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.
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.
*A list of the hospice residential facilities in North Carolina is listed at the end of this section.
In order for a patient to elect the hospice Medicare benefit the patient must be:
* entitled to Medicare Part A,
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:
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.
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. Although each hospice agency has its own policies regarding payment, Medicare certified agencies may not discontinue care to Medicare beneficiaries based on the patient's ability to pay. Agencies provide care based on the need for services rather than the ability to pay.
Hospice agencies providing care to a Medicare patient receive reimbursement based on the level of care the patient receives. There are four levels of care, each with its own reimbursement rate. Three of the four levels of care are paid based on a daily per diem rate, the fourth level of care is paid based on an hourly rate (minimum of eight (8) hours of care required). The four levels of care are as follows:
Routine care is paid for each day the patient is under the care of the hospice and not receiving one of the other levels of care. This rate is paid without regard to the volume or intensity of routine home care services provided on a given day. The care plan includes the amount and frequency of services based on the patient and/or family's needs.
Continuous care is provided when the patient is experiencing a medical
crisis and requires predominantly nursing services to achieve palliation
and symptom control. The hospice agency must provide a minimum of 8
hours of care within a 24-hour day period, beginning and ending at midnight.
The goal of continuous care is to provide necessary medical acute care
interventions at home. Although a registered nurse or licensed practical
nurse provides more than half of the continuous care, homemaker or home
health aide services may supplement the nursing care during the period
General inpatient care is available for pain control or acute or chronic symptom management which cannot be managed in any other setting. The short-term inpatient services must be provided by a Medicare certified facility (hospital, skilled nursing, or hospice inpatient) and must be under contract with the hospice agency. In addition to skilled nursing facilities and hospitals where short-term inpatient care may be provided, North Carolina has a number of hospice inpatient facilities.
*A list of the inpatient hospice facilities in North Carolina is listed at the end of this section.
Note: For routine and continuous care, hospice providers are reimbursed based the geographic location where the patient receives care. Agencies must report the appropriate metropolitan statistical area (MSA) code on the bill to report where routine and continuous care services were provided. This requirement does not apply to general inpatient or inpatient respite care.
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.
There are three mechanisms for ensuring hospice agencies meet established standards of care:
North Carolina has a number of facilities which provide either residential or inpatient services for hospice patients. The name and locations of those residential facilities are listed below: