As regulatory changes and government oversight push changes in the healthcare market overall, hospice agencies must pay attention in 2020 to shifting expectations amid evolving service demand.

With baby boomers aging, preferences leaning toward providing senior care in the home, and regulations aiming to deter avoidable hospitalizations, hospice agencies may see increased demand.

In 2017, Medicare paid $17.8 billion in hospice care benefits for nearly 1.5 million patients, according to the Health and Human Services (HHS) Department. Care settings for hospice services include hospitals, skilled nursing facilities, hospice facilities, and private homes.

As hospice leaders plan strategically for the coming year, these key issues should capture some focused attention:

  • Tightening compliance in the aftermath of critical findings by the HHS Office of Inspector General (OIG). The OIG found that 80% of hospices had one or more deficiencies between 2012 and 2016.
  • Managing the work of physician assistants (PAs) to comply with new responsibilities allowed and those still restricted.
  • Identifying patients eligible for the Seriously Ill Population (SIP) payment model under the Primary Care First initiative.
  • Exploring avenues for facilitating services using telehealth connections in the future.
  • Monitoring quality rating factors and protecting the organization’s reputation.

Let’s delve into these shifting conditions in a bit more detail.

Monitoring Policies and Procedures

To avoid negative hits in surveys and quality ratings, hospice organizations will need to give concerted attention to following care plans and monitoring patient and family complaints.

In a 2019 HHS report, the OIG identified areas of concern after analyzing deficiency and complaint data from the Centers for Medicare and Medicaid Services (CMS).

To avoid the types of problems noted in the OIG report, hospice leaders can put these top takeaways on their 2020 to-do list:

  • Use checklists to ensure that all procedures are followed and documented appropriately, including admission, recertification, revocation, transfer, and death of the patient.
  • Conduct prebilling technical audits to ensure that the required documents for these aspects of hospice care are compliant with regulations. Partner with community providers that may serve your hospice patients to obtain copies of records and communicate about what services are related to hospice and covered by hospice, and what is billable under Medicare Part B.
  • Routinely conduct a hospice eligibility audit to ensure all patients admitted are eligible for hospice care. Create an eligibility audit tool using Local Coverage Determination guidelines and conduct the audit before billing.
  • Make sure the hospice election statement is compliant. Educate the patient about what hospice covers and any planned care outside hospice that would not be covered. Document the patient’s understanding and agreement. By October 1, 2020, hospices must comply with new regulations for the hospice election statement, including making patients aware that they have the right to an election statement addendum. As the National Hospice and Palliative Care Organization (NHPCO) notes, the addendum will be a patient-specific list of what hospices will not cover for that individual.
  • Supervise care teams to ensure that they follow the plan of care and stay compliant. All services identified in the care plan should be provided at the appropriate time. The plan of care should be a living document and evolving as the patient’s condition changes. Use interdisciplinary group meetings to update the plan of care systematically and consistently with the patient’s change in condition. Visits and interventions must mirror what is detailed in the plan of care.
  • Follow up to be sure clinicians and caregivers document care accurately as they provide it. When documentation is missed, altering or backdating records is off limits. Hospice professionals should document the patient’s condition, the hospice’s interventions, and the patient’s response, with time frames. The patient’s decline should be captured in every piece of documentation. Each entry should support “Why hospice, why now?” and what the hospice is providing to support the patient’s goals.
  • Provide continual training options to promote high-quality hospice and palliative care.

Using PAs in Allowable Ways

As federal laws and regulations ease restrictions on the ways PAs can work with patients, hospice organizations will need to examine their policies and consider expanding the use of PAs in hospice as allowed in individual states.

Starting in January 2019, Medicare policy began allowing PAs to act as attending physicians in providing care related to a hospice patient’s terminal illness, including establishing and updating the hospice plan of care. The change, codified under the Bipartisan Budget Act of 2018, is designed to expand the pool of providers who can care for hospice patients and to ensure continuity of care if a PA is a patient’s primary provider before admission to hospice.

CMS this month issued a final rule on the Medicare physician fee schedule for 2020 that allows a stronger role for PAs in hospice by easing physician supervision requirements. A CMS press release notes that the change is designed “to give PAs greater flexibility to practice more broadly in the current health care system in accordance with state law and state scope of practice.”

