What is hospice?
Hospice is a special way of caring for individuals who are in the final stage of their lives due to a terminal illness. The hospice approach to care focuses on palliation and symptom management as opposed to curative care. Hospice services help patients, who are no longer seeking aggressive treatment or a medical cure, manage their terminal illness at home or in a home like environment. Hospice care addresses the physical, psychosocial, and spiritual needs of the patient and his or her family.

Where may hospice care be provided?
Although some hospice services may be provided in a facility (hospital, skilled nursing facility (SNF), or inpatient hospice facility) most services are provided in the patient's residence. The patient's residence may be a private home or apartment, boarding or rest home, assisted living facility, hospice residential* or skilled nursing facility. North Carolina has a number of hospice residential facilities where a patient may receive long term residential care. It is important to realize the hospice Medicare benefit does not cover room and board in the payments made to the hospice agency. In some cases a patient may be eligible for assistance in the cost of room and board from Medicaid, if he or she qualifies.

What are the Medicare eligibility criteria?
In order for a patient to elect the hospice Medicare benefit the patient must be:

• entitled to Medicare Part A,
• terminally ill with a prognosis of six months or less if the disease runs its normal course, and
• certified as hospice appropriate by his or her physician (initial certification requires two signatures, the patient's attending physician and the medical director of the hospice agency; re-certifications only require one physician signature, usually the medical director of the hospice agency). Certification must be received at the beginning of each benefit period.

What is covered under the hospice Medicare benefit?
When a patient elects the hospice Medicare benefit (HMB) the hospice agency provides necessary medical and support services under a medically directed plan of care. The individualized care plan provides reasonable and necessary services in the management of the patient's terminal illness or related conditions and supportive services to the family or caregivers. Intermittent services are available 24 hours a day, seven days a week. The patient's attending physician and the hospice team develop a care plan, which is appropriate to meet the patient and his or her family's needs (medical, psychosocial, spiritual) and may include the following:

• Physician services
• Nursing care (intermittent with 24-hour on call)
• Medical appliances and supplies related to the terminal illness
• Drugs for symptom management and palliation of the terminal condition
• Short-term inpatient care for acute symptom management which may not be controlled in any other setting
• Short-term inpatient respite care (limited to five consecutive days per episode)
• Counseling services including dietary, bereavement, and spiritual
• Therapy services required in the management of the patient's terminal condition. Therapies may include physical and occupational therapy, and speech language pathology
• Ambulance services required for the proper palliation and symptom management of the patient's terminal illness. The hospice team determines an inpatient level of care is required and due to the patient's fragile condition ambulance transport is also required to carry out the needed palliative care
• Medical social services
• Aide and/or homemaker services
• Volunteer services
• Although the hospice agency may arrange for some of the services to be provided by another individual or entity, the hospice agency remains the professional manager of the patient's care.

Who pays for hospice services?
Hospice services are covered under most private insurance plans, such as Blue Cross and Blue Shield of North Carolina or the State Employees' Health Plan. Also, hospice services may be covered under Medicare and Medicaid, if the patient qualifies. In addition, a patient may pay privately for hospice services. More information about Hospice is available online at: http://www.cms.hhs.gov/center/hospice.asp

How long may hospice care continue?
The Medicare/Medicaid benefit periods apply to hospice care. There are two 90-day periods, followed by an unlimited number of 60-day periods. These periods may be used consecutively or at different times. However, while the patient is under hospice care, he or she must be hospice appropriate and be certified as terminally ill at the beginning of each benefit period.
A patient may cancel or revoke his or her hospice election at any time, for whatever reason. An agency may discharge a patient for two reasons. First, when the patient is determined to no longer be terminally ill with a prognosis of six months or less; or when the patient no longer resides in the hospice agency's defined geographic service area (usually if the hospice appropriate patient moves outside of the agency's services area, he or she transfers to another hospice rather than being discharged). When a discharge/revocation occurs, the patient's regular Medicare benefits are reinstated. However, upon discharge or revocation the remaining days in the benefit period the patient is currently in are lost.

Can a patient change hospice agencies?
Yes, a patient may also choose to change hospice agencies once per benefit period. The agencies should coordinate care to ensure the patient's needs are met during the transfer.

Quality of Care...
There are three mechanisms for ensuring hospice agencies meet established standards of care:

State Licensure
All hospice agencies that provide "hands on" care in the home must be licensed by the NC Division of Facility Services. Through licensure (typo), the state ensures the agency meets or exceeds specific standards of care. All hospice agencies must meet requirements for the administration the agency, staff qualifications, patient care, and patient records.

Medicare Certification
Hospice agencies that wish to provide services and receive reimbursement under the Medicare or Medicaid hospice programs must be certified and meet federally mandated requirements, referred to as Conditions of Participation (COPs). Certified hospice agencies are subject to surveys to ensure the agency continues to be in compliance with all of these requirements.

Accreditation
Accreditation is a voluntary process in which a non-profit professional organization conducts a survey of the hospice agency. If the hospice agency meets the standards established by the organization, then the agency is granted "accreditation". A hospice agency may seek voluntary accreditation from one or more of the three accreditation organizations: JCAHO, ACHC, and CHAP.