The purpose of the literature review was to update Mor and Allen's 1987 hospice review (Mor & Allen, 1987) by identifying subsequent completed and ongoing hospice research, and by documenting research findings relating to the utilization, cost and quality of hospice care. A focus of the review was the Medicare hospice benefit in the nursing facility. An extensive search was conducted utilizing online databases and Internet resources. Additionally, unpublished work was solicited from leading health services researchers. The complete methodology including search strategies and subsequent results are detailed below.
Initial online research databases searched for this review included Medline (medical research), Psychlit (psychological research), Sociofile (sociological research), Econlit (economic research) and ERIC (reports). First, a search using the key word "hospice" was employed yielding nearly 3,000 records. This search was refined using the following set of key words in addition to the key word hospice: Medicare, Medicaid, cost, utilization, expenditure, quality of care, quality of life, outcome, grief or bereavement, depression, pain or symptom control, patient or family satisfaction, and. All abstracts found with these key words were reviewed and articles were selected based on their relevance to the goals of the current project and the following criteria: (1) research published after Mor and Allen's 1987 review; (2) research conducted in the U.S.; (3) analytic methods were employed.
The National Hospice Organization (NHO) also provided us with a 1994 bibliography of all identified literature from a variety of databases. Bibliographies from databases that were not initially searched were examined. These databases included Ageline, Cancerlit, Family Resources, CINAHL, Health Periodicals, Religion Index, Sociological Abstracts and Dissertation Abstracts. Finally, a HealthSTAR search (policy and administrative issues in health care) was conducted using hospice and economics cost savings, health expenditures, health care costs, reimbursement mechanisms and cost-benefit analysis.
In addition to online database searches, Internet searches were performed. First, searches were conducted in government web sites for relevant reports, publications, research or demonstration projects. These sites included the Health Care Financing Administration and the Office of the Inspector General. Second, research funded from the following agencies were searched using "hospice" as a keyword: National Institute of Health (NIH), Agency for Health Care Policy and Research (AHCPR), The Robert Wood Johnson Foundation Last Act Initiative, and the Open Society's Project on Death in America Campaign. When relevant research projects were found, the principal investigator was contacted and asked to describe the purpose, current status and findings of the project if available.
Finally, after reviewing the current abstracts and also the previous references reported in Mor and Allen's review, a list of 20 leading health services researchers in hospice care were identified. These researchers were contacted by letter and asked to provide information about any current research (funded or not funded) that they were pursuing relating to hospice care.
The results of the online database search are shown below (Table A.1). Because no program was used to sort the abstracts and identify duplicates, the number of abstracts identified for each category may be an overestimate. The limited number of articles identified for inclusion in the literature review was not surprising given the criterion employed. Indeed, in their final bibliography, Mor and Allen reported only 13% of their total bibliography contained analytic papers and only 7% were based on outcomes of hospice care. Additional references (10) were found in the NHO bibliography and 3 were subsequently used in the review. Similarly, HealthSTAR search yielded an additional meeting abstract and one article.
| TABLE A.1. Search Results Using On-Line Databases | |||
| Key Word(s) | Hits | Articles Reviewed | Met Criteria |
| Hospice and |
2,915 | N/A | N/A |
| Cost | 155 | 16 | 11 |
| Utilization | 124 | 11 | 8 |
| Expenditures | 14 | 2 | 1 |
| Outcome | 91 | 2 | 2 |
| Quality of Care | 127 | 7 | 5 |
| Medicare | 155 | 36 | 23 |
| Medicaid | 22 | 9 | 6 |
| 114 | 5 | 5 | |
| TOTAL | 802 | 88 | 61 |
| Note: Online databases included Medline, Psychlit, Sociofile, Econlit and ERIC. Some "hits" may be duplicated due to the use of multiple databases. | |||
Internet searches provided varied materials including reports, background information and funded grants. The numbers of identified grants are shown on Table A.2 below. Under the Department of Health and Human Services, the Office of the Inspector General search yielded information on three relevant audits that were conducted under Operation Restore Trust. These audits and their findings were included and discussed in the literature review.
| TABLE A.2. Results of Internet Searches for Grants | ||
| Funding Agency | Reviewed | Met Criteria for Inclusion |
| National Institute of Health | 72 | 1 |
| Agency for Health Care Policy & Research | 10 | 3 |
| The Robert Wood Johnson Foundation Last Act Initiative | 27 | 3 |
| Open Society's Project on Death in America Campaign | 81 | 4 |
Finally, of the 20 health researchers that were contacted by letter, 10 return letters were received. Of these, 2 researchers gave us additional information to include in the review on recent research they were conducting.
Attached you will find a sample nursing home contract. Please be aware that this document is meant to be utilized after your organization has made the decision to deliver hospice care in nursing homes.
There are currently more than 1.5 million persons living in nursing homes across the United States. One in four women age 85 or older lives in a nursing home, compared to one in seven men in the same age group. Of Americans age 65 and older, 43% will spend some time in a nursing home before death.
In the past few years, increasing attention has been focused on establishing relationships between hospices and nursing facilities. The Omnibus Reconciliation Act (OBRA) of 1986 first established that hospice care could be provided in a nursing home under the routine home care level. With the passage of OBRA '89, the financial disincentives were removed. The regulatory environment improved with OBRA '90, known as the Nursing Home Reform Act, when nursing homes were required to meet standards similar in philosophy to hospice.
As these changes have occurred, the National Hospice Organization has received an increased number of requests for a sample nursing home contract. Medicaid requires that a contract is in place before hospice services are provided. In response to the needs of its membership, NHO sought legal assistance in developing a generic contract. Providers are advised to utilize this tool as a guide and to make modifications in relation to state laws and their individualized needs under the direction of local legal counsel.
Although the pieces have now fallen into place from a financial, regulatory, and legal standpoint, establishing a mutually beneficial relationship is still difficult. Procedures need to be agreed upon for the following areas:
The above list of issues to be considered in negotiating relationships with nursing facilities is not all inclusive, but rather a sample of the types of issues to be examined.
The intent of this guide to implementing a nursing facility contract was to focus the hospice provider on issues of primary concern. Additional important considerations are your state nursing home regulations and, where applicable, the hospice licensing law.
There are many hospices throughout the United States that have successful programs in place and are willing to provide technical assistance. It is through the sharing of experiences that we will be able to refine the integration of hospice services within this health care setting.
SAMPLE
SERVICE AGREEMENT BY AND BETWEEN A HOSPICE AND A NURSING FACILITY*
NOTICE
THIS FORM OF AGREEMENT IS MADE AVAILABLE TO NHO MEMBERS SOLELY AS AN ILLUSTRATION AND EXAMPLE OF A SERVICE AGREEMENT BETWEEN A HOSPICE AND A NURSING FACILITY. NO REPRESENTATIONS OR WARRANTIES ARE MADE BY NHO OR BY ANY NHO REPRESENTATIVES OR AFFILIATES AS TO THE APPROPRIATENESS, ACCURACY, OR COMPLETENESS OF THE TERMS AND CONDITIONS INCLUDED IN THIS FORM OF AGREEMENT. THIS FORM OF AGREEMENT AND THE TERMS AND CONDITIONS CONTAINED HEREIN MAY NOT BE SUITABLE DOCUMENTATION FOR EVERY CONTRACTUAL ARRANGEMENT BETWEEN A HOSPICE AND A NURSING FACILITY. SHOULD AN NHO MEMBER DESIRE TO UTILIZE THIS FORM OF AGREEMENT, IN WHOLE OR IN PART, IN CONTRACTING WITH ANY NURSING FACILITY, REVIEW OF THIS FORM OF AGREEMENT AND APPLICABLE FEDERAL AND STATE LAW AND REGULATIONS BY SUCH MEMBER'S LEGAL COUNSEL IS ADVISED. PROVISIONS OF THIS FORM OF AGREEMENT THEN SHOULD BE MODIFIED, BY OR IN CONSULTATION WITH LEGAL COUNSEL, TO REFLECT SUCH REVIEW AND THE PARTICULAR CIRCUMSTANCES AND NEEDS OF THE NHO MEMBER.
*This service agreement incorporates provisions of the nursing facility regulations that went into effect October 1, 1990.
I. Recitals
II. Definitions
III. Services to Be Provided by
Hospice
IV. Services to Be Provided by Nursing Facility
V. Records
VI. Designation of Liaison; Administrative Appeals
VII. Representations,
Warranties and Covenants of Hospice
VIII. Representations, Warranties and
Covenants of Nursing Facility
IX. Quality Assurance
X.
Confidentiality
XI. Use of Name or Marks
XII. Reimbursement
XIII.
