Hospice Contract Reminders for SNFs

On a fairly routine basis, I run across SNF Administrators and Directors of Nursing that continue to have issues with hospice patients in their facilities but not from the standpoint of the patient typically; from the standpoint of dealing with the Hospice and the terms of the contract between the Hospice and the SNF.  In fact, because this issue continues to rise frequently enough, a “primer” post on the relationship between a Hospice and an SNF and how these contracts work, by federal code, seemed timely.  Below, I’ve arranged the concepts topically, perhaps even useful as a cheat sheet.

1. Is an SNF Required to Contract with a Hospice? The answer is no.  Regardless of what a surveyor, patient, family, or hospice tells you, there is no requirement for an SNF to establish a contract with a Hospice.  While patients have “choice” under Medicare of providers, the SNF is a “provider” and so is the hospice.  SNF care is treated entirely separate from a hospice level of care and even the Medicare benefit for Hospice requires a different benefit election.  Bottom line: While it likely will make sense for the SNF to have a contract with a Hospice, there is no legal or regulatory requirement for the SNF to do so, if it chooses not to.
2. If an SNF Has a Hospice Contract with One Hospice, Must it Contract with Other Hospices as Well?: Again the answer is not and in many cases, not advisable as I will discuss later.  Once an SNF has decided to contract with a Hospice, it can choose to limit its contract to just that one and no more.  It is possible that changes being discussed around the Hospice Medicare COP (Conditions of Participation) will modify this a bit but as of right now, an SNF can choose to contract with as many or as few (or none) Hospices as it desires.  The rule interpretation that is analogous here involves physicians.  Even if a patient has a right to choose his or her own provider, the law does not require that an SNF allow “any” provider.  Most SNFs limit the number of credentialed physicians they will permit “on-staff” just as hospitals do.  The patient retains the right to use a different hospice, just not within the walls of the SNF.
3. The Patient Resides in the SNF but is Under the Service of the Hospice.  Who is Responsible for the Patient?: Under Federal law, the Hospice is responsible for developing and coordinating the plan of care, providing physician care, medications and supplies related to the terminal diagnoses, and any and all other core services that are required under law for the Hospice to be certified and in business.  Essentially, any care related to the terminal diagnoses is the purview of the Hospice and the SNF becomes by definition, the “home” of the patient.  This does not alleviate the SNF of certain levels of responsibility for the basic care of the patient such as nutrition, activities, medication administration, ADL care, etc.  The Hospice assumes the overall responsibility of managing these “non-core” services and assures that the same are performed according to the plan of care and according to hospice policy.  It also surprisingly, doesn’t mean that a negative outcome caused by the SNF to the patient can’t be cited under the SNF code – it can (such as in the case of a life safety code violation, a medication administration violation or an allegation of abuse on the part of an SNF employee). 
4. What Must be or Should be in a Contract Between a Hospice and an SNF?:  Fundamentally, all of the following need to be clearly addressed. Note: This is not an exhaustive list and each provider should refer to the specific governing Federal and State code as a final reference. 
   1. The services provided by the Hospice
   2. The services provided by the SNF.  The SNF cannot provide, even under contract, the core required hospice services (Physician Services, Nursing, Social Services and Counseling/Bereavement).
   3. Hospice policies and philosophy in writing (as pertinent and applicable)
   4. Statements that specify that the Hospice takes full responsibility for the professional management of the patient’s hospice care and that the SNF provides room and board.
   5. Statements spelling out that the Hospice provides the same level of care and service within the SNF that it does for its home-bound patients including necessary medical care and inpatient care.
   6. Statement prohibiting the Hospice to discharge the patient from its service even if the care becomes costly or inconvenient.
   7. Statement requiring the Hospice to continue care for a Medicare beneficiary, even if the beneficiary cannot pay.
   8. Definition of admission criteria and requirements and necessary statements that the same apply for all payer sources and types.
