Are Reimbursement Changes Affecting Hospice Referrals In The Skilled Nursing Facility?: A Feasibility Study

The purpose of this project was to determine barriers and facilitators to hospice referral in three nursing home settings and to increase the utilization of this service Nearly 1.5 million individuals reside in nursing homes across the United States however only 14.5 percent of those individual are enrolled in hospice at their time of death. There is a large amount of evidence showing that individuals who die while on hospice services have increase in satisfaction and are more comfortable at their time of death. However, there is a dearth of information regarding barriers to referral in the nursing home setting. Three skilled nursing facilities in the Salt Lake Region were identified as appropriate sites for this project. A survey was provided to department heads and direct care staff during their monthly in-service that asked them about their knowledge of hospice, facilitators to hospice referrals and barriers to hospice referrals. A PowerPoint was created based on the needs identified from the survey. An education session was held with the department heads and direct care staff and the PowerPoint was presented. A post education survey was distributed and results showed that 100% of individuals surveyed had an increase in knowledge regarding hospice. The hospice referral rates were then compared for the two months prior to the education and two months post education. There was no significant difference in the hospice referrals pre to post intervention with a significant value of .157 (p<0.05). The biggest barrier to hospice referral identified was reimbursement. During the development phase of the project, we identified that facilities were leasing their beds to county hospitals to take advantage of the Medicaid Upper Payment Limit that increased their reimbursement significantly. However, this increase did not apply to patients enrolled in hospice services. A change to Medicaid reimbursement must be made to provide equal payment to the skilled nursing facility for those patients who use long term Medicaid and those whom use hospice Medicaid. Without this change, there is a disincentive for the facility to place patients on this service.

Running Head: HOSPICE REFERALS Are Reimbursement Changes Affecting Hospice Referrals In The Skilled Nursing Facility?: A Feasibility Study Christina Martin BSN, RN, DNP student Project Chair: Nancy A. Allen The University of Utah College of Nursing 1 2 HOSPICE REFERALS Abstract Purpose: The purpose of this project was to determine barriers and facilitators to hospice referral in three nursing home settings and to increase the utilization of this service Background: Nearly 1.5 million individuals reside in nursing homes across the United States however only 14.5 percent of those individual are enrolled in hospice at their time of death. There is a large amount of evidence showing that individuals who die while on hospice services have increase in satisfaction and are more comfortable at their time of death. However, there is a dearth of information regarding barriers to referral in the nursing home setting. Method/Results: Three skilled nursing facilities in the Salt Lake Region were identified as appropriate sites for this project. A survey was provided to department heads and direct care staff during their monthly in-service that asked them about their knowledge of hospice, facilitators to hospice referrals and barriers to hospice referrals. A PowerPoint was created based on the needs identified from the survey. An education session was held with the department heads and direct care staff and the PowerPoint was presented. A post education survey was distributed and results showed that 100% of individuals surveyed had an increase in knowledge regarding hospice. The hospice referral rates were then compared for the two months prior to the education and two months post education. HOSPICE REFERALS 3 There was no significant difference in the hospice referrals pre to post intervention with a significant value of .157 (p<0.05). Conclusion: The biggest barrier to hospice referral identified was reimbursement. During the development phase of the project, we identified that facilities were leasing their beds to county hospitals to take advantage of the Medicaid Upper Payment Limit that increased their reimbursement significantly. However, this increase did not apply to patients enrolled in hospice services. A change to Medicaid reimbursement must be made to provide equal payment to the skilled nursing facility for those patients who use long term Medicaid and those whom use hospice Medicaid. Without this change, there is a disincentive for the facility to place patients on this service. 