstruction
syndrome.
• Dehydration in the SNF is defined as Output exceeding
Input so quit measuring I&O.
• End of life patients should always be described as high
risk for pressure sore and if they occur should be
charted as unavoidable (presuming this is accurate)
Common Areas of Dissonance
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Designated Decision-makers
Advanced Directives
Psychoactive medications
Communication
• Communication
•Communication
Decision making and Advanced Directives
• Typically facilities have more rigid
documentation needs for this.
• “Full Code” on Hospice very difficult for SNF
based on regulatory issue of meeting needs –
appears inherently contradictory to care plan
Medication Usage
• Psychoactive Medication Use – even for
nontraditional and off-label uses needs
extensive (usually formal) risk-benefit
documentation.
• “PRN” meds need specific instructions – which
symptoms, how often and in this setting are
expected to be truly patient initiated.
– if you don’t expect the patient to be able to ask
for the med – consider scheduling it.
Communication
• Working relationships develop over time but
they have to start well.
• Offering to attend the care plan meetings with
facility staff, patients, and patients’ families
build enormous good will (Care plan meetings
are a formal regular activity for facilities)
• Providing staff education can be an extremely
valuable bridge for better collaboration.
Final Thoughts
• The importance of understanding the care
environment lies in being able to give the
patient the best care, while helping assure the
facility is able participate in that best care and
stay compliant with their regulatory
framework.