Skilled nursing facilities and hospice providers: Bridging the gap

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.

Working With a Hospice Provider

With the recent proliferation of hospice providers—more than 1,600 hospices in the United States, many using elaborate marketing machinery attempting to woo the nursing home administrator into contracting for their services—increased scrutiny of these services is definitely in order. All hospice providers are required to meet basic JCAHO and National Hospice and Palliative Care Organization accreditation standards. However, each hospice provider brings a different degree of expertise and specialty to the table. The nursing facility must select the provider(s) offering the best fit for its organization.

Always remember that the decision to receive hospice services is the decision of the resident and/or responsible party. We assist with that decision by ensuring that there is ample choice of hospice providers available. We facilitate the process by referring the resident/family member to a hospice provider, thus bearing an implicit responsibility to ensure that our referral is done in a fair and equitable environment and that it is in the best interest of the resident.

The Referral Process

The nursing facility should focus all hospice referrals through one central employee or designee in the facility. Usually this would be the facility social worker because of the emotional complexities of the dying process. The more people involved in the referral process, the more chaotic a situation can emerge, especially when referrals are fragmented and not made by consensus.

Nursing facilities must pay particular attention to ensuring the equitable division of responsibilities by both parties in the hospice contract. The nursing facility must ensure that the hospice provider maintains adequate on-site staffing coverage, and contract provisions should address hospice’s active participation in the resident’s care plan and provision of care, particularly addressing expected and unplanned decline.

Medications, supplies, and DME and the parties providing them must be specifically addressed in any hospice care contract. The burden of accountability is on both parties to ensure effective coordination of services.

The contract should specify hospice reimbursement rates for all payer types; it should also address limitations on coverage. Most hospice providers will cover and treat conditions related to the hospice condition only. Inevitably, there will be gray areas, and the effective contract will attempt to be as specific as possible in addressing these. Provision of rehabilitation services, for example, is always a cause for contention. Many hospice providers might argue that some rehabilitation services should not be considered for a dying resident. In many cases, however, rehabilitation services may be critical to preserving residents’ dignity and comfort in their last days. Devices for positioning also come to mind, especially if these services were being provided before hospice assignment. The contract should specify to what extent such services would be provided.

Finally, as in all agreements, termination clauses must be precise, and nursing facilities should be careful not to contractually bind their facilities to a specific provider for too long. They should always leave the opportunity for contract termination with cause.


The importance of quality hospice services in today’s long-term care environment cannot be denied. Quality hospice services provide a much-needed additional layer in the continuum of care. The prudent facility recognizes when the need for these services arises. It is not evidence of the facility not being able to provide palliative services itself, but is an understanding that in providing these services additional support may be required.

Hospice assignment in no way limits the residents’ rights. The resident still has the right to be shown dignity and respect, still has the right to refuse any treatments or services or to request a change in caregivers, still has the right to know the plan of care and any changes in that plan, and still has the right to maintain spiritual or religious beliefs. The hospice resident or legally responsible party does not have to execute a do not resuscitate order before hospice assignment. However, a hospice provider should explain the process of resuscitation and its challenges at this stage in the illness.

The many contradictions, myths, and fallacies associated with the provision of hospice care services—normally determinants to the resident or legally responsible proxy—should serve to assist the long-term care provider in “bridging the gap” and providing as near to seamless services to our customers as possible. Partnering with the right hospice care provider is essential to providing quality interdisciplinary care to residents with limited life expectancy.

Deke Cateau, NHA, is Administrator of College Park Health Care Center, a skilled nursing facility in College Park, Georgia.

For more information, phone (404) 767-8609.To send your comments to the author and editors, please e-mail

Topics: Articles , Leadership