Defining levels of care for managed care contracting
June 1, 1999 3 minutes read
Defining levels of care for managed care contracting
One of the keys to a successful managed care contract is a mutual understanding of what hospice care is and the services covered under the proposed per diem rates. Providers need to clearly define the basics of hospice care and levels of care they provide.
Here is a sample of how hospice care and levels of care should be defined, according to the National Hospice Organization’s (NHO) managed care task force. Lisa Spoden, task force chairwoman and partner in the Columbus, OH-based consulting firm Strategic Health Care, says the task force is developing guidelines and educational material to help NHO members with managed care contracting.
Hospice defined
Hospice is an organized program that, upon informed choice, provides palliative care to terminally patients and supportive services to patients, their families, and significant others in home- and facility-based settings. A 24-hour on-call service is available to evaluate patients’ changing needs.
The range and intensity of services will be consistent with those in the patients’ care plans and those approved by the health plan. Hospice services to be provided by a hospice organization will be in accordance with each patient’s individualized care plan and will include all equipment, medication, treatment, and care required to manage the terminal condition of each health plan patient admitted to the hospice provider.
• Physician services. Physician services provided by hospices are limited to:
— those associated with assisting in the coordination of the hospice program;
— those associated with quality assurance/utilization review functions for the hospice program. Direct physician medical care is billed separately from the hospice per diem.
• Unrelated services. These are the services, equipment, medication, treatment, and supplies that are not related to the terminal condition and, in the patient’s care plan, are not covered under the hospice benefit but may be covered under other benefit categories as stipulated in the plan.
• Professional management. It is understood that hospice care is palliative rather than curative in treatment goals and methods and that the definition of accepted palliative goals and methods is exclusively the province of hospice for each patient and for all patients.
• Patient residence. The patient’s residence is a private home, nursing facility, intermediate care facility, group home, assisted-living facility, hospice facility, or other alternative residence.
Levels of care
• Routine hospice care. This is intermittent scheduled care provided to hospice patients in their place of residence. A 24-hour on-call service is provided. As detailed in the patient’s plan of care, the services may include:
— physician-directed interdisciplinary case management focused on patient symptom control;
— services by licensed nurses, social workers, chaplains, counselors, nursing assistants, and volunteers;
— family counseling services to family members during the time the patient is receiving hospice care;
— bereavement care and counseling for family members for at least one year following the patient’s death;
— all interventions related to the terminal condition and necessary for the implementation of the patient’s plan of care, including therapies, medications, routine medical supplies, and durable medical equipment, excluding ventilators.
• Respite care. A hospice may provide patient care in a facility it owns or contracts with to provide relief and rest for the patient’s primary caregiver.
• Continuous hospice care. A hospice may provide hourly care in the patient’s place of residence during periods of crisis, as necessary to enable the patient to remain at home. A period of crisis is a time in which the individual requires continuous intervention to achieve palliation or management of acute medical or psychosocial symptoms.
• Alternative residential hospice care. A hospice may provide routine hospice care and room and board in a residential facility (if available) it owns, leases, or contracts with. This level of care is commonly given to patients who have no a willing or able caregiver.
• General hospice inpatient care. A hospice may provide pain and symptom control not manageable in a home care setting in a health care facility it owns, leases, or contracts with.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content