First, I want to deal with Continuous Home Care, because it is the most misunderstood, confusing, or abused portion of the Medicare Hospice Benefit. The confusion comes from a bit of a vague description of what qualifies a patient for continuous care and the fact that continuous care doesn’t actually have to be continuous. Many hospices use CHC as a marketing tool to nursing homes, and that has only added to the problems within the hospice community. I’ll deal with the marketing portion more later. First, let me try to define and explain what Continuous Home Care is supposed to be.
In its most basic form, Continuous Home Care is used by the hospice for patients who need skilled nursing care to control acute symptoms. It allows the hospice to place appropriate staff members in the home setting for large chunks of time to get acute problems under control. It is the best weapon a hospice has to avoid a patient needing to be hospitalized.
The Hospice Training Manual from Palmetto GBA (one of the Medicare Intermediaries charged with processing hospice claims) gives these bullet points when discussing coverage of Continuous Home Care:
· Continuous home care should be provided only during a period of crisis as necessary to maintain the terminally ill individual at home.
· A period of crisis is defined as a period in which a patient requires predominately nursing care to achieve palliation or management of acute medical symptoms.
· If a patient’s caregiver has been providing a skilled level of care for the patient and the caregiver is unwilling or unable to continue providing care, this may precipitate a period of crisis because the skills of a nurse may be needed to replace the services that had been provided by the caregiver.
· The hospice must provide a minimum of 8 hours of care during a 24-hour day.
· When ensuring the 8-hour requirement has been fulfilled, remember that the 24-hour day begins and ends at midnight.
· The care need not be “continuous.” For example, 4 hours of care may be provided in the morning and 4 hours may be provided in the evening.
· Nursing care must be provided for more than half of the period of care and must be provided by either a registered nurse or licensed practical nurse.
· Nursing care in the hospice setting can include skilled observation and monitoring when necessary and skilled care needed to control pain and other symptoms.
· Homemaker or home health aide services may be provided to supplement the nursing care.
It actually doesn’t seem confusing when you read the manual, but, as they say, “there’s many-a-slip between a cup and a lip”. What seems easy to define becomes much harder when you add the business side to the equation. Hospices can make good money doing continuous care. The rough math is this: Medicare pays $30/hour for continuous care. A hospice pays a LPN $16/hour or an Aide $11/hour for working a continuous care case. Thus, there is money to be made here. Continuous care is also a popular benefit. It is done when families are at a place where they are not confident about their ability to care for their loved one. At that point, who wouldn’t want a nurse to come stay with them?
As a hospice owner/administrator it is easy to fall into the trap of thinking that Continuous Care is always justifiable. Make money – good! Make the family happy – good! Add to that, the possibility of marketing this service to nursing homes, and it’s almost hard to resist abusing this benefit. If there are two hospices “competing” for patients in one nursing home and one promises to do continuous care for all “actively dying” patients while the other says that continuous care must be evaluated on a case by case basis who do you think the nursing home will choose? They want the hospice that is going to put a staff member in the patients room, so they won’t have to do all the work that comes with a dying patient. It makes their life easier, so they want it.
The Palmetto manual says:
A period of crisis is defined as a period in which a patient requires predominately nursing care to achieve palliation or management of acute medical symptoms.
If a patient is dying peacefully, there are no acute medical symptoms to manage. Thus, I believe that symptom controlled death does not meet the standards of Continuous Home Care.
Palmetto provides a little wiggle room with this though:
If a patient’s caregiver has been providing a skilled level of care for the patient and the caregiver is unwilling or unable to continue providing care, this may precipitate a period of crisis because the skills of a nurse may be needed to replace the services that had been provided by the caregiver.
To me, this means that a caregiver freaking out because of the impending death of a loved one can justify continuous care, but, since a nursing home is seen as the primary caregiver, that could never apply to a patient in a nursing home.
There are a lot of people that disagree with me here. Their logic is what I explained above. If it makes good business sense and is good for the patient, then how can it be wrong? Because it is against the rules, that’s how. A hospice that provides continuous care for all dying patients has chosen to ignore the regulations which is convenient and illegal. Those that market their lack of good judgement as a selling point make it hard on everyone who values following the Medicare regulations. There are times where Continuous Care is appropriate, and those hospices who don’t do Continuous Care (or try to avoid it) because “it is hard to staff” are just as much guilty of wrong here as those who overuse it. Continuous Care is a very valuable tool that a hospice can use to help a patient/family, but it must be used in a responsible evenhanded manner. (If you are doing continuous care to help the nursing home instead of to help the patient, then you’ve clearly gone over the the dark side.)
I would guess that this is the first post on this blog where I have argued against giving a patient more help. This whole discussion goes against my most basic instinct of putting the patient first. I believe the logic above is correct, but it still feels wrong. That feeling in my gut is why this is such a misunderstood or abused level of care. If you break the rules for all the right reasons don’t the ends justify the means? I guess I’ll let you tell me.