4 HOSPICE REFERALS Introduction Problem Description Nearly 1.5 million individuals reside in nursing homes (NH) across the United States. However, only 14.5 percent of those individuals are enrolled in hospice services at the time of their death (National Hospice and Palliative Care Organization, 2015). There has been evidence showing that individuals who die while on hospice services have an increase in satisfaction and are more comfortable at their time of death (Zuckerman, Stearns, & Sheingold, 2016; Gozalo & Miller, 2007). While there has been a large amount of research on the positive effects hospice can provide to the end of life care, there is a dearth of research that has been done to identify barriers at the nursing home level on making referrals to hospice. In 1982, the Medicare hospice benefit was passed into law with the hopes of improving the quality of care delivered to terminally ill beneficiaries whose physician certified that they had six or less months to survive (Centers for Medicare and Medicaid services (CMS, 2016). In 2009, hospice benefits were expanded to include individuals HOSPICE REFERALS with any chronic terminal illness (e.g. dementia) in which a six month prognosis was 5 difficult to predict (Miller, Lima, Gonzalo & Mor, 2010). This has allowed more individuals to qualify for the hospice benefit. If the individual lives beyond the six months but their condition continues to decline, they may recertify by a physician, nurse practitioner or physician assistant for additional time in hospice care. However, if the patient's condition improves, they may be discharged from hospice services but eligible for hospice again if their condition begins to decline (Hospice Foundation of America, 2016). Agreeing to hospice services means the individual forgoes any curative services for the terminal illness and, in place, will receive palliative and supportive services available with hospice care (CMS, 2016). These services would include pain and support management to bereavement services, all in the hopes of improving the quality of end of life care for not only the individual but their family as well. There are several benefits that hospice provides to the patient, caregivers, facilities where patient resides, and U.S. tax payers. Several studies have reported that the patient and their caregivers have increase satisfaction about the quality of end of life when hospice was involved over those who passed away without hospice services (Mackenzie, Buck, Meghani and Riegel, 2016; Oliver et al, 2014). When discussing caregiver and patient satisfaction, most report that the extra care provided by the hospice staff makes the patient feel supported and decrease caregiver stress and burnout (Reese et al, 2014). Another benefit of hospice to the patient is that it decreases their rate of hospitalizations. Gillick (2014) found that many physicians do not discuss with patients the risk and benefits of hospitalizations with patients. When a physician recommends HOSPICE REFERALS hospitalization, often patients assumed that it was the most effective and safe treatment 6 when, in fact, a palliative approach may be the best options. Often when an elderly individual is hospitalized, they undergo several diagnostic testing that can be both invasive and uncomfortable. Knowing their options before hospitalization or treatment may help them chose the palliative care option. Reducing hospitalization by placing a patient on hospice also helps prevent excess Medicare spending. Zuckerman et al (2015) conducted a study researching five specific diseases and found that hospice use over 2 weeks was associated with decrease in hospital days and decrease in Medicare expenditures. The study also found that the most savings was found for individuals who were enrolled in hospice for thirty-one to ninety days. Unroe et al. (2016) showed that individuals who were enrolled in hospice earlier in the disease process prevented excess spending of Medicare dollars and helped prevent readmission rates in the nursing home setting. Likewise, Holden et al., (2015) found that patients who were enrolled in hospice within 30 days of discharge from a hospital had a decrease rate of readmitting to the hospital than those who were not enrolled. A study conducted by Gozalo et al (2015) found that with the increase in hospice enrollment in the nursing home came a drop in the rate of hospital transfers, a decrease in feeding tube use and reduction in intensive care unit (ICU) use. All of these reductions add up to decrease amount of Medicare spending on those items. Patients who pass away in the nursing home while on hospice have improved the patient's quality of life because they have a full palliative care team that is monitoring them and providing additional interventions that the patient most likely would not have received from the nursing home (Miller, Lima, Looze & Mitchell, 2012). Lamba & HOSPICE REFERALS Quest (2011) reports that "hospice as a care system is the most comprehensive, 7 interdisciplinary care system available to patients, families and caregivers living with a terminal illness" (pg 298). This additional attention that the patient receives can truly impact their end of life care. Rationale The Stetler Model of Evidence Based Practice was used in this project as a way to educate the key members in the nursing home setting on the benefits of hospice and increase its use within the facility (Stetler, 2001). There are five steps in this evidence based practice model which are: preparation, validation, comparative evaluation/decision making, translation/application and evaluation: Phase one included reviewing the current research and data that has already been published regarding hospice use. The second phase was time spent