UM Guidelines

 

Hospice Care

Hospice Care

BlueCross BlueShield of Tennessee developed this guideline to supplement the Milliman Care Guidelines®

BCBST modification effective June 28, 2007*

 

 

Exceptions may be required to comply with EPSDT & TennCare regulations.

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.

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.

       I.            Hospice Care Admission

If a covered benefit, hospice care may be approved for members with all of the following:

·         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 the individual, and

·         Evaluation and plan of care.

     II.            Evaluation and Plan of Care

Evaluation of the patient must be submitted including 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 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

  III.            Levels of Hospice Care

  • Routine Home Care
    • Care provided in the home when the individual is not receiving any other level of hospice care.
    • Includes periodic visits by members of the hospice care team as required by the individual’s needs.
  • Continuous Home Care
    • Continuous care 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. In general, BCBST guidelines for private duty nursing will need to be met.
    • Provided only as necessary to maintain the terminally ill individual at home and only if a covered benefit.
  • Inpatient Respite Care
    • Short-term inpatient care 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) and only if a covered benefit.
  • General Inpatient Care
    • General inpatient care provided for medically necessary procedures for pain control or for symptom control/management which cannot feasibly be provided in other settings.

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

  • Updated status report with level of hospice care.

References

Complete Guide to Medicare Coverage Issues [Computer software]. (2005, November). Hospice care (part 418, p. 7-66 to 7-67). St. Anthony Publishing.

Complete Guide to Medicare Coverage Issues [Computer software]. (2005, November). Coverage of hospice services under hospital insurance (chapter 9, p. 4-90 to 4-101). St. Anthony Publishing.

Hospice Patients Alliance. Four levels of care you’re entitled to receive. Retrieved March 1, 2006 from http://www.hospicepatients.org/hospic20.html.

 

* These guideline(s) have been revised from the Milliman USA Milliman Care Guidelines.  The portions of the guideline(s) which have been revised are identified through the use of [insert: italic, boldface, underlined, etc. as appropriate] text, and Milliman USA has neither reviewed nor approved the modified material.  Any statement to the contrary or association of the modified material with Milliman USA is strictly prohibited. This document has been classified as public information.

The above information only contains the modified portion of the Milliman Care Guideline. If you wish to view the complete Milliman Care Guideline, please contact Milliman USA.