CAPC Palliative Care Discussion Forum
Hospital and Hospice Partnerships
I am the medical director of our hospital palliative care program as well as the affiliated hospice program. I work in SNF's so I often follow our patients through to the SNF from the acute under my palliative service but do also start hospice on select patients who have Medicare/MediCal(or MedicAid outside of CA) or the patient was a private pay patient with Medicare at the SNF already. There are many cases who only have Medical and the reimbursement we get from the state does not allow us to pay the daily rate for the SNF. (We are a small program and cannot afford to "buy" or maintain dedicated rooms in a SNF like large programs.) HOWEVER, I do know some programs such as Vitas have two levels of contract with SNF's that allow them to get a higher reimbursement for select MediCal patients that makes it financially feasible to do this. Does anyone know how they do this? Is it under Continuous Care or somehow a GIP level of service? I am always disappointed that I cannot offer hospice in a SNF for some patients who have only MediCal and want to offer this if economically feasible. Thanks!
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Discharges to SNF's on Hospice from the Acute
There are many nuances and components to hospice criteria, regulations, levels of care, etc. What we have explained in this forum is a general response. Hospice By The Bay can provide additional information about these topics in the form of an in-service or a face-to-face meeting, so that we may explain in further depth the details and answer some of these complicated and important questions.
I have pieced apart the email statement and questions, so as to respond most appropriately, as this statement and following questions involves many components of hospice care, regulations, and criteria for hospice levels of care.
Statement: “There are many cases who only have Medical and the reimbursement we get from the state does not allow us to pay the daily rate for the SNF”.
Response: Approximately 90% of the straight Medi-Cal patients that Hospice By The Bay sees, have the type of coverage that pays for Room & Board. In those cases Medi-Cal pays the hospice for the hospice care and the Room & Board. The hospice then passes the exact Room & Board rate, given by Medi-Cal, through to the SNF as the payment for the Room & Board. We call this a “pass through” rate. In the rare case that the patient does not have the type of Medi-Cal coverage that pays for both Room & Board and hospice care, the Social Worker assigned to the patient will work with the Medi-Cal representative to apply for the coverage that is missing (either Room & Board, or hospice care). If a patient has dual coverage of Medi-Care and Medi-Cal, hospice bills Medi-Care for the hospice services and the pass through rate for room and board is as described above.
Questions: “HOWEVER, I do know some programs such as Vitas have two levels of contract with SNF’s that allow them to get a higher reimbursement for the select MediCal patients that makes it financially feasible to do this. Does anyone know how they do this? Is it under Continuous Care or somehow a GIP level of service?
Response: There are four levels of care in hospice: routine, continuous care, GIP (general in patient), and respite. Included below is an explanation of these levels of care. It is possible to have different levels of care written into a contract between a hospice and a SNF. Hospice By The Bay has contracts with SNF’s for three of the four levels of care (continuous care is the responsibility of the hospice to provide), however, we are only able to have a patient on a level of care other than routine if it is medically appropriate and if the patient qualifies for a higher level of care.
Levels of Hospice Care
Routine Hospice Services
Routine Home Care is the most basic level of care and is provided where the patient resides. This might be a private home, a contracted skilled nursing facility, or an assisted living facility. If the patient does not have room and board coverage through Medi-Cal, the payment to the SNF for room and board would be the patient’s private responsibility.
General Inpatient
General inpatient services are either provided in a contracted hospital or SNF, which must be certified by both Medicare and Medi-Cal. If symptoms cannot be managed where the patient resides, the patient will be moved to an inpatient facility until the patient’s condition is stabilized. This level of care is reimbursed at a higher rate than routine care as the hospice is responsible for paying all the hospital/SNF charges. Room & Board is not considered paid for when a patient is on GIP level, however, the hospice pays the SNF or Hospital the rate that they had contracted for, which theoretically includes what would be considered the cost of room & board as well as the cost of a higher level of acuity.
Respite Care
Respite Care is provided in a contracted facility. This level of care is available to give the caregiver(s) of the patient a respite (i.e. rest), because it is acknowledged that caring for a dying person is difficult and can be tiring. This level of care is comparable to the Routine level but the patient moves temporarily from their private home into the SNF. It is available for periods of up to five (5) consecutive nights, in a hospice contracted SNF which must be certified by both Medicare and Medi-Cal.
Continuous Care
Continuous Care is a level of care provided by hospice during a period of crisis with the goal of managing symptoms in the patient’s place of residence. Examples of a “period of crisis” may include a patient with uncontrolled pain, dyspnea, seizures, hemorrhaging, agitation, or other acute symptoms. During Continuous Care, hospice provides increased nursing presence in order to alleviate the symptoms. Continuous Care is not meant to take the place of a patient’s care system, although a breakdown of the care system may precipitate a “period of crisis” as above. Continuous Care is typically short-term (often one or two days), with a minimum of eight hours of care provided as the patient’s condition requires. Once the crisis has been resolved, Continuous Care will end and the patient will continue to receive routine hospice services according to the Plan of Care.
Resources to consider:
National Hospice and Palliative Care Organization – General Information
http://www.nhpco.org/templates/1/homepage.cfm
National Hospice and Palliative Care Organization – Levels of Care
http://www.nhpco.org/i4a/pages/index.cfm?pageid=5504
GIP Hospice Care - Coverage of Hospice Services Under Hospital Insurance
http://www.cms.hhs.gov/manuals/Downloads/bp102c09.pdf
Conditions of Participation for Hospice
http://www.gpo.gov/fdsys/pkg/FR-2008-06-05/pdf/08-1305.pdf