Home Health & Hospice Week

Hospice COP wolf comes in regulatory sheep's clothing.

Mum is no longer the hospice discharge word, now that Medicare won't cut off reimbursement as soon as you mention the possibility of a patient's ineligibility for the benefit.

Hospices need to get with the program or risk survey trouble now that the Centers for Medicare & Medicaid Services' final rule on hospice amendments took effect Jan. 23. The rule's changes include provisions on discharge for cause and discharge planning (see Eli's HCW, Vol. XIV, No. 43).

Hospices may be confused by the new discharge requirements because CMS implemented the changes not as part of the hospice Conditions of Participation, but as separate "hospice amendments." Nevertheless, the final rule does change the COPs, notes attorney Mary Michal with Reinhart Boerner Van Deuren in Madison, WI.

The upshot: That means survey trouble if surveyors find hospices out of compliance with the new requirements.

The official, pending COP changes, which CMS proposed last May, cover comprehensive assessments, plans of care, quality improvement, criminal background checks and a number of other areas (see Eli's HCW, Vol. XIV, No. 21 and No. 22).

While the discharge, admission and other "amendments" took effect Jan. 23, the National Hospice and Palliative Care Organization expects the final rule for the other COPs to appear in 2008.

Discharge Not 'Single Moment'

Hospices have been concerned because "some [intermediaries] have stated that the hospice was responsible for discharging the patient as soon as it was determined that the patient was no longer terminally ill," NHPCO notes in a summary of the rule. "Thus, payment was liable to stop when any discussion of need for discharge appeared in the medical record."

But hospices shouldn't feel pressured to discharge a patient immediately, CMS takes pains to emphasize in the final rule, published in the Nov. 22, 2005 Federal Register. "We do not expect that a discharge would be the result of a single moment that does not allow time for some post-discharge planning," CMS says in the rule. "Discharge planning should be a process, and planning should begin before the date of discharge."

The discharge issue can be clouded further by an improvement in the patient's symptoms due to hospice care beginning, Michal notes. CMS' final rule recognizes the need for the hospice interdisciplinary group to follow a patient for some period of time to determine whether the disease itself is stabilizing, or merely the patient's symptoms, Michal says.

Tip: Hospices should implement structured discharge systems for evaluating ongoing eligibility and determining the need for discharge--and for documenting those steps, Michal advises.

CMS asks "that the judgment be supported by documentation in the medical record indicating the reason why hospice should continue if there seems to be improvement such that discharge is under consideration," the rule says.

Educate Staff To Avoid Citations

Hospices have welcomed the new discharge for cause provision, which allows providers to discharge patients when their behavior is "disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired," according to the final rule. That applies to other persons in the patient's home as well.

The decision to discharge for cause may not be cut-and-dried, especially in the early days of the policy, cautions Burtonsville, MD-based health care attorney Elizabeth Hogue. "The concept of discharging patients is quite new to hospice providers," Hogue tells Eli. "The option provided by the regulations must prompt hospices to think more carefully than they may have in the past about this whole issue," Hogue urges.

Lighten the load: And hospices must remember that they aren't responsible for implementing post-discharge plans for patients, especially ones discharged for cause, Michal adds. Hospices should "engage in and prepare for after-hospice care, but it is up to the patient (and the patient's supporters) to take advantage of other sources of care after discharge."

Do this: Surveyors will be ready to pounce on hospices misusing the new discharge for cause option, experts warn. Be sure to have systems in place that will ensure you follow the regulatory requirements for discharging patients--and that you document those actions.

The new discharge requirements are so fraught with compliance dangers that you should focus on training staff on how to appropriately use them. "The key to dealing with the new requirements is staff education," Hogue counsels. "Hospices should provide in-depth information to all staff about them." 

Note: The final rule is at www.access.gpo.gov/su_docs/fedreg/a051122c.html.