The American Academy of PAs (AAPA) in March explained the ins and outs of the relevant federal law and regulations, noting that limitations on PAs still existed. The issuance of the Nov. 1 CMS final rule allows PAs more leeway. As AAPA notes, in addition to managing the hospice plan of care in the attending physician role, granted in January 2020, a PA may order medication if the PA is not employed by the hospice organization and if state law allows it. The face-to-face encounter that is required for hospice recertifications is not yet open to PAs; currently, an NP or physician must complete this task.

Considering the Primary Care First Payment Model

CMS is implementing the Primary Care First initiative, which bases payments on patient needs and outcomes, not services provided. The initiative asks participating clinical practices to assume financial risk based on patient outcomes in return for a reduced administrative burden.

The Primary Care First program includes the Seriously Ill Population (SIP) payment option, which is designed to improve SIP coordination for patients across the continuum of care, including transitions to hospice and palliative care services.

Primary Care First goals for SIP are to coordinate previously fragmented care, reduce avoidable hospitalizations, and control costs for these patients. Applications from stakeholder organizations are due in January, and the program’s launch is set for 2021.

As hospice organizations consider ways to diversify their services, adding home health primary care as a business line could provide a way to serve seriously ill populations before they need hospice care services. Some hospices are already piloting programs to provide palliative care services to home care patients.

As the January application deadline looms, hospice leaders have expressed concerns about unanswered questions, as noted in Hospice News, such as who will contact patients to educate them about opting in. The NHPCO outlines key factors of the initiative for its members to consider as the launch approaches.

Planning for Telehealth Options

A bill introduced in the U.S. Senate in October would allow expanded use of telehealth services starting Jan. 1, 2021. The bill’s Senate sponsors note that the provisions of the bill are designed to improve access to healthcare—especially in rural areas—and drive down costs.

The legislation, titled Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2019, or CONNECT for Health Act of 2019, could open up hospice use of telehealth, according to Hospice News. The National Partnership for Hospice Innovation advocates using telehealth and other options to modernize the requirements for face-to-face encounters for recertifying a terminal illness for hospice.

Monitoring Quality Ratings and Reviews

Paying attention to outcomes measured by the CMS Hospice Quality Reporting Program (HQRP) is vital to an agency’s reputation and business standing.

As part of the HQRP, CMS is developing a patient assessment tool to inform the care plan, guide patient and family choice, and provide meaningful outcome-based measurements.

CMS is seeking stakeholder engagement and planning for initial testing of the Hospice Outcomes and Patient Evaluation (HOPE) tool in the coming months. Hospice organizations will need to stay tuned into the HOPE effort and offer comments when CMS solicits feedback.

Hospice leaders naturally need to monitor their agency’s reputation. This means not only HQRP data and official complaints, but also online reviews from patients and family members.

Taking corrective action is vital to protecting future patients, encouraging referrals, and hiring and retaining the best team of clinicians and caregivers available.

Consider how you can ensure the best in hospice and palliative care by monitoring clinical skills and continually enhancing your team’s learning. Quality outcomes require quality clinicians and caregivers.

Susan Heinzerling, RN, CHPN

Susan Heinzerling, RN, CHPN, began her nursing career as a med/surg nurse. Renal patients in acute care, with multiple chronic conditions and repeated hospitalizations, inspired her practice of hospice nursing, where she began as a hospice admissions nurse and later became a hospice RN case manager. Susan has practiced hospice nursing in both a large urban area and in a rural setting. Susan earned a BS in biology and a BS in nursing from the University of North Carolina at Chapel Hill and a master’s degree in physiology from North Carolina State University. She became a PhD candidate in immunology at the University of South Alabama. Her research experiences in the biomedical sciences led to an interest in evidenced-based practices.

Terrey L. Hatcher

Terrey is a Content Marketing Manager at Relias. She has worked in professional development and curriculum design organizations for more than 20 years. At Relias, she has collaborated with physicians, nurses, curriculum designers, writers, and other staff members to shape healthcare content designed to improve clinical practice, staff expertise, and patient outcomes. Besides her current focus on healthcare solutions, Terrey’s experience includes sharing best practices in education, IT, and international business.

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