Insurance and Indemnification
XIV. Term and Termination
XV. General
Provisions
THIS AGREEMENT (the "Agreement") is made and entered into this ___day of _______, 19__, by and between [full legal name of hospice], a [insert state of incorporation] corporation ("Hospice") and [full legal name of nursing facility], a [insert state of incorporation] corporation ("Nursing Facility").
I. RECITALS
1.1 Hospice is a patient-and family-centered program engaged in the provision of interdisciplinary services for the palliation and management of terminal illness.
1.2 Nursing Facility is skilled and experienced in the operation of a nursing facility and in the provision of long term care services to its residents, including certain assistance with activities of daily living. Nursing Facility is certified to participate in the Medicaid program and has established policies and protocols for the care of terminally ill patients consistent with those of Hospice.
1.3 The parties contemplate that from time to time individuals residing in Nursing Facility will need Hospice Services as defined in Section 2.6, and individuals previously accepted into Hospice will need care in Nursing Facility. Hospice and Nursing Facility desire by entering into this Agreement to make it possible for individuals with terminal illness to receive needed Hospice Services in conjunction with Nursing Facility Services (as defined in Section 2.10).
II. DEFINITIONS
2.1 "Attending Physician" means a doctor of medicine or osteopathy, duly licensed under applicable state and local law and regulations, who, upon the election of Hospice Services, is identified by a Hospice Patient (or such patient's legal representative) as having the most significant role in the determination and delivery of such Hospice Patient's medical care.
2.2 "Effective Date" means the date of execution of this Agreement.
2.3 "HCFA" means the Health Care Financing Administration.
2.4 "Hospice Patient" means an individual who elects, directly or through such individual's legal representative, to receive Hospice Services and is accepted by Hospice to receive Hospice Services.
2.5 "Hospice Physician" means a duly licensed doctor of medicine or osteopathy employed by Hospice to render physician services to each Hospice Patient, as necessary, in accordance with the applicable Plan of Care.
2.6 "Hospice Services" means those services provided to a Hospice Patient for the palliation and management of such Hospice Patient's terminal illness, either directly or under arrangement by Hospice, as specified in the Plan of Care. Hospice Services include nursing care and services by or under the supervision of a registered nurse; medical social services provided by a qualified social worker under the direction of a physician; physician services to the extent that these services are not provided by the Attending Physician; counseling services (including bereavement, dietary and spiritual counseling); physical therapy, occupational therapy and speech-language pathology services; home health aide/homemaker services; medical supplies; drugs and biologicals; use of medical appliances; and inpatient care when needed for pain control, symptom management and respite purposes.
2.7 "Interdisciplinary Group" means the Attending Physician and certain Hospice employees which employees shall include, without limitation, the following individuals: (a) a doctor of medicine or osteopathy, (b) a registered nurse, (c) a social worker, and (d) a pastoral or other counselor.
2.8 "Medicaid Eligible Residential Hospice Patient" means a Residential Hospice Patient who either (a) is eligible for Medicaid benefits in a state which has a hospice benefit and who has elected to receive the state's Medicaid hospice benefit or (b) is eligible for both Medicaid and Medicare Part A benefits and who has elected the Medicare hospice benefit.
2.9 "Medicare Eligible Residential Hospice Patient" means a Residential Hospice Patient who is eligible for Medicare Part A benefits and who has elected to receive the Medicare hospice benefit.
2.10 "Nursing Facility Services" means collectively Nursing Facility Room and Board Services and Other Nursing Facility Services.
2.11 "Nursing Facility Room and Board Services" means those personal care services provided by Nursing Facility as specified in the Plan of Care for a Residential Hospice Patient, including, but not limited to, providing food (including individualized requests); assisting in activities of daily living, socializing activities, and in the administration of medicine; providing and maintaining the cleanliness of the Residential Hospice Patient's room; supervising and assisting in the use of any durable medical equipment and therapies included in the Plan of Care; providing laundry and personal care supplies; and providing the usual and customary room furnishings provided to Nursing Facility Residents, including, but not limited to, beds, linens, lamps, and dressers.
2.12 "Other Nursing Facility Services" means all items and services provided by Nursing Facility which are not related to treatment of the Residential Hospice Patient's terminal illness but specified in the Plan of Care.
2.13 "Plan of Care" means a written care plan established, maintained, reviewed and modified, if necessary, at intervals established by the Interdisciplinary Group, which includes (a) an assessment of each Hospice Patient's needs, (b) an identification of the Hospice Services, including management of discomfort and symptom relief, needed to meet such Hospice Patient's needs and the related needs of the Hospice Patient's family, (c) details concerning the scope and frequency of such Hospice Services, and (d) details concerning the Nursing Facility Services to be provided to the Hospice Patient. The Hospice and Nursing Facility will jointly develop and agree upon a coordinated Plan of Care which is consistent with the hospice philosophy and is responsive to the unique needs of the Residential Hospice Patient and his/her expressed desire for hospice care.
2.14 "Private Pay Residential Hospice Patient" means a Residential Hospice Patient who is not eligible for the Medicare hospice benefit or the Medicaid hospice benefit or, if so eligible, has revoked or elected not to receive the Medicare hospice benefit and/or the Medicaid hospice benefit, as the case may be.
2.15 "Purchased Hospice Services" means those Hospice Services specified in Exhibit B that Hospice has contracted with Nursing Facility to provide.
2.16 "Residential Hospice Care Day" means a day on which a Residential Hospice Patient receives Nursing Facility Room and Board Services.
2.17 "Residential Hospice Patient" means a Hospice Patient who resides in Nursing Facility.
2.18 "Uncovered Items and Services" means those services provided by Nursing Facility which are not Hospice Services, Nursing Facility Room and Board Services or Other Nursing Facility Services, including, but not limited to, telephone, guest trays, and television hookup.
III. SERVICES TO BE PROVIDED BY HOSPICE.
3.1 Admission to Hospice Program.
If a resident of Nursing Facility requests the provision of Hospice Services, Hospice shall perform an assessment of such resident and shall notify the Nursing Facility, either orally or in writing, whether such resident is authorized for admission as a Residential Hospice Patient. Hospice shall maintain adequate records of each authorization of Hospice admission.
On or prior to the execution of this Agreement, Hospice will provide Nursing Facility with its current criteria for admission. Hospice will promptly provide Nursing Facility with any modification to these criteria.
3.2 Design and Maintenance of Plan of Care.
Nursing Facility Residents. In accordance with applicable Federal and state laws and regulations, Hospice shall coordinate with Nursing Facility to develop a Plan of Care for each new Residential Hospice Patient. Hospice shall furnish Nursing Facility with a copy of the Plan of Care.
Non-residential Hospice Patients. Promptly upon admission of Hospice Patient, who has not been residing in a nursing home, to the Nursing Facility and consent of the Hospice Patient (or his/her legal representative), Hospice will furnish Nursing Facility with a copy of the then-current Hospice Plan of Care. In coordination with the Nursing Facility, Hospice shall promptly modify the Plan of Care, as necessary, to accommodate Hospice Patient's change in residence.
Modifications. At intervals established by the Interdisciplinary Group, the Interdisciplinary Group will review and modify, if necessary, the Plan of Care. The Hospice will consult and coordinate with Nursing Facility, as reasonably necessary, with respect to any modification to the Plan of Care, and will provide the Nursing Facility with any modification to the Plan of Care.
Monitoring. Hospice will promptly inform Nursing Facility of any identified change in the condition of a Residential Hospice Patient which requires supplementation, modification or alteration of the Plan of Care.
Physician Orders. All physician orders communicated to Nursing Facility on behalf of Hospice in connection with Plan of Care shall be in writing and signed by the applicable Attending Physician or Hospice Physician; provided, however, that in the case of urgent or emergency circumstances, such orders may be communicated by the Attending Physician or the Hospice Physician orally and confirmed in writing thereafter. Hospice shall maintain adequate records of all physician orders communicated in connection with the Plan of Care.
3.4 Notification of Hospice Services. Hospice shall fully inform Residential Hospice Patients of the Hospice Services to be provided by Hospice and the Nursing Facility Room and Board Services and Purchased Hospice Services, if any, to be provided by Nursing Facility.
3.5 Provision of Hospice Services. Hospice shall be available to provide Hospice Services, as required by applicable Federal and state laws and regulations, twenty-four (24) hours a day, seven (7) days a week. Hospice will provide Hospice Services to each Residential Hospice Patient in accordance with the Plan of Care for that patient.
3.6 Supervision of Hospice Plan of Care. Hospice will be responsible for the professional management of the Plan of Care, including any Purchased Hospice Services.
