Hospice Continuous Home Care LEGACY HOSPICE

Hospice Continuous Home Care LEGACY HOSPICE

The Basics CONTINUOUS HOME CARE OF THE HOSPICE PATIENT

What is Continuous Home Care? A day on which an individual who has elected to receive hospice care is not in an inpatient facility and receives hospice care consisting predominately of nursing care on a continuous basis at home. It is only furnished during brief periods of crisis and only as necessary to maintain the terminally ill patient at home. CHC is an attempt to de-escalate a crisis to prevent hospitalization A minimum of 8 hours of care must be furnished on a particular day to qualify for the CHC rate.

When is CHC Appropriate? During a brief period of crisis, such as: Frequent medication administration to control symptoms Collapse of family support system Symptom management requiring staff (primarily nursing) at the bedside for a total of 8 or more hours during a 24 hour period beginning at midnight. (does not have to be consecutive) Rapid deterioration of patient s condition Imminent death

What to consider? What symptoms need to be controlled? What care needs are not being met? Is my documentation reflecting a patient at high risk for hospitalization if symptoms can not be controlled?

Who provides CHC? Primarily RNs and LPNs regulations state that at least 51% of the hours of care are provided by an RN or LPN. Homemaker of health aide services may be provided to supplement the nursing care. Services provided by a nurse practitioner that, in the absence of a nurse practitioner, would be performed by an RN or LPN, are considered nursing services and are paid at the same CHC rate. Other disciplines such as SW or Chaplains are important but are not included in the definition of CHC and are not counted towards total hours.

Where is CHC provided? In the patient s home In a long-term care facility, i.e. nursing homes or assisted living facilities Never in an inpatient facility such as a hospital or in-patient hospice facility

Billing Information CONTINUOUS HOME CARE FOR THE HOSPICE PATIENT

How is payment determined? Payment varies depending on the number of hours of continuous service provided The CHC rate is divided by 24 to yield an hourly rate. The number of hours provided is then multiplied by the hourly rate to yield the CHC payment for that day. Documentation of care, supervision of HCA s, care plan revision can not be counted towards hours.

Billing Requirements A minimum of 8 hours must be furnished during a 24 hour period beginning at midnight. When fewer than 8 hours are required, the services are covered as routine home care. At least 51% of the continuous care hours must be provided by an RN or LPN with the remaining time being provided by a homecare aide. When aide hours exceed nursing hours, CHC will be denied & paid at the routine home care rate. Appropriate documentation of care to necessitate continuous care.

Documentation CONTINUOUS HOME CARE FOR THE HOSPICE PATIENT

Documentation Requirements Documentation must justify need for this specialized level of care and should be hourly. Documentation should include: Circumstances leading up to CHC Interventions Results of interventions All direct care provided to patient Education/teaching/emotional support provided to caregiver ALL staff providing care to the patient should document their care, even if their hours can not be counted towards CHC.

CPC Documentation Nursing Notes: PRN note or Progress note Level of Care Change Order: Should include calculation of total time to be billed for CHC, not total time spent with pt and/or caregiver. Calculation of time should be broken down by discipline and time. Example: RN: 11am-1pm, 3pm-4pm, 7pm-11pm, HCA: 1pm-4pm RN total CHC hours: 6 hours HCA total CHC hours: 3 hours Total CHC hours: 9 hours

CPC Documentation Physician s Order Any change in level of care requires a signed Physician s Order The Level of Care Change order needed to document your time and provide to your biller is not a physician s order as it is not signed by a physician

The Technicalities CONTINUOUS HOME CARE FOR THE HOSPICE PATIENT

Important Points to Remember! Must be a minimum of 8 hours during a 24 hour period beginning at midnight. (does not have to be consecutive) At least 51% of the time must be provided by an RN or LPN, with remaining time provided by an aide. When fewer than 8 hours of nursing care is required, the services are billed at the routine home care rate. Services provided by SWs or Chaplains are not included in the definition of CHC and are not counted towards total hours of continuous care. These services are expected during periods of crisis, but are included in the provisions of routine hospice care.

Important Point to Remember! When the patient s needs require interventions by more than one covered discipline resulting in overlapping of hours between nurse and home health aide, these hours would be counted separately. The hospice MUST ensure that the direct patient care services are clearly documented and are reasonable and necessary. Documentation of care, modification of the plan of care, and supervision of aides or homemakers would not qualify as direct care nor would it qualify as necessitating the services of more than one provider.

What if Aide hours exceed Nursing hours? Computation of hours of care should reflect the total hours of direct care provided to an individual that support the care that is needed and required. All nursing aide hours should be included in the computation for CHC. When the aide hours exceed the nursing hours, CHC would be denied and routine payment will be made. Deconstructing what is provided in order to meet payment rules is not allowed. Hospices cannot discount any portion of the hours provided in order to qualify for a continuous home care day.

Scenarios CONTINUOUS HOME CARE FOR THE HOSPICE PATIENT

What would you do? Does this qualify for Continuous Home Care? NO. Despite 8 hours of service, this does not constitute CHC since 2 of the 8 hours were not activities related to direct patient care Scenario 1: The patient has had a central venous catheter inserted to provide access for continuous Fentanyl drip for pain control and for the administration of antiemetic medication to control continuous nausea and vomiting. The nurse spends 2 hours teaching the family members how to administer IV medications. She returns in the evening for 1 hour. The homecare aide provides 3 hours of care. The nurse spends 2 hours phoning physicians, ordering medications, documenting, and revising the plan of care.

