Hospice Conditions of Participation focus on quality, patients' rights
Quality assessment requires thorough look at performance
For the first time since the Medicare Conditions of Participation (COPs) were created for hospice in 1983, significant revisions that affect the way hospice care is delivered have been developed. The revisions focus on patient rights, improvement in outcomes, and strengthened quality improvement programs.
In June, the National Hospice and Palliative Care Organization (NHPCO) hosted a two-day conference for state leaders, the organization's board and regulatory committee, and others to hear representatives of the Centers for Medicare & Medicaid Services (CMS) present the new COPs and answer questions. "It was an extraordinary two days," says Marion F. Keenan, president of Coastal Hospice in Salisbury, MD. "There are some COPs that will be challenging for some hospices, but the rationale for the revisions makes sense because the focus is on improving patient care."
The process to begin rewriting the COPs began in 1999 when CMS asked NHPCO to submit a revision of the COPs that reflected the evolution of hospice, says Susan Swinford, MSW, vice president of administration for Hospice of the Bluegrass in Lexington, KY, and a member of the NHPCO committee that worked on the initial rewrite. "A proposed rule that looked much like what we submitted was published in 2005, and CMS solicited comments," she says. "The final rule is a true collaborative effort between CMS and the hospice industry and is designed to raise the standard of hospice care."
Malene S. Davis, MSN, MBA, CHPN, president and CEO of Capital Hospice in Falls Church, VA, and president of NHPCO, says, "Now, the hard work starts as we communicate with hospices in all of the states and get everyone to start working on their plans to comply with the regulations. I think everything in the COPs is doable, even for rural or small hospices."
The key to successfully complying with the regulations is to begin studying the COPs now; evaluating your agency's current compliance, and using resources such as NHPCO, state organizations, and other hospice agencies to develop your plan, she says. Key changes in the COPs, which will be effective Dec. 2, 2008, include:
- Patient rights.
The patient rights section, which was not included in the prior COPs as a separate section, describes a hospice patient's right to participate in the treatment plan, to obtain effective pain management, to refuse treatment, and to choose his or her own physician.
"One of the things I like about this section is that it spells out exactly what hospices should do for patients," says Swinford.
Although many hospices already include patients and family members in the treatment plan and make sure that patients understand their rights to pain management and to choose their physician, not all hospices make it clear to patients what they can expect from the hospice at the initial contact, she says. Hospice staff may discuss different aspects of care as they go along, but families may not be given the whole picture up front, Swinford explains.
"This regulation will not be difficult for hospices that have been doing the right thing anyway, and it will standardize care throughout the industry," she says.
- Assessments.
Initial assessment of the patient must be conducted within 48 hours of the patient's election of the hospice benefit, and a comprehensive assessment must be completed within five days.
"We already see patients within two days of their decision to choose hospice, so this will not be a change for us," says Swinford.
At that time, the nurse begins gathering the information needed for the care plan and identifies immediate needs, such as pain control, she explains. "Even though we see 1,100 patients each day, we do not want any new patient to be in pain for one more day than they have been," Swinford adds.
The comprehensive assessment must include input from all disciplines to ensure that the care plan is a true interdisciplinary effort, she points out. "The regulations require that the comprehensive assessment be updated every 15 days, so it is a living document that is not only driven by nurses," Swinford says.
One part of the comprehensive assessments that must be completed for each patient is a complete drug profile that looks at effectiveness of drug therapies as well as potential interactions and side effects, she says. Initially, the regulation called for a pharmacist to prepare the profile, but comments from the hospice industry expressed concerns that smaller hospices and rural hospices would not easily have access to pharmacists, Swinford says. "CMS listened to us and rewrote the requirement to say that a nurse can provide this service," she says. Nurses must be able to assess effectiveness of the drug therapies and identify potential interactions, Swinford explains. If a nurse is not able to complete the drug profile, the hospice can use another provider, such as a pharmacist, to complete it, she adds.
- Hospice care provided in a nursing home.
Nursing home patients make up a large percentage of most hospice patients, points out Swinford.
"The new regulations are very clear about agreements that must be in place between a hospice and a nursing home and are clear about what services nursing home personnel can perform for hospice patients," she says.
The hospice is expected to provide hospice core services that would be provided by its own staff if the patients were in their own homes, Swinford says. "For example, hospice staff is expected to perform any professional services such as drawing blood rather than the nursing home staff," she explains. "We cannot expect nursing home staff to perform activities that we would not have family caregivers in a home perform."
Coastal Hospice will rewrite all of its nursing home contracts, Keenan says. "It will be time-consuming, but worthwhile, because the regulations do ensure a coordinated plan of care for the patient by both the nursing home and the hospice," she says.
The only concern that many hospice representatives have is that the nursing home regulations that put the same requirements into place for nursing homes are not published and may not be for some time, says Swinford. Her agency will rewrite contracts with the nursing homes but will have to include stricter requirements and narrower parameters than the nursing homes must accept, she explains.
- Quality assessment and performance improvement.
The most challenging part of the new regulations for hospices will be the requirement for ongoing performance improvement projects, says Swinford.
"Hospice organizations that are [accredited by The Joint Commission] will not have a problem with this regulation because we've been using data and studies to determine performance and assess quality," she says.
Because hospices have not had to collect data with tools such as OASIS (Outcome and Assessment Information Set), many organizations will have to develop data collection methods, so this requirement is not to be implemented until early February 2009, explains Keenan. Collection of performance, quality, and outcome data is a natural progression for hospice, based on recently implemented billing rules, she adds. "This fits with the new hospice billing rule that now requires us to include visit and cost data on our claims," Keenan says.
Although the new COPs will require time and effort by hospice staff members, the result will be worthwhile, says Davis. "There is a focus on quality that is woven throughout all of the conditions that will improve our ability to raise the standard of care for all hospice patients."
Need More Information?
For more information about Hospice Conditions of Participation, contact:
- Malene S. Davis, MSN, MBA, CHPN, President and CEO, Capital Hospice, 6565 Arlington Blvd., Suite 500, Falls Church, VA 22042. Telephone: (703) 538-2065. E-mail: [email protected].
- Marion F. Keenan, President, Coastal Hospice, 2604 Old Ocean City Road Salisbury, MD 21804. Phone: (410) 742-8732. Fax: (410) 548-5669. E-mail: [email protected].
- Susan Swinford, MSW, Vice President of Administration, Hospice of the Bluegrass, 2312 Alexandria Drive, Lexington, KY 40504. Telephone: (800) 876-6005 or (859) 276-5344. Fax: (859) 223-0490. E-mail: [email protected].
- To download a copy of the Hospice Conditions of Participation, go to www.nhpco.org. In the "Breaking News" section, under "New Medicare COPs," select "Download the PDF of the final COPs from the Federal Register (06/05/08)."
- For copies of Quality Assessment Performance Improvement tools, go to www.nahc.com select "Facts and Stats" from top navigational bar, then scroll down to "Hospice QAPI Tools."
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