IV. SERVICES TO BE PROVIDED BY NURSING FACILITY.
4.1 Admission to Nursing Facility.
Request for Admission. In the event that a pre-existing Hospice Patient requests admission to the Nursing Facility, Nursing Facility shall admit such Hospice Patient, subject to Nursing Facility's admission policies and procedures and the availability of beds. Nursing Facility shall notify Hospice, either orally or in writing, whether such Hospice Patient is authorized for admission as a Residential Hospice Patient. Nursing Facility shall maintain adequate records of all such authorizations of admission.
Admission Policies. On or prior to the execution of this Agreement, Nursing Facility will provide Hospice with its current admission policies and procedures. Nursing Facility will promptly provide Hospice with any modification to these policies and procedures.
4.2 Notification of Nursing Facility Residents. Nursing Facility shall inform each terminally ill resident of the Nursing Facility of that resident's option to elect to receive Hospice Services, subject to such resident's meeting the Hospice's criteria for admission.
4.3 Notification of Services. Nursing Facility shall fully inform Residential Hospice Patients of the Other Nursing Facility Services and Uncovered Items and Services to be provided by Nursing Facility.
4.4 Coordination with Hospice Regarding Plan of Care.
Design of Plan. In accordance with applicable Federal and state laws and regulations, Nursing Facility shall coordinate with Hospice in developing a Plan of Care for each new Residential Hospice Patient.
Modification. The Nursing Facility will assist with periodic review and modification of the Plan of Care. Nursing Facility will consult with Hospice, as reasonably necessary, with respect to any modification of the Plan of Care.
Monitoring of Residential Hospice Patient. Nursing Facility shall immediately inform Hospice of any change in the condition of a Residential Hospice Patient.
4.5 Provision of Nursing Facility Services. Nursing Facility shall be available to provide Nursing Facility Room and Board Services, as necessary or as appropriate, twenty-four (24) hours a day, seven (7) days a week. Nursing Facility will provide Nursing Facility Room and Board Services and Purchased Hospice Services, if any, to each Residential Hospice Patient in accordance with the Plan of Care for that Residential Hospice Patient.
4.6 Facility Requirements.
Patient Room. Nursing Facility shall provide each Residential Hospice Patient with a clean, home-like room, designed and equipped for the comfort, privacy and safety of the Residential Hospice Patient and his/her personal belongings, which will accommodate visitors as contemplated by Section 4.5(b) hereof.
Visiting Privileges. Nursing Facility shall permit free access and unrestricted visiting privileges (including, but not limited to, visits by children of any age) on a twenty-four (24) hours a day basis, each day of the calendar year.
Visitor Accommodations. Nursing Facility shall provide adequate space, located conveniently to the Residential Hospice Patient, for private visiting among the Residential Hospice Patient, the Residential Hospice Patient's family members and any other visitors. Nursing Facility shall provide adequate accommodations for the Residential Hospice Patient's family members to remain with the Residential Hospice Patient up to twenty-four (24) hours a day and to permit family members privacy following the death of the Residential Hospice Patient.
Hospice Access to Facility. Nursing Facility shall permit employees, contractors, agents and volunteers of the Hospice free and complete access to the Nursing Facility twenty-four (24) hours per day, as necessary, to permit Hospice to counsel, treat, attend and provide services to each Residential Hospice Patient.
Personnel and Training. Upon Hospice's request, Nursing Facility shall cause Nursing Facility personnel who provide Nursing Facility Services to Residential Hospice Patients under this Agreement (i) to attend, at reasonable times and locations, training provided by Hospice in the care of Hospice Patients and (ii) to attend meetings and conferences of the Interdisciplinary Group. Nursing Facility personnel who provide Nursing Facility Services to Hospice Patients shall be reasonably acceptable to Hospice.
4.7 Facility Protocols. Nursing Facility shall institute, maintain and conduct administrative procedures and patient care protocols which are (a) consistent with the procedures and protocols of Hospice, including, but not limited to, Hospice protocols relating to resuscitation, nutrition and hydration, (b) in accordance with recognized professional standards of care for terminally ill patients and (c) reasonably necessary to implement the provisions of this Agreement. Upon the execution of this Agreement, Nursing Facility shall provide Hospice with Nursing Facility's established policies and protocols and shall promptly provide Hospice with any amendments or modifications thereto.
4.8 Patient Care. Nursing Facility shall provide care to each Residential Hospice Patient to keep him/her comfortable, clean and well groomed and protected from accident, injury or infection.
4.9 Patient Transfer. Nursing Facility agrees not to transfer any Residential Hospice Patient to another care setting without the prior approval of Hospice. If Nursing Facility fails to obtain the necessary prior approval, Hospice bears no financial responsibility for the costs of transfer and the costs of care provided in another setting.
V. RECORDS
5.1 Compilation of Records.
Preparation. Nursing Facility and Hospice shall each prepare and maintain complete and detailed clinical records concerning each Residential Hospice Patient receiving Nursing Facility Services and Hospice Services under this Agreement in accordance with prudent record-keeping procedures and as required by applicable Federal and state law and regulations and applicable Medicare and Medicaid program guidelines. Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning, each Residential Hospice Patient (including evaluations, treatments, progress notes, authorizations to admission to Hospice and/or Nursing Facility and physician orders entered pursuant to this Agreement). Nursing Facility and Hospice shall cause each entry made for services provided hereunder to be signed by the person providing the services.
Storage. Nursing Facility and Hospice shall each retain such records for five (5) years from the date of discharge of each Residential Hospice Patient or such other time period as required by applicable state law. Each such record [shall document that the specified services are furnished in accordance with this Agreement and] shall be readily accessible and systematically organized to facilitate retrieval by either party.
5.2 Access. Subject to any required authorization by the subject Residential Hospice Patient (or his/her legal representative), Nursing Facility and Hospice shall each permit the other party or its authorized representative, upon reasonable notice, to review and make photocopies of records maintained by Nursing Facility or Hospice, as the case may be, relating to the provision of services under this Agreement, including but not limited to, the Plan of Care, medical records and records relating to billing and payment.
5.3 Inspection. To the extent required by applicable Federal or state law and regulations, Nursing Facility and Hospice and any respective agents thereof shall make available, upon written request by the Secretary of the United States Department of Health and Human Services, the Comptroller General of the United States, or any other authorized Federal or state official, or the duly authorized representative of the foregoing, their respective books, documents, and records necessary to verify the nature and extent of costs of Nursing Facility Services or Hospice Services until the expiration of four (4) years after the Nursing Facility Services or Hospice Services provided under this Agreement are furnished.
5.4 Destruction of Records. Nursing Facility and Hospice shall take reasonable precautions to safeguard records against loss, destruction, and unauthorized disclosure.
VI. DESIGNATION OF LIAISON; ADMINISTRATIVE APPEALS
6.1 Liaison. On or prior to the execution of this Agreement, Hospice and Nursing Facility shall each designate [a [number]] representative(s) to serve as liaison between them and to facilitate cooperative efforts in performance of their respective obligations under this Agreement. Thereafter, each of Hospice and Nursing Facility will promptly notify the other party of any change in its representative(s).
6.2 Resolution. Within [sixty (60)] days of execution of this Agreement, Hospice and Nursing Facility shall develop, maintain, and conduct, as necessary, clearly articulated dispute resolution procedures and shall act promptly to mediate any disputes with respect to the appropriateness of the Plan of Care, Hospice Services or Nursing Facility Room and Board Services.
VII. REPRESENTATIONS, WARRANTIES AND COVENANTS OF HOSPICE.
Hospice hereby represents, warrants and covenants to Nursing Facility as follows:
7.1 Organization. Hospice is a corporation duly organized, validly existing and in good standing under the laws of the state of [specify state] and has all requisite corporate power to conduct its business as presently conducted. [Hospice is duly qualified to do business as a foreign corporation in the state of [specify state].]
7.2 Authorization of this Agreement. The execution, delivery and performance of this Agreement has been duly authorized by all requisite corporate action on the part of Hospice. This Agreement has been duly executed and delivered by Hospice and constitutes a valid and binding obligation of Hospice.
7.3 Compliance. Hospice has materially complied with, and in performing this Agreement shall comply, in all material respects with all Federal, state and local laws and regulations applicable to it, its business and operations, including, without limitation (i) all applicable Federal, state and local laws and regulations relating to health and safety and (ii) all applicable Federal, state and local laws and regulations relating to hospice care.
