MDS Alert

Published on Mon Jan 28, 2013 PDF

Test your knowledge — and beware survey scrutiny.

You hear a lot about palliative care in long-term care settings, but are you really sure you understand the specifics a palliative care program should include from a surveyor’s point of view? Before you’re hit with citations for non-compliance, review this advice to ensure your up to speed on the essentials.

Simply defined, palliative care aims to improve the quality of life for patients and families facing chronic or life-threatening illness through prevention, assessment, and treatment of pain and other physical, psychological, and spiritual problems, according to the World Health Organization. While that’s an undeniable fit for the mission of the nation’s nursing homes, advocates of enhanced palliative care in nursing homes are the first to note that the current regulations still focus more on cure than comfort—often clashing with palliative care goals.

Case in point. Consider survey citations for weight loss for a resident who is in his final weeks.

The disconnect between current regulations and palliative care goals means that many long-term care facilities are falling behind in fully embracing palliative care, contends Diane Meier, M.D., of the Center to Advance Palliative Care at the Mount Sinai Medical Center in New York City.

To stay in the race—and stave off costly survey citations—take steps now to educate yourself about a long-term care subspecialty that’s likely to be vital to the future of your business.

In the news. Palliative care is making headlines lately for myriad reasons, notes health care attorney Joseph Bianculli of Arlington, VA. There’s been impressive growth in hospital-based palliative care programs in recent years, and the Affordable Care Act is bolstering incentives for exploring palliative care.

While health reform did not specifically address palliative care as a distinct service from hospice care, the Act does call on federal agencies to "develop a research agenda on palliative care to address issues such as the development of practice guidelines and methods of quality improvement, as well as the exploration of reimbursement options, reads an executive summary of the Affordable Care Act published by George Washington University Medical Center in Washington, DC.

Win-win. New research is already making a strong case for post-acute palliative care. A newly published study by researchers at the Hebrew Rehabilitation Center in Boston, MA, suggests that palliative care can reduce the likelihood that residents will require emergency room care. The study also found a correlation between palliative care in the nursing home and reduced rates of depression among residents.

Learn more. The study, "Palliative Care for Long-Term Care Residents: Effect on Clinical Outcomes," appears in the December 2012 issue of The Gerontologist and is available at http://gerontologist.oxfordjournals.org/content/current.

Take These Steps Now

Providers need to know that palliative care is now squarely on surveyors’ radar screens, stresses Kimberly Steele, RN, WCC, RAC-CT, a regional consultant with Topsfield, MA-based Harmony Healthcare International.

On Nov. 30, 2012, the Centers for Medicare & Medicaid Services rolled out important new changes to its Interpretive Guidelines for Long-Term Care: Facilities F Tag 309, Quality of Care. The guidance gives new prominence to "palliative care," defining it as "patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering." Furthermore, the guidance notes, "Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice," calling on nursing homes to "identify the resident’s prognosis with supporting documentation; and initiate discussions/considerations with the interdisciplinary team regarding advance care planning and resident choices to clarify resident goals and preferences regarding care as the resident is approaching the end of life."

That means that assessing, managing, and documenting palliative care is now paramount for many long-term care residents.

CMS has noted that by 2030, half of the 3 million individuals likely to be living in a nursing home are apt to die there.

Translated: You may not be a provider of hospice care, but end-of-life (read "palliative") care is now vital to the well-being of your residents—and your business.

Important distinction: Hospice fits under the palliative care umbrella, but in many cases, you will need to address palliative care concerns even when talk of hospice seems distant. Remember, palliative care may be warranted even when hospice isn’t ultimately a resident’s best or preferred option.

When a Resident Does Request Hospice

Don’t miss this red text in CMS’s new guidance: "If a resident requests hospice care, and a facility does not offer or contract for hospice or with the particular hospice requested, the facility must (1) arrange with a Medicare certified hospice to provide care to the individual resident, or (2) help the resident and/or the resident’s legal representative arrange for a transfer of the resident to a facility that provides the hospice care and/or services the resident desires."

Did you know? "Many nursing facilities aren’t aware of that regulatory requirement," cautions Steele. "If a resident asks about hospice, a nursing home must either provide [Medicare-certified] hospice or guide the resident to that service."

Furthermore, when hospice services are required, a facility partnering with a hospice becomes jointly responsible for coordinating and documenting a resident’s plan of care.

The devil may be in the details, cautions Steele. For example, if the hospice agency has arranged for a social services consult every Monday, for example, and the hospice provider doesn’t show up, what is the nursing facility’s response? "Every detail of the arrangement between the hospice and nursing facility should be spelled out" in advance, coaches Steele.

Nursing facilities will also continue to have to scrutinize the balance between "curative" and palliative care, keeping in mind the documented wishes of the residents and his or her representatives.

Example: In palliative care, a resident with abdominal pain may be helped by reducing doses of medications with high anticholinergic properties that can lead to constipation or intestinal ileus.

Bottom line: The revised criteria for compliance with F Tag 309 stresses that facilities must continue to provide care that helps a resident maintain his or her "highest practicable level of physical, mental, and psychosocial well-being" even at the end of life, summarizes Jeannie Adams of Hancock, Johnson & Nagle, PC, in Glen Allen, VA.