Nursing Homes Forum
This article explores hospice, how it works (and how it doesn’t) in three
parts.
PART II — Nursing Homes & Hospice
Hospice In A Nursing Home
Hospice can be provided in any setting, including a nursing home. The nursing home provides 24-hour care to the patient, and the hospice assumes the medical oversight. The nursing home room & board will continue to be paid by whatever payment source was in place before the patient was admitted onto a hospice program, such as Medicaid, private-pay, V.A, and long-term care insurance.
If the patient is on Medicaid, the federal government reduces the Medicaid payments to the nursing home by 5% - this is because, in theory, patients who receive hospice care save the nursing home on its labor costs. I say “in theory,” because the nursing home is still responsible to provide for all of the patient’s 24-hour care, including bathing and nursing services. (Most hospices pay that 5% back to the nursing home rather than risk the nursing home not allowing them in the facility).
Duplication of Service
As mentioned in Part I, patients who live at home don’t cost the federal government anything for their care — all of the costs of actually caring for the patient are paid privately by the patient or his family. Hospice supplements the care in the home by providing a C.N.A. to help bathe and provide personal care and an R.N. Case Manager to oversee the patient’s medications, contact the doctor as needed, and ensure that supplies and equipment are provided. Medications that are related to the patient’s terminal diagnosis are delivered to the home.
When a patient is in a nursing home, the facility is required to provide most equipment, 24-hour care & supervision, ensure medications are provided, contact the doctor, etc. This is why Medicaid views hospice as a duplication of service — Medicare pays the hospice its full rate of $140 per day for services that Medicaid is paying the nursing home to provide.
Hospice care can be beneficial to those nursing facility patients whose pain and symptoms need to be closely managed; some physicians won’t or can’t prescribe medications sufficient to meet the patient’s pain without the expertise of hospice. Sometimes the patient or family require support as the patient nears death — hospice programs can provide for these extra needs and help guide them through the process as the patient/family experiences a great loss.
Nursing Home Waiver Programs
There are a few patients who receive services from Medicaid at home or in an Assisted Living Facility. These home-based programs allow low-income patients to remain in their homes and receive a nursing home level of care by providing C.N.A. services 2-3 times per day, as well as homemaking, Case Management, and home modification for the patient. These patients can receive services from Medicaid, or services from hospice — but not from both.
This doesn’t make sense; people who live at home need hospice so much more than do nursing home patients - and they cost the government less to care for at home - but the government will only allow them to receive hospice if they enter a nursing home. These patients are forced to choose between dying at home surrounded by family members, or dying in a nursing home with pain and symptom management provided by hospice.
Nursing Home Patients are Desirable to Hospice Providers
Nursing home patients are highly desired by hospice providers - Medicaid pays the nursing home at least $4,000 per month to provide the majority of the care while the hospice collects $4,200 per month from Medicare. Hospice providers receive the same amount as if the patient were at home, while providing less care.
The reason that nursing home patients are less expensive for the hospice is because the nursing home is already providing 24-hour care from licensed professionals to its residents, so caregiver training and support isn’t necessary; the nursing home provides most of the equipment and supplies; the patient and family have usually accepted the patient’s declining health status so extra support from the hospice isn’t needed — and hospices rarely provide the same level of aide and nursing visits to nursing home patients as they do for patients who live at home. Simply stated, these patients cost the hospices substantially less, yet they receive the same reimbursement as if the patient were at home.
Since patients generally move into nursing homes toward the end of their lives, it only follows that a majority of them would qualify for hospice care. It’s a patient base waiting for a provider to come along.
Sharon Johnson, BSW, is a Social Worker with over 18 years of direct experience working with the elderly. She is the author of several books on senior care issues and Executive Director of Case Management Solutions, LLC. Her books can be purchased at at www.cmseldercare.com
4 comments on “Hospice Programs Explained: Nursing Homes & Hospice”
Add a comment about "Hospice Programs Explained: Nursing Homes & Hospice"
Joined: 9 Sep 2009
Posts: 0
Comments: 1
Wow, I am very shocked that someone writing books on senior care telling the way it is, that seems to be an expert in the field can be so wrong. Let me say that in general hospice pts are more expensive in the nursing home for several reasons, Hospice is SUPPOSE to provide everything at the nsg home that is provided to the home patient, Now if that is not the case then maybe we are discussing another topic such as shady companies, not providing what the regs require. The hospice does pay the extra 5% to the facilities normally, and still provides supplies,equipment,medications, etc. I am an advocate for the nsg home patients as well as the home patients that suffer from a terminal illness. As far as the family accepting the pt decline–nsg home families in general have not accepted the pt’s decline any more than home patients. Think about this-If your family member is dying and lives in the nsg home would you prefer to have expert in pain and symptom mgmt overseeing the care of him/her? Can we as a country survive without hospice in the nursing homes-absolutely, BUT would the end of life care quality diminish-in my opinion absolutely, and I have numerous families that would stand behind me on this statement. Another thing to think about in the nsg home—Do you think the nursing homes bring in extra staff to give extra support to the patients and families of declining patients?? or do you even think these more sick patients deserve extra care?? I am a proud Registered Nurse with many years of Hospice experience.