7.4 Licensure. Hospice is duly certified as a Medicare provider under Title XVIII of the Social Security Act [and as a Medicaid provider under TitleXIX of the Social Security Act.] Hospice possesses all Federal, state and local licenses and permits material to and necessary in the conduct of its business as presently conducted. Such licenses and permits are in full force and effect, no violations are or have been recorded in respect of any such licenses or permits, and no proceeding is pending or, to the knowledge of Hospice, threatened to revoke or limit any thereof. Upon request of Nursing Facility, Hospice shall furnish true and complete copies of any of the aforementioned licenses or permits.
[7.5 No Litigation. [There is no action, suit, investigation or proceedings pending or, to the knowledge of Hospice, threatened against Hospice before any court or by or before any governmental or administrative body or arbitration board or tribunal.] Hospice shall promptly notify Nursing Facility of the commencement of any action or proceeding against Hospice with respect to any of its licenses, permits or other legal authorizations, including, but not limited to any sanctions, intermediate or otherwise, administrative or judicial fines, penalties, investigations or reports of action by Federal or state officials against Hospice pursuant to Federal or state laws or regulations.]
7.6 Insolvency. Hospice shall inform Nursing Facility in the event that any proceeding shall be instituted by or against Hospice in bankruptcy, or seeking liquidation, winding up, reorganization, protection, relief or composition of its debts under any law relating to bankruptcy, insolvency, reorganization or relief of debtors or seeking the appointment of a receiver or trustee.
7.7 Adequate Staffing and Facilities. As of the date hereof, Hospice has, and will maintain throughout the term of this Agreement, a sufficient number of medical, nursing and other staff to permit Hospice to perform its obligations hereunder. Such staff will be duly licensed, certified or registered in accordance with applicable Federal and state laws.
VIII. REPRESENTATIONS, WARRANTIES AND COVENANTS OF NURSING FACILITY.
Nursing Facility hereby represents, warrants and covenants to Hospice as follows:
8.1 Organization. Nursing Facility is a corporation duly organized, validly existing and in good standing under the laws of the state of [specify state] and has all requisite corporate power to conduct its business as presently conducted. [Nursing Facility is duly qualified to do business as a foreign corporation in the state of [specify state].]
8.2 Authorization of this Agreement. The execution, delivery and performance of this Agreement has been duly authorized by all requisite corporate action on the part of Nursing Facility. This Agreement has been duly executed and delivered by Nursing Facility and constitutes a valid and binding obligation of Nursing Facility.
8.3 Compliance. Nursing Facility has materially complied with, and in performing this Agreement shall comply, in all material respects with all Federal, state and local laws and regulations applicable to it, its business and operations, including, without limitation (i) all applicable Federal, state and local laws and regulations relating to health and safety and (ii) all applicable Federal, state and local laws and regulations, including, but not limited to, the Patient Self-Determination Act, relating to nursing facilities.
8.4 Licensure. Nursing Facility is duly certified as a Medicaid provider under Title XIX of the Social Security Act. Nursing Facility possesses all Federal, state and local licenses and permits material to and necessary in the conduct of its business as presently conducted. Such licenses and permits are in full force and effect, no violations are or have been recorded in respect of any such licenses or permits, and no proceeding is pending or, to the knowledge of Nursing Facility, threatened to revoke or limit any thereof. Upon request of Hospice, Nursing Facility shall furnish true and complete copies of any of the aforementioned licenses or permits.
[8.5 No Litigation. [There is no action, suit, investigation or proceedings pending or, to the knowledge of Nursing Facility, threatened against the Nursing Facility before any court or by or before any governmental or administrative body or arbitration board or tribunal.] Nursing Facility shall promptly notify Hospice of the commencement of action or proceeding against Nursing Facility with respect to any of its licenses, permits or other legal authorizations, including, but not limited to any sanctions, intermediate or otherwise, administrative or judicial fines, penalties, investigations or reports of action by Federal or state officials against Nursing Facility pursuant to Federal or state laws or regulations.]
8.6 Insolvency. Nursing Facility shall inform Hospice in the event that any proceeding shall be instituted by or against Nursing Facility in bankruptcy, or seeking liquidation, winding up, reorganization, protection, relief or composition of its debts under any law relating to bankruptcy, insolvency, reorganization or relief of debtors or seeking the appointment of a receiver or trustee.
8.7 Adequate Staffing and Facilities. Nursing Facility has, and will maintain throughout the term of this Agreement, a sufficient number of nursing and other staff who have the requisite training, skills and experience to permit Nursing Facility to perform its obligations hereunder. Such staff will be duly licensed, certified or registered in accordance with applicable Federal and state laws. Nursing Facility has, and will maintain, adequate facilities and equipment throughout the term of this Agreement to perform its obligations hereunder.
[8.8 Care of Hospice Patients. Nursing Facility has familiarized itself with the administrative, recordkeeping and personal care needs of Hospice Patients and the Nursing Facility is, and will be, fully competent and able to perform its obligations under this Agreement in accordance with recognized professional standards for the care of terminally-ill patients.]
IX. QUALITY ASSURANCE
Hospice shall develop, maintain, and conduct an ongoing, comprehensive assessment to evaluate the quality and appropriateness of Hospice Services and Nursing Facility Room and Board Services, as set forth and described in Exhibit A attached hereto and made a part hereof ("QualityAssuranceProgram"). Nursing Facility shall cooperate with Hospice in the conduct of the Quality Assurance Program and facilitate the administration of such program in relation to Purchased Hospice Services and Nursing Facility Room and Board Services performed by Nursing Facility. Hospice shall cooperate with Nursing Facility in the conduct of Nursing Facility's quality assessment and assurance committee as it relates to Residential Hospice Patients.
X. CONFIDENTIALITY
10.1 Confidentiality of Hospice Information. In the performance of its obligations under this Agreement, Hospice shall be required to disclose to Nursing Facility certain information pertaining to Hospice Patients (including, but not limited to, assessments, medical records, patient and family histories and the Hospice Plan of Care (collectively "Patient Information")) and may be required to disclose certain business or financial information of the Hospice (collectively, with the Patient Information, the "HospiceConfidential Information"). Nursing Facility agrees that it shall treat the Hospice Confidential Information with the same degree of care Nursing Facility affords to its own similar confidential information and shall not, except as specifically authorized in writing by Hospice or as otherwise required by law, reproduce any Hospice Confidential Information or disclose or provide any Hospice Confidential Information to any person.
10.2 Confidentiality of Nursing Facility Information. In the performance of its obligations under this Agreement, Nursing Facility shall be required to disclose to Hospice certain Patient Information (as defined in Section 10.1) pertaining to Nursing Facility residents (including the Plan of Care) and may be required to disclose to Hospice certain business or financial information of the Nursing Facility (collectively, with the Plan of Care and the Patient Information, the "Nursing Facility Confidential Information"). Hospice agrees that it shall treat the Nursing Facility Confidential Information with the same degree of care Hospice affords to its own similar confidential information and shall not, except as specifically authorized in writing by Nursing Facility or as otherwise required by law, reproduce any Nursing Facility Confidential Information or disclose or provide any Nursing Facility Confidential Information to any person.
XI. USE OF NAME OR MARKS. Neither Nursing Facility nor Hospice shall have the right to use the name, symbols, trademarks or service marks of the other party in advertising or promotional materials or otherwise without receiving the prior written approval of such other party; provided, that one party may use the name, symbols or marks of the other party in written materials previously approved by the other party for the purpose of informing prospective Residential Hospice Patients and Attending Physicians of the availability of the services described in this Agreement.
XII. REIMBURSEMENT
12.1 Medicaid Patients. Nursing Facility agrees to bill Hospice a fixed payment rate for each Residential Hospice Care Day provided to a Medicaid Eligible Residential Hospice Patient as set forth in Exhibit C and to accept such payment as payment in full for Nursing Facility Room and Board Services provided such Medicaid Eligible Residential Hospice Patient; provided, however, that Nursing Facility may bill such Medicaid Eligible Residential Hospice Patient for any items or services set forth in Section12.4. For Medicaid Eligible Residential Hospice Patients, Nursing Facility also agrees to bill Hospice for any Purchased Hospice Services provided to a Medicaid Eligible Residential Hospice Patient and to accept such payment as payment in full for such services.
12.2 Medicare Patients. Nursing Facility agrees to bill Hospice for any Purchased Hospice Services provided to a Medicare Eligible Residential Hospice Patient, as set forth in Exhibit B. Nursing Facility will accept such payment as payment in full for Purchased Hospice Services provided under this Agreement to such Medicare Eligible Residential Hospice Patient. Nursing Facility shall bill each Medicare Eligible Residential Hospice Patient (or the Medicare Eligible Residential Hospice Patient's third-party payor, if applicable), for Nursing Facility Room and Board Services provided such Patient and accept such payment as payment in full for Nursing Facility Room and Board Services.
