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UM Guidelines
Initial Hospice Care

Hospice Care

BCBST last reviewed September 21, 2016*

 

 

Exceptions may be required to comply with EPSDT & BlueCare® regulations.

Background

Hospice care provides for the palliation or management of a terminal illness and related conditions for individuals who are terminally ill. An individual with a medical prognosis of a life expectancy of six months or less is considered to be terminally ill. According to the Hospice Foundation of America, “the goal of hospice care is to improve the quality of a patient's last weeks, days and hours by offering comfort and dignity… Hospice addresses all symptoms of a disease, with a special emphasis on controlling a patient's pain and discomfort.”

Whether or not to use intravenous fluids (IV), tube feedings and/or total parenteral nutrition (TPN) may be discussed during hospice care. ”The American Academy of Hospice and Palliative Medicine endorses the ethically and legally accepted view that artificial nutrition and hydration, whether delivered parenterally or through the gastrointestinal tract via a tube, is a medical intervention. Like other medical interventions, it should be evaluated by weighing its benefits and burdens in light of the patient's clinical circumstances and goals of care.” An example of use would be when an intestinal blockage is causing vomiting, and use of an IV fluid would allow the bowel to rest and thus stop the vomiting.

An interdisciplinary hospice team, which includes the individual and the family/caregiver, develops the plan for hospice care. The hospice team offers comprehensive support through the following services: medical doctor, registered nurses, licensed practical nurses, social worker services, certified home health aide care, chaplain, bereavement counseling, and volunteers. In addition, other ancillary services (e.g., registered dietitian, therapists) are available when required for palliation. Nursing care and services are provided by or under the supervision of a registered nurse.

Clinical Indications for Admission to Hospice Care

  • Formal hospice care [A] (if a covered benefit) may be provided to manage the terminally ill patient and includes many levels of care including ALL of the following:
    • Admission into formal hospice requires ALL of the following documentation:
      • Certification by the individual’s attending physician of a terminal illness with a life expectancy of six‐months or less
      • Election of hospice care by individual
      • Evaluation and plan of care submitted
    • Levels of Care must be met by ANY ONE of the following:
      • Home Healthcare is needed for appropriate care of the patient because of ALL of the following:
        • Patient has terminal illness (i.e., life expectancy of 6 months or less if illness runs its expected course)
        • Provided in the home when the individual is not receiving any other levels of hospice care
        • Includes periodic visits by members of the hospice care team as requested by the individual’s needs
      • Continuous Home Healthcare is needed for appropriate care of the patient because of ALL of the following:
        • Patient has terminal illness (i.e., life expectancy of 6 months or less if illness runs its expected course)
        • Provided in the home only during a period of crisis. A period of crisis is a period in which the individual requires continuous care which is predominantly nursing care to achieve palliation or management of acute (out-of-control) medical symptoms. Provided only as necessary to maintain the terminally ill individual at home
      • Inpatient Respite Care is needed for appropriate care of the patient because of ALL the following are met:
        • Patient has terminal illness (i.e., life expectancy of 6 months or less if illness runs its expected course)
        • Provided only when necessary to relieve the family members or other persons caring for the individual at home
        • Provided only on an occasional basis and for a short period of time (e.g., up to five days)
      • Inpatient Palliative Care (formal inpatient hospice) is needed for appropriate care of the patient because of ALL of the following:
        • Patient has terminal illness (i.e., life expectancy of 6 months or less if illness runs its expected course)
        • Provided for medically necessary procedures for pain control or for symptom control/management, which cannot feasibly be provided in other settings.

Treatment Plan (Evaluation and Plan of Care)

  • Evaluation of the individual must be submitted, including ALL the following as appropriate:
    - Ordering MD & last visit - Gait analysis
    - Primary diagnosis - Circulation & sensation
    - Date of diagnosis onset - Cooperation & comprehension
    - Baseline status  - Developmental delays (pediatric patients)
    - Current functional abilities  - Other therapies or treatments
    - Functional potential  - Individual's goals
    - Strength  - Medical compliance
    - ROM  - Support system
  • Plan of care must be submitted, including ALL the following as appropriate:
    - Short- and long-term goals  - Proposed admission date
    - Discharge goals - Frequency of treatment
    - Measurable objectives - Specific modalities, therapy, exercise
    - Functional objectives - Safety & preventive education 
    - Home program  - Community resources

Extension of Services for periods of 30 days at a time requires the following documentation:

Updated status report with level of hospice care.

References

  1. American Academy of Hospice and Palliative Medicine. (2013, September). Statement on artificial nutrition and hydration near the end of life. Retrieved June 6, 2016 from http://aahpm.org/positions/anh.
  2. BlueCross BlueShield of Tennessee network physicians. September - December 2016.
  3. Centers for Medicare & Medicaid Services. (2015, September). Hospice. Retrieved June 6, 2016 from https://www.cms.gov/Medicare/Medicare-fee-for-service-payment/hospice/index.html.
  4. Hospice Patients Alliance. Four levels of care you’re entitled to receive. Retrieved July 14, 2009 from http://www.hospicepatients.org/hospic20.html.
  5. Hospice Foundation of America. (2009). What is hospice? Retrieved June 6, 2016 from https://hospicefoundation.org/End-of-Life-Support-and-Resources/Coping-with-Terminal-Illness/Hospice-Services.  
  6. National Comprehensive Cancer Network. (2015). NCCN Clinical Practice Guidelines in Oncology®. Palliative care. Retrieved September 24, 2015 from the National comprehensive Network.

Footnotes

[A] Hospice is a concept of care, an organization to provide care, and a payment benefit for care at the end of life. (7)

 

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