   9. The Agreement should clearly define that roles and duties of each provider separately as well as in coordination with each other.
   10. The Agreement should specify all of the reimbursement and billing requirements and understandings between both parties.  This is particularly critical when a patient is dually eligible (Medicaid and Medicare) and may be using Medicaid to cover the cost of room and board in the SNF and Medicare for the hospice benefit. Bed hold requirements also need to be addressed.
5. What Duties are Joint Between the Hospice and the SNF?: Both providers must jointly develop the plan of care and share the responsibilities for completion of the MDS.  Each must also establish a communication plan for changes of condition or other events but it is the responsibility of the Hospice to change the plan of care (SNF may not alter the plan of care).  Medication changes (terminal condition related), lab reports and action/in-action, etc., are all the responsibility of the Hospice and the SNF may not take action without the approval of the Hospice.  An example that occurs all too frequently concerns the responsibilities between the providers when a patient falls or has frequent falls.  SNFs are accustomed to addressing falls almost instantaneously, developing new interventions and care plans.  In the case where the patient is under the care of the Hospice, this is the responsibility of the Hospice.  The SNF needs to be aggressive in getting the Hospice involved and responsive, timely but it (the SNF) cannot alter the care plan without Hospice involvement and approval.
6. Which Provider Has to Deal with Difficult Patients or Difficult Families?: For the most part, this is the responsibility of the Hospice, not the SNF.  Clearly, because difficult circumstances arise with patients when the Hospice is not present, the SNF will bear a large portion of the burden but all negative interactions or difficulties need to be shared with the Hospice.  For example, the Hospice is required to provide counseling and social service to patients and their families and SNFs need to hold the Hospice accountable for this.  Even a difficult family situation in the middle of the night needs to be handled by the Hospice and the SNF should not expect to wait until morning for the Hospice to intervene.   If the patient is restless or needs more attention than the SNF can directly provide because the patient is dying, the Hospice must provide the adjunct staff, including Volunteers.  Hospice staffing issues, etc. are not the concern of the SNF.  The Hospice is required by law to have its personnel available to the SNF and their patient, twenty-four hours per day, 365 days per year.
7. What Happens with Hospice Patients in the SNF During Survey and How are Surveyors Required to Review the Care Provided to these Patients?: Essentially, the plan of care and the direction of the care for the Hospice patient in an SNF is the responsibility of the Hospice and surveyors may not take issue with the SNF for adequacy of the care plan, etc.  The SNF must still be responsible for the legal requirements of its scope of duties as spelled out in the Hospice/SNF contract.  Surveyors may not however, take issue with an SNF because of the actions of a Hospice employee (or the lack of action, etc.).  The surveyor can and is only legally bound, to take actions with an SNF regarding the role and responsibility of the SNF as the patient’s “room and board”.   All of this said however, it is very important for an SNF to remember that it is responsible for holding the Hospice accountable for the Hospice’s responsibilities under the contract and as set forth by law.  An SNF runs the risk of having severe regulatory problems if it chooses not to hold a Hospice accountable for providing required care as needed by the patient or for addressing serious issues in a timely fashion such as a change of condition or adverse, unplanned event that occurred with the patient or his/her family.
8. Why Not Have Contracts with Multiple Hospices?:  Developing one good, functioning and workable contract takes time and energy.  Mutliple contracts take twice as much (if not more) time and frankly, for an SNF already limited in resources and responsible for a house-full (hopefully) of patients, more work in this case is not warranted or advised.  Multiple contracts lead to more opportunities for error, confusion and a burden on staff to have to think-through another set of players and nuances.  I have never seen an instance where having multiple contracts is beneficial for an SNF and to be quite honest, presents more opporunities for problems than what the extra contracts are worth.  My advice: Find a good Hospice, develop a contract, and take the time and energy to work and build a very solid program within the SNF.  If the relationship turns sour and issues can’t be resolved, don’t add another contract without eliminating the one that isn’t working.