12.3 Private Pay Residential Hospice Patients. With respect to any Private Pay Residential Hospice Patient, Nursing Facility agrees to bill [select one: Hospice or Private Pay Residential Hospice Patient] for any Purchased Hospice Services provided to that Private Pay Residential Hospice Patient, as set forth in Exhibit B, and to accept such payment as payment in full for such Purchased Hospice Services. Nursing Facility shall bill each Private Pay Residential Hospice Patient (or the Private Pay Residential Hospice Patient's third-party payor, if applicable), for Nursing Facility Room and Board Services provided such Patient and accept such payment as payment in full for Nursing Facility Room and Board Services. Neither party shall seek reimbursement from the other in the event of default of financial obligations on the part of the Private Pay Residential Hospice Patient.
12.4 Other Services. Nursing Facility shall bill any Residential Hospice Patient (or the Residential Hospice Patient's third party payor, if any) for (a)Other Nursing Facility Services, (b)Uncovered Items and Services, and (c)care provided by Nursing Facility upon the advance written request of a Residential Hospice Patient which is not reasonable or necessary for palliation or management of terminal illness and not rendered in accordance with the applicable Plan of Care. Hospice shall bear no responsibility, obligation, or other liability to reimburse Nursing Facility for the cost of these services.
12.5 Billing. Within [thirty (30)] days after the provision of Nursing Facility Room and Board Services or Purchased Hospice Services, Nursing Facility shall submit to Hospice all bills issued pursuant to Section 12.1, 12.2 or 12.3 on forms acceptable to Hospice that include information usually provided to third party payors to verify the services and charges reflected in such billings. Hospice shall pay Nursing Facility either [(a)] within sixty (60) days after receipt of each Nursing Facility bill [or (b) if applicable, upon payment by Medicaid to Hospice, whichever is later.] Payment by Hospice in respect of such bills shall be considered final, unless adjustments are requested in writing by Nursing Facility within [thirty (30)] days of receipt of payment.
12.6 Financial Recordkeeping. Nursing Facility will keep accurate books of account and records (the "Financial Records") at its principal place of business covering all transactions relating to this Agreement. [Not more than once a year, Hospice may, at its expense, retain an independent public accountant or other auditor to review the Financial Records and prepare a detailed statement showing the charges made to Hospice by Nursing Facility.] Hospice and its duly authorized representatives, including any [such] independent public accountant or other auditor, shall have the right during regular business hours and on reasonable written notice to Nursing Facility to examine Nursing Facility's Financial Records and to make copies thereof.
XIII. INSURANCE AND INDEMNIFICATION
13.1 Nursing Facility Insurance. Nursing Facility shall obtain and maintain, at its sole cost and expense, professional liability insurance, including coverage for any acts of professional malpractice, covering Nursing Facility, its directors, officers, employees, or agents in an amount not less than $_____ per claim and $_____ in the aggregate and comprehensive general liability insurance in an amount not less than $_____ in the aggregate and shall name Hospice as an additional insured party. At the request of Hospice, Nursing Facility shall furnish to Hospice satisfactory evidence of its liability insurance coverage and shall notify Hospice thirty (30) days prior to any material change in or termination of insurance coverage.
13.2 Hospice Insurance. Hospice shall obtain and maintain, at its sole cost and expense, professional liability insurance, including coverage for any acts of professional malpractice, covering Hospice, its directors, officers, employees, volunteers, and agents in an amount not less than $_____ per claim and $_____ in the aggregate and comprehensive general liability insurance in an amount not less than $_____ in the aggregate and shall name Nursing Facility as an additional insured party. At the request of Nursing Facility, Hospice shall furnish to Nursing Facility satisfactory evidence of its liability insurance coverage and shall notify Nursing Facility thirty (30) days prior to any material change in or termination of insurance coverage.
13.3 Indemnification.
Nursing Facility agrees to indemnify and hold harmless and defend Hospice, its directors, officers, employees, volunteers, and agents from and against any and all claims, suits, damages, fines, penalties, liabilities and expenses (including reasonable attorney's fees and court costs) resulting from or arising out of, any claimed [willful or negligent?] act or omission by Nursing Facility or any of its directors, officers, employees, agents or volunteers pertaining to the services hereunder.
Hospice agrees to indemnify and hold harmless and defend Nursing Facility, its directors, officers, employees, volunteers, and agents from and against any and all claims, suits, damages, fines, penalties, liabilities and expenses (including reasonable attorney's fees and court costs) resulting from or arising out of, any claimed [willful or negligent?] act or omission by Hospice or any of its directors, officers, employees, agents, or volunteers, pertaining to the services hereunder.
For purposes of such indemnification, the following provisions shall apply. A person or entity entitled to be indemnified under paragraph (a) or (b) above (an "Indemnified Person") shall promptly notify the party having the obligation under this Agreement to indemnify the Indemnified Person (the "Indemnifier") with respect to any notice of a claim, threat to institute a proceeding or the commencement of an action. The Indemnifier will, if requested by the Indemnified Person, assume the defense of any litigation or proceeding for which indemnity hereunder is available, including the retention of counsel and payment of reasonable fees of such counsel, in which event, except as provided below the Indemnifier will not be responsible for any other fees or expenses of any other counsel retained by the Indemnified Person. However, if the Indemnified Person and Indemnifier reasonably conclude that the representation of both parties by the same counsel may involve a conflict due to actual or potential differing interests between them, the Indemnifier shall pay the reasonable fees of counsel for the Indemnified Person. The Indemnifier shall not be liable for any settlement of any litigation or proceeding effected without its written consent, which shall not be unreasonably withheld. If the Indemnifier assumes the defense of any litigation or proceeding, the Indemnifier will not settle such litigation or proceeding without the Indemnified Person's written consent, which shall not be unreasonably withheld.
XIV. TERM AND TERMINATION
14.1 Term of Agreement. The initial term of this Agreement shall be [one year] beginning with the Effective Date, with automatic [one year] renewals, unless sooner terminated as provided in this Article XIV of this Agreement.
14.2 Termination Without Cause. Either party may terminate this Agreement for any or no reason prior to the expiration of its term by providing at least [ninety (90)] days written notice of termination to the other party prior to the date of such termination. Such termination shall be effective without prior notice or consent of any Residential Hospice Patient, Attending Physician, or other third party.
14.3 Termination for Cause.
Either party shall have the right to terminate this Agreement for the following reasons:
In the event that the Nursing Facility does not provide a material portion of the Nursing Facility Room and Board Services or Purchased Hospice Services, if any, to be provided under this Agreement for a period of thirty (30) consecutive days, upon ten (10) days written notice given prior to the effective date of such termination;
In the event that the Hospice does not provide a material portion of the Hospice Services to be provided under this Agreement for a period of thirty (30) consecutive days, upon ten (10) days written notice given prior to the effective date of such termination;
If any license, certification or accreditation of a party which is material to the performance of this Agreement is suspended or revoked;
If any administrative or judicial fines, penalties or sanctions in excess of [$1,000] are imposed on one of the parties;
If one of the parties commences or has commenced against it proceedings to liquidate, wind-up, reorganize or seek protection, relief or a composition of its debts under any law relating to insolvency, reorganization or relief of debtors or seeking the appointment of a receiver or trustee;
If Hospice fails to develop and maintain a Plan of Care pursuant to applicable Federal, state or local law and regulations and in accordance with this Agreement;
If Nursing Facility fails to assist in developing and maintaining a Plan of Care pursuant to applicable Federal, state or local law and regulations and in accordance with this Agreement; or
If an action is prosecuted to final judgment against a party for violation of Federal or state laws or regulations.
14.4 Effect of Termination on Availability of Service.
In the event that this Agreement is terminated pursuant to Section 14.2 or 14.3, each of Nursing Facility and Hospice may negotiate separately with any former Residential Hospice Patient (or such patient's legal representative) to contract for the continuation of care. Nursing Facility agrees not to discharge any former Residential Hospice Patient until an alternative placement is found that is mutually agreeable to Nursing Facility, Hospice, and former Residential Hospice Patient.
14.5 Termination of Hospice Services by Residential Hospice Patient
A Residential Hospice Patient may terminate receipt of Hospice Services and/or any Nursing Facility Services provided pursuant to this Agreement by written notice, including, but not limited to, use of Hospice's revocation form, given by the Residential Hospice Patient (or his/her legal representative) to Hospice and Nursing Facility. Such termination shall be effective upon delivery of such notice to both Nursing Facility and Hospice or upon such time as specified in the written notice.
Termination of the receipt of Hospice Services and/or Nursing Facility Services by an individual Residential Hospice Patient shall not constitute a termination of this Agreement as a whole.
