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Skilled nursing facilities and hospice providers: Bridging the gap

November 1, 2006
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What should be expected of the relationship

The importance of properly negotiated hospice care contracts and high-quality hos-pice care services cannot be overstated. Hospice care services play a critical role in death and dying and in the quality of resident life in the end-of-life process.

Hospice care actually evolved as a response to the recognition of the importance that palliative care can play in the dying process and the even greater recognition that just as human beings deserve and expect dignity in life, so too are we all entitled to as much comfort and dignity as is possible during the very natural process of dying.

Two myths do exist and must first be clarified: (1) hospice does not mean “do not treat,” and (2) hospice does not mean that we should in any way expedite or delay the dying process. Our responsibility as long-term care providers is to return the resident to the highest practicable level of functioning. To this extent, we are under a legal man-date and very closely regulated.

To many, an inherent contradiction exists in the assignment of hospice services, as this assignment suggests that our measured goals and expectations of residents' functioning or “practicable levels of functioning” are in many cases greatly lowered. As will be seen later, the effective hospice care provider is the one that successfully bridges the gap that may be caused by this contradiction.

What Is Hospice?

Hospice is a philosophy of care that acknowledges that death and dying comprise the final stage of life but residents can be helped to remain as alert and pain-free as possible, offering them dignity and quality of life during these last days. Hospice neither hastens nor postpones death, but is more concerned with treating the person rather than the disease; as some commonly put it, “care over cure.”

The modern hospice philosophy was first applied in 1967 when Dame Cicely Saunders used the term to categorize specialized care for dying patients in St. Christopher's Hospice in London. Its antecedents far predate this and can be traced to the age-old concept of being “hospitable” to sick persons during wars and military campaigns and offering refuge, refreshment, and hospitality to pil-grims and travelers.

Although we have indeed come a long way since then in the provision of these services, essential elements remain the same, and for the purposes of this article should guide our negotiation of hospice care contracts and the resulting provision of hospice care services.

As alluded to earlier, an inherent contradiction sometimes surfaces when the nursing home mandate and responsibilities seem to collide or conflict with hospice care expectations. Perhaps a deeper appreciation for the hospice philosophy is needed. Comfort is the focus, not the cure, but the philosophy does promote as high a quality of life as possible during a resident's final days. Here the conflict seems to lessen, in that this is also the nursing home's ultimate responsibility in its provision of care and services.

Interdisciplinary care and services are the foundation of the services nursing homes provide. Hospice care services must be seen and negotiated as simply another aspect of this interdisciplinary care, another discipline or department working together for continuity of care. The well-negotiated hospice care contract will provide this interdisciplinary care daily, with no disconnect between hospice care services and general resident care services, no disconnect between regulatory requirements and hospice care contractual obligations and, most importantly, no disconnect between the level and quality of care given to all residents, regardless of their source of payment for services.

Types of Services

Hospice care is offered to a resident who a physician has determined has six months or less to live. A resident's physician is still required to follow, treat, and document the resident's condition and progress during the period of hospice service, and in no way is his/her clinical obligation to the resident lessened.

The hospice designation will explain many of the conditions, symptoms, and side effects of the disease process, in particular many conditions that would otherwise be seen as serious or sentinel events for the skilled nursing facility. But the difficulty exists between determining whether these symptoms or conditions are in fact caused by the “hospice diagnosis” or are caused by an alternate developing condition. Herein lies the source of conflict between nursing home and hospice provider obligations for treatment and financial reimbursement. It is the proverbial “Which came first? The chicken or the egg?” A good rule of thumb when this dichotomy exists is to put the resident first. Provider and financial obligations must be seen as secondary.

Hospice care providers offer varying degrees of nursing home support services—typically, supplemental licensed and nonlicensed nursing services, including pain management and symptom control, palliative care, social services, emotional and spiritual guidance (e.g., bereavement care), and other consultative services, as needed, such as dietary or other specialist consults. Many providers also will offer an additional per diem—an agreed upon amount paid to the facility instead of the hospice provider—in lieu of these supplies and services. Facilities must pay particular attention to these provisions in negotiating their hospice care agreements, and they should always do a cost/benefit analysis before contracting in this manner. As in any contractual arrangement, nursing facilities must ensure that the burden of responsibility is equally shared by both parties.