Vol. 2 Issue 16
Hospice in Long-Term Care
The scope of hospice care has grown as the needs of the patient have expanded
Hospice care has traditionally been thought of as care of the terminally ill in the home care setting. This is no longer the case. The scope of hospice care has grown as the needs of the patients have expanded. We now see hospice care in the hospital, in long-term care (LTC) and in traditional home-care settings.
Hospice is no longer exclusive to the cancer patient. Today, hospice care is provided to individuals with cardiac, pulmonary, renal, liver and neurological diseases, as well as diabetes, the final stages of Alzheimer's and non-Alzheimer's dementia. Hospice care can be provided to someone who's simply dying of "old age," when we see a multi-system failure.
Death at any age is difficult for those left behind. Because a hospice staff is better able to assist family and friends in the bereavement period, we must support such palliative care in LTC settings when traditional medical care aimed at curing a disease is no longer appropriate.
Coverage and Delivery
Medicare allows for hospice care in the LTC setting for any end-stage disease process where life-sustaining treatment has been terminated and the palliative treatment plan is initiated.
Hospice care in a LTC setting provides a unique opportunity for patients to receive enhanced care at a time when it's needed most. Under Medicare, a patient that meets specific hospice criteria cannot be denied access to hospice care simply because the patient resides in a LTC facility. The patient is allowed to choose a hospice provider, who will then provide hospice care within the confines of the LTC facility.
Room and board at the LTC facility continues to be paid privately or by Medicaid. Medicare pays for hospice benefits, which are dictated by the admission diagnosis. As part of a patient's hospice benefits, medications, durable medical equipment, oxygen and wound care are provided. A variety of skilled and non-skilled services are provided on an intermittent basis. The individual patient can receive up to 10 hours of CNA assistance per week in addition to the care provided by the LTC facility staff. Hospice care provides for care plan oversight management by a qualified RN who assists with the facility staff in meeting the individual needs of the specific resident.
Home vs. LTC
When you have a terminal patient who cannot be managed at home yet has a life expectancy of 1-6 months, it may be necessary to place this individual in a LTC setting. The hospice benefit is provided just as it would be if the patient remained in his home. In this instance, the "home" is the LTC facility. To reiterate, Medicare does not pay for the room and board in LTC. This must be paid privately or by Medicaid, which is subject to financial criteria being met.
However, many insurance companies are now paying for hospice care in the LTC setting, including room and board charges. Managed care is recognizing the cost effectiveness of caring for a hospice patient in a LTC venue. The insurance industry is now accepting palliative care as a viable option of treatment.
Comfort Corner Hospice Unit at Oakland Care Center opened its doors in November 2001. This 15-bed unit allows hospice care to be provided in the LTC setting, yet allows the family the choice of not having to place their loved one in a geriatric-specific setting. Staff members are trained in the hospice philosophy. The Comfort Corner Hospice Unit boasts a separate building entrance that allows families to enter the "comfort" of this unit without having to traverse the boundaries of the attached nursing home.
The Comfort Corner Hospice Unit is the first unit of its kind in New Jersey. The New Jersey State Ombudsman Office has recognized Oakland Care Center for its palliative care initiative in the LTC setting. It is speculated that other long-term care facilities will follow suit as the need for these special units is recognized by the industry.
Catering to Younger Patients
The long-term care of the terminally ill patient is an issue that cannot be ignored by the LTC industry. You cannot effectively care for the young adult or middle-aged adult in the normal "nursing home" environment. The issues surrounding the younger terminally ill patient and the affected family are overwhelming for the standard nursing unit in a LTC facility.
These patients need special care. What do you do when there is no extended family to assist in the care of this individual? Frequently, the spouse must continue working in order to provide continued insurance coverage, as well as financial security for the family. In-home, 24-hour nursing care is cost prohibitive and is generally not covered by medical insurance. But until recently, the alternatives were slim picking, including a temporary stay at a hospice inpatient unit or placement at a nursing home.
It is extremely traumatic for a family to not only deal with a terminal illness but to also face placing a loved one into a nursing home environment. When the loved one is a young or middle-aged adult, the burden of guilt can be overwhelming when faced with the reality of LTC placement. By allowing for the placement of this special patient on a dedicated LTC hospice unit, their needs can be met in a care setting that is designed to meet the needs of the younger terminally ill patient and his surviving family.
Easing the Pain
At the same time, the terminally ill geriatric patient can be more effectively managed on the LTC hospice unit, as the staff is versed in all aspects of care of the dying patient. Pain management issues, emotional issues of the patient and family, comfort measure issues, etc., are all addressed in a forum designed to meet the needs of the terminally ill. According to "Chronic Pain Management in Long-Term Care, Clinical Practice Guidelines 1999," estimates of the number of nursing facility residents who have chronic pain range from 45 to 80 percent. Chronic pain in the LTC setting is generally under recognized and under treated.
The staff members who choose hospice and palliative care as their life work are dedicated to performing the highest standard of care. Though chronic pain management in long-term care is an issue that is not isolated to the terminal patient, the issues of chronic pain management in the terminally ill patient are better managed on a LTC hospice unit or with the support of hospice staff.
A social worker specializing in hospice care is available to the patient and family to address any social or psychosocial issues that arise. The hospice chaplain works closely with the patient and family on any spiritual issues. The hospice chaplain coordinates care needs with the patient's personal spiritual advisor (pastor, priest, rabbi, other) to insure that all needs are met. In addition, hospice volunteers are available to provide a variety of services, all designed to improve the quality to the patient's life for the time that is left.
When the loved one has passed on, the bereavement program is initiated. The chaplain and trained bereavement counselors work with the family, nursing home residents affected by the death, and nursing home staff to resolve bereavement issues that may exist. The hospice provider in LTC recognizes that a resident has established many ties within the walls of the facility. Those who are left behind will feel the pain of this loss. The presence of hospice allows for these issues to be addressed in a healthy forum.
Any patient with a terminal diagnosis should be educated about palliative care options and given the opportunity to receive hospice benefits.
"Hospice care is Medicare's hidden treasure," said U.S. Sen. Chuck Grassley (R-Iowa), during a September 2001 hearing of the special committee on aging. "Too few people use the hospice benefit for too little time. That has to change."
In any disease entity, specific criteria must be met before hospice care can be instituted. Your local hospice provider can determine when a patient is appropriate for hospice care. The important factor is that the individual resident in a LTC facility be allowed hospice benefits when they are appropriate.
Further information on hospice care in LTC can be obtained by calling any of the following organizations:
• Medicare: 800-MEDICARE
• The National Hospice Organization:
• The Hospice Association of America:
• New Jersey Hospice & Palliative Care
• New York State Hospice Association:
• Pennsylvania Hospice Network:
Barbara Offner is director of case management & marketing at Oakland Care Center, Oakland, NJ. Comfort Corner Hospice Unit is located at Oakland Care Center.