In the event that a Residential Hospice Patient terminates receipt of Hospice Services and Nursing Facility Services pursuant to this Agreement, each of Hospice and Nursing Facility may negotiate separately with such former Residential Hospice Patient (or such patient's legal representative) to contract for the continuation of care.
XV. GENERAL PROVISIONS
[APPLICABLE STATE OR LOCAL LAWS AND REGULATIONS MAY AFFECT THIS CONTRACT. THE NHO MEMBER'S LEGAL COUNSEL SHOULD BE CONTACTED REGARDING APPROPRIATE MODIFICATIONS.]
15.1 Notices. Except as otherwise specified herein, all notices, demands, requests, or other communications which may be or are required to be given, served, or sent by any party to any other party pursuant to this Agreement shall be in writing and shall be delivered personally, mailed by first-class, registered or certified mail, return receipt requested, postage prepaid, or transmitted by facsimile transmission, addressed as follow:
If to
Hospice:
__________
__________
__________
Attention:
__________
Fax No.: __________
with a copy (which shall not constitute notice)
to:
__________
__________
__________
If to Nursing
Facility:
__________
__________
__________
Attention:
__________
Fax No.: __________
with a copy (which shall not constitute notice)
to:
__________
__________
__________
Each party may designate by notice in writing a new address to which any notice, demand, request or communication may thereafter be so given, served or sent. Each notice, demand, request or communication which shall be mailed, delivered or transmitted in the manner described above shall be deemed sufficiently given, served, sent and received for all purposes at such time as it is (a) delivered personally to the addressee, (b) received in the mail by the addressee (with the return receipt, the delivery receipt or the affidavit of messenger being conclusive evidence of its receipt), (c)with respect to a facsimile transmission, the machine confirmation being deemed conclusive evidence of such delivery or (d) at such time as delivery is refused by the addressee upon presentation.
15.2 Severability. If any part of any provision of this Agreement or any other agreement, document or writing given pursuant to or in connection with this Agreement shall be invalid or unenforceable under applicable law, said part shall be ineffective to the extent of such invalidity or unenforceability only, without in any way affecting the remaining parts of said provision or the remaining provisions of said agreement.
15.3 Survival. It is the express intention and agreement of the parties hereto that Articles V, X, XI, XII, XIII, and XIV of this Agreement shall survive the termination of this Agreement for any reason and that the covenants contained in Articles VII and VIII shall survive the execution of this Agreement until they are no longer effective by their terms.
15.4 Waiver. Neither the waiver by either of the parties hereto of a breach of or a default under any of the provisions of this Agreement, nor the failure of either of the parties, on one or more occasions, to enforce any of the provisions of this Agreement or to exercise any right or privilege hereunder shall thereafter be construed as a waiver of any subsequent breach or default of a similar nature, or as a waiver of any such provisions, rights or privileges hereunder.
15.5 Binding Effect. Subject to provisions hereof restricting assignment, this Agreement shall be binding upon and shall inure to the benefit of the parties hereto and their respective successors and permitted assigns.
15.6 Non-assignability. This Agreement shall not be assignable, in whole or in part, by either party without the prior written consent of the other party hereto. If Nursing Facility is duly permitted by Hospice to assign or subcontract any obligation or obligations under this Agreement, Nursing Facility shall cause any such permitted assignee or subcontractor to agree to applicable provisions of this Agreement, including, but not limited to, Articles V, X, XI and XIII.
15.7 Limitation on Benefits of this Agreement. It is the explicit intention of the parties hereto that no person or entity other than the parties hereto is or shall be entitled to bring any action to enforce any provision of this Agreement against either of the parties hereto, and that the covenants, undertakings, and agreements set forth in this Agreement shall be solely for the benefit of, and shall be enforceable only by, the parties hereto or their respective successors and assigns as permitted hereunder.
15.8 Amendment. This Agreement shall not be amended, altered, or modified, except by an instrument in writing duly executed by the parties hereto.
15.9 Entire Agreement. This Agreement, including Exhibits A, B, and C hereto, constitutes the entire agreement between the parties hereto with respect to the subject matter hereof, and it supersedes all prior oral or written agreements, commitments or understandings with respect to the matters provided for herein.
15.10 Headings. Article and Section headings contained in this Agreement are inserted for convenience of reference only, shall not be deemed to be a part of this Agreement for any purpose, and shall not in any way define or affect the meaning, construction or scope of any of the provisions hereof.
15.11 References. Except as otherwise specified, references to Articles and Sections contained in this Agreement shall be to the correspondingly numbered Articles and Sections as set forth in this Agreement.
15.12 Governing Law. This Agreement, the rights and obligations of the parties hereto, and any claims or disputes relating thereto, shall be governed by and construed in accordance with the laws of the state of __________ (but not including the choice of law rules thereof).
IN WITNESS WHEREOF, the undersigned have duly executed this Agreement, or have caused this Agreement to be duly executed on their behalf, as of the day and year first here in above set forth.
HOSPICE:
Attest: [full legal name of hospice]
_______________
By: _______________ its authorized agent
NURSING FACILITY:
Attest: [full legal name of nursing facility]
_______________ By: _______________ its authorized agent
Exhibit A. [Hospice Quality Assurance Program to be set forth and described as Exhibit A]
Exhibit B. PURCHASED HOSPICE SERVICES [Service/Charge]
Exhibit C. [Reimbursement Agreements to be set forth as Exhibit C]
Published by
The National Hospice Organization
Copyright 1996, by
the National Hospice Organization. All rights reserved.
Published by
The National Hospice Organization
1901 North Moore Street, Suite 901
Arlington, VA 22209
Written by
Standards and Accreditation Committee
Medical Guidelines Task Force
Brad Stuart, MD
Carla Alexander, MD
Cheryl
Arenella, MD
Stephen Connor, PhD, Medical Guidelines Task Force Chair
Laurel Herbst, MD, American Academy of Hospice and Palliative Medicine
Diane Jones, MSW, Hospice Association of America
Barry Kinzbrunner, MD
Paul Rousseau, MD
True Ryndes, ANP, MPH, Standards and Accreditation
Committee Chairperson
Michael Wohlfeiler, MD, JD
Chris Cody, RNC, MSN,
Staff Liaison
Susan Buckley, CRNH, MS, Staff Liaison
©Copyright 1996, by the National Hospice Organization. All rights reserved. No portion of this publication may be duplicated without the written permission of the National Hospice Organization. Printed in the United States of America. These documents also are available at www.guideline.gov.
Item Number 713008 ISBN 0-931207-50-9
Introduction and Overview
General Guidelines for Determining
Prognosis
Heart Disease
Pulmonary Disease
Dementia
HIV Disease
Liver Disease
Renal Disease
Stroke and Coma
Amyotrophic Lateral
Sclerosis
References
Appendices:
I. Type,
Strength and Consistency of Evidence
II. Karnofsky
Performance Status Scale
III. New York Heart Association
Functional Classification
IV. Functional Assessment
Staging (FAST) Scale: Dementia
V. Typical Time Course of
Alzheimer's Disease
VI. Diagnostic Imaging Factors
Indicating Poor Prognosis After Stroke
Worksheets
This document is written to help identify which patients with non-oncologic terminal illness are likely to have a significantly decreased prognosis if the disease runs its normal course. These Guidelines may also be helpful in determining patient eligibility under the Medicare/Medicaid Hospice Benefit by defining a population that may have a life expectancy of approximately six months.
Increased access to hospice services for patients with diagnoses across the medical spectrum is also a goal of this effort. Until recently, hospice in the US has been identified with care of the end-stage cancer patient.1 Dissemination of these Guidelines to hospice programs and the medical community should facilitate hospice referrals for patients with heart, lung, liver, Alzheimer's dementia, HIV and other non-cancer diseases.
Recent studies support this effort as timely and relevant. Earlier this year, Christakis and Escarce2 reported that in 1990, less than twenty percent of hospice referrals in five major states carried a non-cancer diagnosis. Since that time, the proportion of hospice admissions for diseases other than cancer has risen steadily. However, because of inherent challenges in predicting prognosis in non-cancer disease, a large proportion of patients surviving longer than six months are in this category. In the Christakis and Escarce cohort, for example, hospice patients with dementia had a median survival of 74 days, and 34.7 percent of these patients survived for longer than six months. These findings suggest that physicians and hospice programs might benefit from help in determining which non-cancer patients are likely to have a prognosis of approximately six months.