validating the information found during phase one for qualifiers of application to this study. Phase three was complying the research findings and putting the knowledge gained from research into effect and moving forward to identifying the problem, educating those individuals about the problem and creating education materials from the research obtained. Phase four consisted of taking the information gathered in phase 3 and putting together education materials, developing a referral algorithm, creating a PowerPoint and providing education to the appropriate individuals at the nursing home. Lastly, the fifth phase was used to evaluate if the practice had changed due to the education and information identified. Specific aim: The purpose of this project was to determine barriers and facilitators to hospice referral in three nursing home settings and to increase the utilization of this service. HOSPICE REFERALS Methods 8 Context Three skilled nursing facilities in the Salt Lake region were identified as appropriate sites for this project. These facilities are similar in that they all have both long term care patients as well as short term patients and have several hospice contracts already in place. They also have similar patient demographics however their daily census is different ranging from sixty-five patients to one hundred and fifteen patients. Lastly, they all have similar structure in the way the management and the direct care staff report to one another. Intervention The first step to the project was to identify barriers that may delay or defer the patient from being referred to hospice and the facilitators that may increase the referrals by nursing home staff. A survey was given to the management team as well as the registered nurses and license practical nurses to evaluate the barriers and facilitators (Table 1. and Table 2.). This was implemented during a morning meeting for the management team and surveys were placed at the nurses stations for direct care staff to fill out during their shift. The second step was to develop education material addressing the knowledge deficits, barriers identified by the assessment and other resources that may increase appropriate hospice referrals. Using the barrier and facilitators identified in the surveys as well as information collected through peer review articles, an educational power point was developed that helped correct misperceptions and teach about hospice and its HOSPICE REFERALS 9 potential impact on the skilled nursing facility. This was prepared in collaboration with a content expert whom has experience in both the skilled nursing setting and hospice. The third step was to implement the education program with nursing home staff. This was accomplished with the management team during their morning meeting and the monthly nurse in-service for the direct care staff. They were given the presentation and then allowed time to ask questions, clarification and add comments. Their comments were written down for future use in refining the educational presentation. The last step was to evaluate changes in hospice referrals pre- to post education. The business manager at each facility provided the number of hospice referrals 2 months prior to the educational presentation and 2 months post education. Pre-education numbers were then compared to post-education numbers to determine the effect of the education on the number of hospice referrals made by the skilled nursing facility staff. Study of the Interventions The approach chosen for assessing the impact of the intervention was to use change statistics to compare the number of hospice admissions pre implementation of education to post implementation of the education program. Measures A survey was created to assess the barriers and facilitators to hospice referral. The survey was reviewed with a content expert for understandability as well as to identify any areas that may be unclear or needing adjustment and then to validate before using with subjects. The educational power point was also reviewed by the content expert for its complexity and understandability. HOSPICE REFERALS 10 The sample group for both surveys included individuals whom participated in the morning management meeting including the administrator, director of nursing, assistant director of nursing, physician, social worker, dietary manager, social worker, director of rehabilitation, MDS nurse, case manager, and certified nursing assistant manager. The survey was also administered during the December in-service with the direct care staff, which included the registered nurses, license practical nurses and certified nursing assistants. The survey took the individuals less than 5 minutes to fill out. The information obtained from the survey was then studied and reviewed by the content expert. An educational PowerPoint was developed that included the following topics: what is hospice, who qualifies for hospice, benefits that hospice provide for a patient in a facility and how to overcome barriers that were identified in the survey. These barriers included: who to talk to about putting a resident on hospice, how to educate the family/resident about hospice or how to have that conversation with the family and reimbursement consideration. The educational