What would you do? Does this qualify for CHC? Yes. This constitutes a medical crisis, including collapse of family structure. The caregiver has been providing skilled care and the change in pt. s condition requires the nurse s interventions. If the caregiver had been providing custodial care and his medical crisis resolved within a short time frame, this situation would not have qualified as CHC. How many hours of care would be computed as CHC? 16.5 hours since there is no overlap in nursing care. The social worker hours would not be incorporated. The patient experiences new onset seizures. He continues to have episodes of vomiting. The nurse remains with the patient for 4.5 hours (10am -230pm) until the seizures cease. During that time she provides skilled care and family teaching. The patient s wife states she is unable to provide any more care for her husband. A home health aide is assigned to the patient for monitoring for 24 hours, beginning at 2pm, with a total of 8 hours of direct care in the first day. The nurse returns intermittently for a total of an additional 4 hours to administer medication, assess the patient and to relieve the aide for breaks. The Social Worker provides 3 hours of services to work with the patient s wife in identifying alternative methods to care for the patient.

What would you do? Does this qualify for CHC? No. There is little care that requires a nurse. What would be a more appropriate intervention? Respite. The patient would be a candidate for respite due the primary caregiver being exhausted and scared. 77 year old patient with lung cancer whose caregiver is 80 years old. The caregiver has been caring for this patient for 4 months and is now exhausted and scared. The care provided consists of assisting with bathing, assisting the patient to ambulate, preparing meals, housekeeping and administering oral medications. Since the patient is dyspneic at rest, she requires assistance in all ADLs, which equates to 9 hours of assistance within a 24 hour period.

What would you do? Does this qualify for CHC? NO. Because only 3 of the 11 hours were skilled care requiring the services of a nurse. The previous patient s condition deteriorates. The patient now has circumoral cyanosis, RR of 44, and labored with intermittent episodes of apnea. The nurse performs a complete assessment and teaches the caregiver on methods to make the patient comfortable. The nurse returns twice within the 24-hour period to assess the patient. She revises the plan of care after conferring with the patient s attending physician and with the hospice physician. The homecare aide is sent to assist the caregiver. Within the 24-hour period, the direct care provided by the nurse equates to 3 hours and homecare aide 8 hours.

What would you do? How many hours would be billable as CHC? 10. 6 hours nursing care + 4 hours aide care = 10 total hours. The nurse provided over ½ of the time. Since the nurse and aide provided direct care simultaneously, it would be appropriate to bill for each. How would the 2 hours provided by the SW be billed? They would not be billed. The next day, the patient s condition deteriorates further. She has increased periods of apnea and air hunger. In addition she is experiencing continuous vomiting and increasing pain. Her blood pressure is beginning to decrease and her respirations are increasing. The nurse remains at the bedside for 4 hours while attempting to control her pain and symptoms. The homecare aide provides care during 1 hour of this period. The nurse leaves and the aide remains at the bedside for 3 hours. The SW comes and talks with the caregiver and remains for 1 hour. The nurse returns while the aide leaves. The nurse remains with the patient for 2 hours until she dies. The SW returns and stays with the caregiver for 1 hour until the mortuary arrives.

What would you do? You and an aide spend a total of 10 hours at a patient s bedside beginning at 6pm on Thursday and ending at 6am on Friday. Would you document as CHC? NO. The time frame is 24 hours beginning at midnight. How would 4 consecutive hours at the bedside by the RN and 2 by the HCA be documented and billed? As Routine Home Care.

The Regulations CONTINUOUS HOME CARE OF THE HOSPICE PATIENT

Regulations Hospice Conditions of Participation (CMS-1983) Web link: http://www.access.gpo.gov/nara/cfr/waisidx_04/42cfr418_04.html Sec. 418.302 Payment procedures for hospice care. (2) Continuous home care day. A continuous home care day is a day on which an individual who has elected to receive hospice care is not in an inpatient facility and receives hospice care consisting predominantly of nursing care on a continuous basis at home. Home health aide or homemaker services or both may also be provided on a continuous basis. Continuous home care is only furnished during brief periods of crisis as described in Sec. 418.204(a) and only as necessary to maintain the terminally ill patient at home. (4) The hospice payment on a continuous care day varies depending on the number of hours of continuous services provided. The continuous home care rate is divided by 24 to yield an hourly rate. The number of hours of continuous care provided during a continuous home care day is then multiplied by the hourly rate to yield the continuous home care payment for that day. A minimum of 8 hours of care must be furnished on a particular day to qualify for the continuous home care rate.

Regulations Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance Web Link to Chapter 9:http://www.cms.gov/Center/Provider-Type/Hospice- Center.html 40.2.1 - Continuous Home Care (CHC) (Rev. 188, Issued: 05-01-14, Effective: 08-04-14 Implementation: 08-04-14) Continuous home care may be provided only during a period of crisis as necessary to maintain an individual at home. A period of crisis is a period in which a patient requires continuous care which is predominantly nursing care to achieve palliation or management of acute medical symptoms. If a patient s caregiver has been providing a skilled level of care for the patient and the caregiver is unwilling or unable to continue providing care, this may precipitate a period of crisis because the skills of a nurse maybe needed to replace the services that had been provided by the caregiver. This type of care can also be given when a patient resides in a long term care facility. However, Medicare regulations do not permit CHC to be provided in an inpatient facility. The hospice must provide a minimum of eight hours of nursing, hospice aide, and/or homemaker care during a 24-hour day, which begins and ends at midnight. This care need not be continuous, e.g., 4 hours could be provided in the morning and another 4 hours in the evening. In addition to the 8 hour minimum, the services provided must be predominately nursing care, provided by either an RN, an LPN, or an LVN. Services provided by a nurse practitioner that, in the absence of a nurse practitioner, would be performed by an RN, LPN, or LVN, are nursing services and are paid at the same CHC rate. This means that more than half of the hours of care are provided by an RN, LPN, or LVN. Homemaker or home health aide services may be provided to supplement the nursing care.