These Guidelines are a starting point, both for hospice programs evaluating patients for admission and recertification, and for critically-needed research on prognosis in end-stage disease. Pending confirmation and refinement through ongoing research with hospice patients, they provide a set of working criteria to use in determining prognosis. The Guidelines do not pretend to predict prognosis exactly in each case. In fact, even if based directly on clinical research, any set of criteria defines a range of probabilities for mortality in a specific population. Prediction of prognosis in individual cases cannot be expected; clinical judgment is always required on the original assessment and throughout the admission.
As of this writing, research is underway to assess the accuracy of existing Guidelines, and to amend them based on new findings. For example, one group has already documented that the previously-published NHO Guidelines3 for Alzheimer's disease do indeed predict six-month mortality in about 85% of patients who fit previous Guideline criteria.4 This is an improvement over Christakis and Escarce's findings from 1990 data, where only about 65% of hospice patients with dementia died within six months. Recent findings also have allowed us to refine the criteria for severity of dementia past Stage 7 of the FAST criteria.5 These changes have been included in this edition.
These Guidelines are based on medical findings. However, decisions to admit patients to hospice are often not based on medical factors alone. They are routinely influenced by nonmedical factors which would generally be reflected in the treatment plan, e.g. patient decisions to receive strict symptom control rather than life-prolonging care, or selection of "optimal" rather than "maximal" treatment regimens tempered by intolerance or refusal of medication due to side-effects.
In addition, it is important to make a distinction between admitting a patient to the hospice program and certifying a patient for the Medicare Hospice Benefit. Individual hospice programs may establish admission criteria that reflect the unique characteristics and values of their communities. This may mean that some patients could be admitted to hospice care prior to an estimated six months before death. However, care must be taken to certify patients for the Benefit only when it is reasonable to conclude that their prognosis is six months or less. In other cases alternative modes of reimbursement, often provided through community support, can be sought outside the Medicare Hospice Benefit.
Emphasis should be placed on evaluating the whole person and the entirety of the illness. It is important to note, for example, that a patient may have multiple medical problems, none of which individually amount to a terminal diagnosis, but when taken together indicate a terminal condition. In short, clinical judgment that takes both medical and nonmedical factors into account is necessary for accurate estimation of prognosis.
Several caveats are in order when using these Guidelines for prognostic purposes. They are a first attempt at extrapolating a large amount of heterogeneous evidence from many studies to predict survival in non-cancer diseases (see Appendix I). Their accuracy will need to be validated by further research. These Guidelines should be applied to individual cases very cautiously, for at least the following reasons:
Many of the studies referenced here indicate an increased likelihood of death, sometimes within an uncertain time frame. The six month definition of terminal illness adopted for the Medicare Hospice Benefit has rarely been used as a specific outcome measure in most of this research. Further studies with larger populations of hospice patients are needed to determine median survival accurately with reference to the six month standard.
Clinical judgment must always be applied in each individual case to supplement these Guidelines. All studies are performed on large enough populations to attain statistical significance, so that individual differences in disease progression are averaged and lost to view. An individual patient who may meet Guideline criteria that were significant in a study of a large cohort might respond in unpredictable ways and have unexpected outcomes as his or her disease runs its own unique course. Therefore the Guidelines must be applied to patients not only on admission, but at intervals throughout the patient's course in hospice.
Many of the studies referenced here were done in institutionalized populations. They may or may not be generalizable to patients living at home with family caregivers.
Many studies pool patients at all stages of disease. Studies done with selected cohorts of end-stage patients might yield different conclusions. For instance, for a large population of patients with dementia at all stages of severity, antibiotics may be shown to postpone mortality. However, the same drugs have not been shown to lengthen survival in the subpopulation with very end-stage dementia.6 Again, further research is needed in the terminal population.
Almost all studies have been done with patients who received standard medical therapy when they became acutely ill, thus prolonging the course of the illness. Little recent research has been done to study the natural course of untreated end-stage disease. Thus, much of the literature may be defining length of life as inappropriately long for patients who choose a non-curative approach.
The course of most non-cancer disease is inherently difficult to predict. The natural history of most non-cancer diseases is characterized by periods of relative stability punctuated by acute downturns, as opposed to the comparatively relentless, and thus more predictable, downhill course in cancer. This natural tendency toward stabilization in non-cancer disease may be augmented by hospice intervention, which may bring about a prolongation of the terminal phase due to improved patient compliance, symptom control and prevention of complications.
This difficulty in predicting mortality in non-cancer disease is compounded by the fact that palliation of non-cancer disease is frequently similar, and sometimes identical, to standard medical treatment. Therefore hospice can and frequently does coincidentally extend the life of the non-cancer patient in the act of palliating symptoms. This situation is new to many hospices, who have been trained to treat cancer pain but to leave treatment of cancer itself to the oncologist. To palliate cancer symptoms, hospice employs medications and other interventions which in most cases do not prolong life. Chemotherapy or radiation for palliation are generally used by hospices only when pain and symptoms can not be managed by other interventions. On the other hand, hospice frequently uses the same medications and interventions to palliate non-cancer symptoms that the primary physician or medical specialist uses for active treatment. For instance, skillful palliation of end-stage congestive heart failure requires not only morphine for dyspnea, but also judicious use of diuretics and vasodilators. But these drugs do more than make the patient comfortable -- it is well established that they also prolong life significantly.7 Thus good hospice care can stabilize patients with non-cancer disease, creating a dilemma for the program if the patient survives for longer than six months without evidence of serious clinical decline.
Fiscal intermediaries and hospice programs alike would benefit from a thorough awareness of these factors. These Guidelines are just a starting point in decision making in non-cancer disease. It is clear that they must be supplemented by clinical judgment at the time of admission. But frequent clinical reassessment, decisions concerning recertification versus possible discharge from the Medicare/Medicaid Hospice Benefit, thorough documentation of medical evidence of continued disease progression and cooperative review of appropriateness of care with intermediaries are all important ongoing considerations.
Recognition should be given to other systems of prognostication already devised for use in advanced medical illness.8 However, these Guidelines were developed de novo for several reasons. First, previous systems were developed for predicting prognosis in seriously ill hospitalized patients who were all receiving aggressive medical therapy. This is a different population than those who are generally considered hospice candidates, although this situation could change. Also, prior prognostic systems require large amounts of detailed clinical and laboratory data. This quantity and quality of information is primarily utilized in research studies, and generally unavailable to providers in the field. Additionally, unlike other systems, these Guidelines were designed for ease of application by the average hospice program, whose staff may not have access to the computer hardware, software and programming expertise needed to use more sophisticated prognostic systems. The medical knowledge and clinical experience needed to understand and apply these Guidelines should be well within the existing capabilities of the hospice staff, ideally under the active leadership of a qualified and enthusiastic Medical Director.
The following parameters may be used to help determine whether a patient is appropriate for hospice care and/or eligible for the Medicare/Medicaid Hospice Benefit. These General Guidelines apply to all patients referred to hospice. However, they may be specifically applied to patients who do not fall under any of the specific diagnostic categories for which disease-specific Guidelines have been written. An example might be the elderly debilitated patient whose intake of food and fluid has declined to the point where weight loss has become significant, although no specific disease predominates in the clinical picture.
The patient should meet all of the following criteria:
A "life limiting condition" may be due to a specific diagnosis, a combination of diseases, or there may be no specific diagnosis defined.9
The patient and/or family have elected treatment goals directed toward relief of symptoms, rather than cure of the underlying disease.
This section is meant to assist in the determination of prognosis for patients with end-stage heart disease. It is important to remember that with skillful palliation including judicious use of diuretics and vasodilators, particularly angiotensin-converting enzyme (ACE) inhibitors, some patients may survive for long periods with extremely severe symptoms. These drugs definitely promote patient comfort, but they also prolong life.31 On the other hand, some patients with advanced coronary disease may die suddenly and unexpectedly from acute ventricular arrhythmias.
The likelihood of early mortality is increased in patients who show all of the following characteristics:
Ejection fraction of 20% or less is helpful supplemental objective evidence, but should not be required if not already available.33
Although newer beta blockers with vasodilator activity, e.g. carvedilol, have recently been shown to decrease morbidity and mortality in chronic CHF,34 they are not included in the definition of "optimal treatment" at this time.
Determining prognosis in end-stage lung disease is extremely difficult. There is marked variability in survival.41 Physician estimates of prognosis vary in accuracy, even in patients who appear end-stage.42 Even at the time of intubation and mechanical ventilation for respiratory failure from acute exacerbation of chronic obstructive pulmonary disease (COPD), six-month survival cannot be predicted with certainty from simple data easily available to the clinician.43 Far less information than this is available to most hospice programs at the time of referral.