PowerPoint was limited to a 10 minute presentation in order to maximize the attention and time from the participants. A post education survey was requested by participants that included demographic and feedback after the educational PowerPoint. Data Analysis The Wilcoxon Signed Rank Test was used to measure the change between preeducation and post-education hospice referrals. Descriptive statistical analysis was also conducted on the demographics of individuals receiving the education and their response to the questions. Ethical Considerations 11 HOSPICE REFERALS This study was determined to be non-human subjects research by the University of Utah. The University of Utah Institutional Review Board determined this study to be exempt from human subjects review. Results The facilitators/barriers and knowledge survey was administered at the educational in-services at three skilled nursing facilities. There were 57 (54%) of one 106 employees that attended the in-service. Of the 29 individuals who wrote in a response for a barrier, 18 (62%) identified reimbursement was a barrier, 7 (24%) identified end of life conversation was barrier and 4 (14%) wrote that they did not know whom to contact within the facility regarding hospice. The education session was attended by 71 (67%) of 106 employees. A post education survey was administered to the individuals and 100% of them identified that the education session increased their knowledge regarding hospice services. The results of hospice referrals pre intervention and post intervention were compared using the Wilcoxon Signed Rank Test. There was not a significant difference in the hospice referrals pre to post intervention with a Wilcoxon signed rank value of .157 (p<0.05). The first facility referred the same amount of residents to hospice pre intervention to post intervention (3 residents). The remaining two facilities also referred the same amount of residents each month however, they both increased their number by one the second month of intervention (6 residents pre intervention to 7 post intervention) (see chart 1). Discussion Summary HOSPICE REFERALS 12 This study was conducted from 11/1/17-2/28/18. The purpose of the study was to determine if providing target education regarding the barriers to hospice would increase hospice referrals. The results of this study show that an educational program addressing the benefits and barriers to hospice services in the skilled nursing setting did not significantly increase the hospice referrals made during the two month tracking period. There was a slight increase in hospice referrals but this was not significant. The hospice education program was well received and post-survey results indicated all participants (n=106) had increased their knowledge of hospice care and the process for making referrals. Upon further investigation into the major barrier to hospice referral which was reimbursement, it was discovered that a change took place during the pre-intervention phase regarding reimbursement. Facilities can gain more Medicaid reimbursement by leasing their beds to a county owned hospital. The hospital then bills the state for the Medicaid beds for the nursing homes. The state pays the county owned hospital more than the actual cost the facility incurs for medical services they provide. The state then draws down federal matching funds based on the inflated payments it has made to the hospital; this is called the Medicaid Upper Payment Limit (UPL) (Ku, 2017). As a result, the state collects additional federal money without contributing any state funds. The reimbursement rate than increases for the Medicaid beds close to what the facility is reimbursed for Medicare bed. The difference can be anywhere from $50-$100 per bed per day. Meanwhile, when a patient in the skilled nursing facilities gets placed on hospice, the hospice company is reimburse through Medicare and with that money, pays the facility the Medicaid daily rate but does not give them the UPL difference. HOSPICE REFERALS 13 In a post study follow-up with the skilled nursing facility administrators, they all indicated that with Medicaid UPL reimbursement, this hospice educational program would not realize its desired outcome for more hospice referrals because the skilled facilities could not afford the loss in revenue. Ironically, they all acknowledge the hospice benefit provides services that there facility could not and felt that it was beneficial for the patient, however, they still felt reimbursement was more essential. Interpretation During the development phase of this study, the reimbursement level for a long term Medicaid patient was the same as a hospice Medicaid patient. However, unbeknownst to our team, skilled nursing facilities were rapidly leasing their beds to the few county owned hospitals in the state to take advantage of the UPL reimbursement. While this is a legal way to increase their reimbursement, it deprives patients in the skilled nursing facility of receiving not only a benefit they have earned by paying Medicare taxes, but also care that can improve the quality of their life. If the UPL is not going to change, then Medicare needs to increase the reimbursement hospice companies receive so they can match the Medicaid rate plus the UPL rate the