With the hospice market (in most areas) fairly well saturated and the core (source) demand from traditional referral sources “flat”, growing census is a challenge for agencies. Some agencies have experienced referral growth but alas, length of stay has shortened. Others have experienced erosion as, while improper, the “skilled to death phenomenon” erodes days and referrals. Recall, the “skilled to death” concept is the SNF referral/discharge where the patient meets the 3-day prior inpatient criteria and “may” require a skilled service by Medicare SNF definition (nursing or therapy) even though the same is imprudent or not truly related to the patient’s condition. I have written about this issue before: It is fraudulent by all indications and merely a ploy to avoid out-of-pocket costs (applicable under hospice) for institutional care (at least for the first 20 days, if such meet the “skilled’ definition under the Medicare SNF benefit). The question oft asked of me is where can growth or additional days be found? My answer is at the “institutional” end (sort of). The reaction I soon get is “too much risk” or “been there, done that, got probed” or “those places won’t deal with hospice”. The last comment is why I say “sort of”.
To start; Hospice is a perfect complement for an SNF, and Assisted Living Facility, a Memory Care facility or a Seniors Housing complex (including CCRCs). As I have written before, I encourage all of these groups to partner with a (yes one) agency or perhaps two (no more). By the way, and I have beat this issue to death with numerous people, it is perfectly legal and appropriate for an SNF or any other of the aforementioned provider types to partner with just one Hospice (you will find ample reference on this site and explanations as to why in the comments section, other posts, etc.). For an SNF, hospice is clear survey risk-reduction and efficiency enhancement for any patient/resident that is simply trending toward end-of-life, naturally. The SNF COP (Medicare federal requirements) loathe patient/resident decline and thus, as patients/residents naturally trend toward death, the ante to prove all things interventionist to stave-off decline or at the least, justify that decline occurs despite best efforts to prevent, falls to the SNF. As ridiculous as this is, it is the SNF reality. Hospice and palliation, done right, resolve this issue and release (though not totally) the SNF, and the patient/resident, from the illogical burden (the patient/resident no longer bothered with weights, lab tests, etc.). The benefit in the Assisted Living/Memory Care environment, while less regulated, is the ability of hospice to elongate a stay where perhaps, the resident has exceeded the regulatory care parameter (boundaries) set by the State. In short, most states will allow residents to remain in the Assisted Living environment, even when the care required exceeds the regulatory boundary, if the purpose is to facilitate natural death in the environment rather than relocate the resident.
The risk for hospice today lies within the focus the CMS/Department of Health OIG and Department of Justice have placed on the industry, for agencies with large caseloads in institutional care settings. The reason for such scrutiny is the large (rather) amount of inappropriate enrollment and care provision exhibited by certain agencies (predominantly national agencies such as Vitas) in SNF and Assisted Living environments. Bluntly: These environments are the locus for a great deal of fraudulent activity in the industry. For those interested, the January OIG report on hospice activity in Assisted Living environments is available here: http://oig.hhs.gov/oei/reports/oei-02-14-00070.pdf Understanding the level of scrutiny the Federal government is placing on hospices with a large institutional caseload is key to building a proper risk management model/approach. To be sure, the agencies that play heavily in the SNF and Assisted Living environments will be audited more frequently. When audit frequency increases, the risk for claim errata and mistakes increases (mathematically logical). Knowing and understanding this risk is imperative to building a proper “institutional” care program. The risk of improper enrollment/certification and insufficient care isn’t worth a comment as no agency should ever breach these risk areas as doing so is clear fraud.
(There is one additional somewhat looming risk and that is a possible payment reduction in the future as CMS continues to look at revamping and modernizing the Hospice benefit. A concept within the discussions is a per diem reduction for any patient residing in an institutional care setting like an SNF or Assisted Living. As I have no solid information, nor does anyone else, as to what (and when) CMS will do regarding a change in the Hospice benefit, I won’t integrate any additional comments regarding payment changes into this post).
Taking the risk into account as discussed prior, how would or should an agency integrate additional institutional patients into its caseload and build a risk management model. The assumption is that a greater focus on an additional caseload will trigger scrutiny from the Medicare intermediary or perhaps, a CMS contracted auditor. Below I have outlined the approaches and recommendations I provide to hospice agencies.
- Limit the settings and in advance, perform due diligence on the provider setting and the provider. Partner with providers that have high quality, solid compliance histories (CMS 5 star, good survey history, well-regarded, etc.). Lots of data sources for an agency to use exist to determine the quality of any setting, formal and anecdotal.
- Understand the compliance/code requirements of the institutional setting. Hospices know their own requirements but all too frequent, don’t know the SNF requirements or Assisted Living requirements. Become knowledgeable or acquire talent that is. This will make discussions and planning and ongoing internal auditing much more effective and efficient.
- Build a strong interface agreement with each institutional setting. I have resources here if anyone needs. The key point is define in writing, everything to the best of each parties ability – who does what, who is accountable for what, etc. Focus on key risk areas such as documentation.
- Know the setting documentation and integrate the setting documentation into the hospice documentation/record. For example, in an SNF make sure the hospice has copies of the MDS, care plans, pain and other assessments, ADL information/records. Fundamentally, both parties should be seeing, recording and saying the same things.
- Structure your IDG/IDT process to incorporate a review of the institutional care setting’s documentation. Make certain institutional care staff are part of the process. I like to see the same representative group.
- Train key personnel – Hospice, the SNF, the Assisted Living, etc. on what each party is looking for in terms of care delivery, documentation, etc. Implement an ongoing program of inservice education. I like to see, on the part of the hospice, the same individuals tasked to a site – limit rotation of staff.
- Develop institutional care pathways and algorithms for common disease states found in SNFs, Assisted Living. Many hospices use Local Coverage Determination criteria – I am not a huge fan unless the same are tweaked or updated recently. CMS has clamped down on failure to thrive, generalized neuro, end-stage dementia as appropriate diagnosis/reasons for certification. This is not to say that the same are irrelevant reasons for certification merely, more elaboration is required. Look beneath the surface to find what is going on. Institutional setting patients, particularly SNF patients, generally have a good medical record with tons of data. Likewise, AMDA is a great pathway source. Local universities with medical schools can help with identifying criteria for end-stage Parkinson’s, post stroke (CVA, hemorrhagic, etc.), heart failure, end stage diabetes with/without renal failure, etc. Build your algorithm to assure key definitional points/milestones and share it with the institutional care setting.
- Utilize an external source to perform quarterly audits of your institutional caseload. Have this individual/organization sit through an IDG/IDT and then review records, particularly focused on certifications/re-certifications and charting – both Hospice and the institutional site. I like to have a focus on continuity of charting/documentation and clear role congruence between the parties (their staffs particularly).