Patients who fit the following parameters can be expected to have the lowest survival rates. Although the end stages of various forms of lung disease differ in some respects, most follow a final common pathway leading to progressive hypoxemia, cor pulmonale and recurrent infections. Thus, these Guidelines refer to patients with many forms of advanced pulmonary disease. At the present time, it is uncertain what number or combination of these factors might predict six-month mortality; clinical judgment is required.
Physical signs of RHF.
Oxygen saturation less than or equal to 88% on supplemental oxygen.
pCO2 equal to or greater than 50 mm Hg.
Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months.53, 54
Resting tachycardia greater than 100/minute in a patient with known severe chronic obstructive pulmonary disease.55, 56, 57, 58
This section is meant to assist in determining whether a patient with end-stage dementia is appropriate for hospice care and/or eligible for the Medicare/Medicaid Hospice Benefit. Although dementia shortens life independent of culture or ethnicity,59 prediction of six-month mortality is challenging. Severity of dementia alone correlates with poor survival in studies of institutionalized60 and outpatients,61 but patients with very advanced dementia can survive for long periods with meticulous care as long as they do not develop lethal complications. Death usually occurs, in fact, as a result of comorbid conditions.62
The term "dementia" refers here to chronic, primary and progressive cognitive impairment of either the Alzheimer or multi-infarct type. Although most research on prognosis in dementia is done with Alzheimer's patients, the vascular (multi-infarct) dementias appear to progress to death more quickly.63, 64, 65 These guidelines do not refer to acute, potentially reversible or secondary dementias, i.e., those due to drug intoxication, cancer, AIDS, major stroke, or heart, renal or liver failure.
Ability to speak is limited to approximately a half dozen or fewer intelligible and different words, in the course of an average day or in the course of an intensive interview.
With the introduction of new classes of anti-retroviral therapy such as protease inhibitors (PI's), and better control of opportunistic infections, the perception of HIV may be changing from that of inexorably fatal disease to that of chronic illness.78 The ability to measure the amount of circulating virus (viral load, HIV RNA)79, 80 has dramatically changed both the management of disease81 and the ability to predict survival. Previously published data using the CD4+ cell count82 alone as a prognostic marker will not be as helpful in determining appropriateness for hospice care.
With the announcement that viral load could be suppressed to undetectable levels for at least a year in 90% of treated patients by a combination of AZT, 3TC and indinavir, a PI,83 a new air of hopefulness exists in AIDS treatment. Although authorities now discuss the possibility of eradicating HIV from patients, it is far from certain that new drugs will result in complete reconstitution of the immune system,84 or in recovery of other organ systems already seriously damaged by HIV. Therefore, at this time these Guidelines must reflect past literature until newer studies are available.
HIV mortality is influenced by new and changing therapies, practitioners' skill and experience in management, and individual patient tolerance for treatment. Other factors contribute to the difficulty of prognosis in this disease. It occurs predominately in the young, who are both constitutionally better able to withstand a heavy burden of disease, and less likely to forego intensive therapies, than the more elderly populations typical of other end-stage illnesses. Because of improved prophylactic regimens, most deaths from AIDS are now caused by opportunistic infections, persistent wasting, or neoplasm.
It is important to discuss a patient's clinical course with a physician who is experienced in caring for persons with HIV disease85, 86 or with one who is experienced in Palliative Medicine. As in any end-stage disease, optimum therapy should have been exhausted or refused by the patient. The course over the previous month may reflect the patient's prognosis.
Concerning protease inhibitors, unless patients taking these medications fit the CD4+ and viral load criteria listed below, they may have a prognosis considerably longer than six months. Thus these drugs may be considered life-prolonging, not palliative, in the hospice setting. Additionally, patients already enrolled in hospice who decide to start these medications may lengthen their prognosis considerably. Programs will have to take these issues into account when deciding whether to cover PI's under the Medicare/Medicaid Hospice Benefit.
The following factors are correlated with early mortality and therefore may be helpful when evaluating a patient for terminal care or for coverage by the Medicare/Medicaid Hospice Benefit:
Patients with CD4+ count above 50 cells/mcL who are followed by an experienced AIDS practitioner probably have a prognosis longer than six months unless there is a non-HIV-related co-existing life-threatening disease. In one study of CD4+ counts and mortality, median survival of the entire population of patients with CD4+ <50 was 11.9 months.87
They are experiencing complications listed in IV below.
| A. CNS lymphoma89 | 2.5 months |
| B. Progressive multifocal leukoencephalopathy90 | 4 months |
| C. Cryptosporidiosis91 | 5 months |
| D. Wasting (loss of 33% lean body mass)92 | <6 months |
| E. MAC bacteremia, untreated93 | <6 months |
| F. Visceral Kaposi's sarcoma unresponsive to therapy94 | 6 month mortality 50%. |
| G. Renal failure, refuses or fails dialysis95, 96 | <6 months |
| H. Advanced AIDS dementia complex97 | 6 months |
| I. Toxoplasmosis98 | 6 months |
Prognosis in advanced liver disease has been widely studied to assess readiness for liver transplantation.109, 110 Clinical symptoms and signs and laboratory values contained within the Child-Turcotte classification111 as modified by Pugh,112 not included here, have been shown to correlate significantly with early mortality.113, 114 Some of these variables, with the addition of other clinical syndromes associated with mortality, are shown below.
Although accurate, albeit complex, prognostic indices based on multivariate analyses have been developed,115 they are still controversial. They are not recommended here since:
Nearly every study on prognosis in advanced liver disease has been done outside the US, and World Health Organization data reveals that patterns of death from liver disease, as well as risk factors such as alcoholism and hepatitis B, can differ widely among countries.116
The following factors have been shown to correlate with poor short-term survival in advanced cirrhosis of the liver due to alcoholism, hepatitis, or uncertain causes (cryptogenic). Their effects are additive; i.e. prognosis worsens with the addition of each one. Clinical judgment is vital. The following factors should be followed and reviewed over time. Patients should have end-stage cirrhosis; those who are newly decompensated, i.e. in their first hospitalization, may improve dramatically with treatment compared to those who are in the terminal phase of a chronic process.117
The patient should not be a candidate for liver transplantation.
Serum albumin < 2.5 gm/dl.
This section is meant to assist in determining whether a patient with end-stage renal disease is appropriate for hospice care and/or eligible for the Medicare/Medicaid Hospice Benefit. Absent other comorbid conditions, the patient should not be seeking dialysis or renal transplant. Patients who do refuse dialysis or transplant are generally appropriate for hospice services if they fit dialysis criteria.140, 141 When evaluating patients with end-stage renal disease (ESRD),142 a nephrology consultation may be helpful since individual patient variables can influence longevity.143
Hospitalized patients may develop acute renal failure (ARF) following trauma or major surgery. Short-term survival may be difficult to predict during initial evaluation and treatment. However, factors listed in III. below may be helpful in evaluating these acutely-ill patients for hospice admission.144
Chronic renal failure (CRF) can be treated with either hemo- or chronic ambulatory peritoneal dialysis (CAPD), which prolongs survival indefinitely. If dialysis is discontinued, the chance of early death is greatly increased. An occasional patient with residual renal function after dialysis is discontinued may remain alive for a period of time, but survival beyond six months is highly unlikely.
Care should be taken in assessing patients with nephrotic syndrome. This illness often follows a protracted course; nephrology consultation can assist with prognosis.
Blood urea nitrogen (BUN) values are not used in the determination of critical renal failure, since they can be extremely elevated from prerenal azotemia due to dehydration, hypovolemia or other causes.
Intractable fluid overload.
Gastrointestinal bleeding.168
After stroke, patients who do not die during the acute hospitalization tend to stabilize with supportive care only. Continuous decline in clinical or functional status over time means that the patient's prognosis is poor.
Conversely, steady improvement in the patient's functional or physiologic status may indicate that the patient is not terminally ill. Care should be taken to distinguish true recovery of performance and physiologic function from the improvement in symptoms and subjective well-being that can accompany hospice intervention.
If computed tomographic (CT) or magnetic resonance imaging (MRI) scans are available, certain specific findings may indicate decreased likelihood of survival, or at least poor prognosis for recovery of function even with vigorous rehabilitation efforts, which may influence decisions concerning life support or hospice. Please see Appendix VI for a list of these diagnostic imaging factors. It should be borne in mind that clinical variables, not imaging studies, are the primary criteria for hospice referral.
Fever recurrent after antibiotics.
Amyotrophic lateral sclerosis (ALS) is a progressive neurologic disease that is fatal in about three fourths of patients within one to five years after symptom onset,192 with median survival of 4 years or less,193 although some studies indicate longer survival in some patients with symptom onset before age 45.194 The cause is unknown in 90% of cases, and at present there is no effective treatment.195, 196 Crude mortality r