Joined: 24 Aug 2007
Posts: 161
Comments: 2818
elliemae's website
Some hospice companies pay the extra 5% to nursing homes because they want to remain competitive with other hospices, not to reward the nursing home. However, it is up to the discretion of the hospice to pay that amount or not.
It should be noted that across the country many home-based Medicaid-based programs won’t allow patients to receive hospice because it’s considered to be a duplication of service. I find that ironic - home-based patients benefit greatly from hospice due to the additional support but they can’t get it, while nursing home patients with skilled 24-hour caregivers is a safe environment can receive hospice without question.
Hospice in a nursing home is wonderful for patients who have pain & symptom management needs that are beyond the expertise of the nursing home, or for those who need extra support. But I stand by my statement that a hospice doesn’t provide the level of support for nursing home patients that they do for home care patients with unskilled family members acting as caregivers, and certainly shouldn’t be paid the full $140 per day they receive for home care patients.
Does the nursing home bring in extra staff to give extra support to the patients and families of declining patients? No, but often neither does the hospice. The 24-hour care is provided by the nursing home, which is staffed with professionals who don’t need the training or support that an in-home caregiver needs. The nursing home doesn’t need assistance with obtaining medications, contacting the doctors, understanding how to care for a bed-bound patient… nor do they generally need all of the equipment that is provided to a home patient.
You asked if I think that these more sick patients deserve extra care - I believe that every nursing home patient deserves the highest level of care possible. But the nursing home is responsible for bathing, feeding, dressing, grooming, and ensuring that the needs are met for nursing home patients. Generally hospices provide up to one hour per day aide visit (max), one monthly visit from a social worker, 1-2 times per week visit from a hospice nurse and a contact each month from a chaplain. The medications are already provided via the Medicare benefit at a substantially lower cost than the $4,000 plus the hospice is paid each month, as is equipment. A limited amount of supplies that would normally be provided by the nursing home are provided by the hospice.
Unless a patient is actively dying, hospice doesn’t have to do much at all. Even when they’re actively dying, the nursing home is provding the majority of the care and according to the Medicare benefit itself these patients don’t necessarily need a higher level of care. (Medicare states that patients who are dying with no problems regarding pain or symptom management generally require a higher level of care). Hospices don’t sit with patients as they die - although there are hospices that provide continuous care in nursing homes. This should not be allowed under any circumstance.
It can be argued that every elderly patient in a nursing home is in their declining years, and that many qualify for hospice care whether it makes a difference to them or not. Hospices hire professional marketers whose job it is to obtain as many patients as possible, and they target nursing homes because of the large potential patient base.
I, too, am an advocate for patients in nursing homes and in their homes. I am a proud Social Worker with many years of experience - and I recognize that we are in the midst of a healthcare crisis. One of the many ways that costs could be contained would be to reduce the hospice benefit for nursing home patients. Again, I do believe that hospice can be beneficial in certain circumstances in nursing homes, but not in every instance.
Joined: 21 Oct 2009
Posts: 0
Comments: 1
I am a Office Manager for a Hospice and I am very proud to say we take very good care of our patients. All Hospices will get complaints because you simply cannot make everyone happy. I have seen our nurses who are salary work 100 hours in 2 weeks and they only get paid for 80 hours. This happens more often than not. I have seen some of our patients come off service for aggressive treatment and after hours our employees still call to check on them even though they are not on Hospice. As with any medical field where patient care is concerned we all know there is never enough caregivers in the home or the nursing home. Here are some of the services our hospice provides in the nursing home; Durable Medical Equipment-hospital bed, wheelchair, oxygen, etc. Then we pay for all medications pertaining to the diagnosis. We take out supplies like underwear, briefs, shampoo, calmoseptine, nutritional drinks, underpads, etc. I spend over a thousand dollars a week on supplies for our patients. Thats 4000.00 a month and that isn’t counting all the other things we pay for. I say if you don’t like hospice don’t use it. But I have a survey book that proves our people love us and appreciate ours people coming out all ours of the night.
Joined: 24 Aug 2007
Posts: 161
Comments: 2818
elliemae's website
I have never said that most hospices don’t take good care of their patients. I believe in hospice in many circumstances - but stand by my opinion that hospice in a nursing home is often a duplication of service - an opinion shared by CMS in many circumstances. The supplies that you mentioned are already provided to the nursing home patient. Most hospice nurses, social workers & cna’s are hard working people who are overworked and underpaid.
It should be noted that your survey book contains voluntary responses and that many people don’t respond to surveys after a patient dies. I’m sure that many people appreciate your services, but the survey isn’t representative of all of the patients that your agency serves.
Hospice care can be a wonderful service for patients at the end of their life, but it isn’t the only answer.