facility is getting. This study highlights the need for a policy change. Aside from the reimbursement barriers experienced, we demonstrated that it is feasible and acceptable to provide hospice education. The amount of time needed to educate the staff was minimal and the education was very straightforward and easy to understand. It would be of minimal work to provide the education to staff in all skill nursing facilities during an in-service and while it may not increase the number of 14 HOSPICE REFERALS referrals immediately, it may heighten the staff's awareness of hospice admission criteria and overtime, which may lead to additional hospice referrals. Limitations The sample size of the study makes it difficult to apply the data to all skilled nursing facilities. Another limitation was the short timeline for implementation. It is possible that in a 6 or 12 month data collection period, we would have seen an increase in the hospice referral rate. Conclusions There is still much work to be done to affect change in the lower hospice referral rate in the skilled nursing facilities. This study provides initial evidence that a major barrier to hospice referrals is the lower rate of Medicaid reimbursement for hospice patients in long term care facilities. These financial disincentives will negatively affect hospice referral rates until Medical policies are changed. In the post study survey, long term care facility administrators agreed that patients need hospice services. Hospice benefits are well known and many benefits can be derived from this type of care. Further study and policy changes are needed. References Center for Disease Control, (2016). Vitals and Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/series/sr_03/sr03_038.pdf HOSPICE REFERALS Center for Medicare and Medicaid Services. (2016). Medicare Hospice Benefits. 15 Retrieved from https://www.medicare.gov/Pubs/pdf/02154.pdf Gillick, M. R. (2014). When frail elderly adults get sick: alternatives to hospitalization. Annals Of Internal Medicine, 160(3), 201-201 1p. doi:10.7326/M13-1793 Gozalo, P., Plotzke, M., Mor, V., Miller, S. C., & Teno, J. M. (2015). Changes in Medicare costs with the growth of hospice care in nursing homes. New England Journal Of Medicine, 372(19), 1823-1831 9p. doi:10.1056/NEJMsa1408705 Holden, T. R., Smith, M. A., Bartels, C. M., Campbell, T. C., Yu, M., & Kind, A. J. (2015). Hospice Enrollment, Local Hospice Utilization Patterns, and Rehospitalization in Medicare Patients. Journal Of Palliative Medicine, 18(7), 601-612 12p. doi:10.1089/jpm.2014.0395 Hospice Foundation of America. (2016). What is Hospice? Retrieved from https://hospicefoundation.org Ku, L. (2017) Limiting Abuses of Medicaid Financing: HCFA's Plan to Regulate The Medicaid Upper Payment Limit. Retrieved from https://www.cbpp.org/archiveSite/9-27-17health.pdf Lamba, S., & Quest, T. E. (2011). Hospice Care and the Emergency Department: Rules, Regulations, and Referrals. Annals Of Emergency Medicine, 57(3), 282-290 9p. doi:10.1016/j.annemergmed.2010.06.569 MacKenzie, M. A., Buck, H. G., Meghani, S. H., & Riegel, B. (2016). Unique Correlates of Heart Failure and Cancer Caregiver Satisfaction With Hospice Care. Journal Of Pain & Symptom Management, 51(1), 71-78. doi:10.1016/j.jpainsymman.2015.09.001 HOSPICE REFERALS Miller, S. C., Lima, J. C., Looze, J., & Mitchell, S. L. (2012). Dying in U.S. Nursing 16 Homes with Advanced Dementia: How Does Health Care Use Differ for Residents with, versus without, End-of-Life Medicare Skilled Nursing Facility Care?. Journal Of Palliative Medicine, 15(1), 43-50 8p. doi:10.1089/jpm.2011.0210 Miller, S., Lima, J., Gozalo, P., & Mor, V. (2010). The growth of hospice care in U.S. nursing homes. Journal Of The American Geriatrics Society, 58(8), 1481-1488 8p. doi:10.1111/j.1532-5415.2010.02968.x National Hospice and Palliative Care Organization, (2015). NHPCO's Facts and Figures: Hospice care in America. Retrieved from http://www.nhpco.org/sites/default/files/public/Statistics_Research/2015_Facts_Fi gures.pdf Oliver, D. P., Washington, K., Kruse, R. L., Albright, D. L., Lewis, A., & Demiris, G. (2014). Hospice Family Members' Perceptions of and Experiences With End-ofLife Care in the Nursing Home. Journal Of The American Medical Directors Association, 15(10), 744-750 7p. doi:10.1016/j.jamda.2014.05.014 Reese, D. J., Smith, M. R., Butler, C., Shrestha, S., & Erwin, D. O. (2014). African American Client Satisfaction With Hospice: A Comparison of Primary Caregiver Experiences Within and Outside of Hospice. American Journal Of Hospice & Palliative Medicine, 31(5), 495-502 8p. doi:10.1177/1049909113494462 Stetler, C. (2001). Updating the Stetler model of research utilization to facilitate evidence-based practice. Nursing Outlook, 49, 272-279 HOSPICE REFERALS Unroe, K. T., Sachs, G. A., Dennis, M. E., Hickman, S. E., Stump, T. E., Tu, W., & 17 Callahan, C. M. (2016). Effect of Hospice Use on Costs of Care for Long-Stay Nursing Home Decedents. Journal Of The American Geriatrics Society, 64(4), 723-730 8p. doi:10.1111/jgs.14070 Zuckerman, R. B., Stearns, S. C., & Sheingold, S. H. (2016). Hospice Use, Hospitalization, and Medicare Spending at the End of Life. Journals Of Gerontology Series B: Psychological Sciences & Social Sciences, 71(3), 569-580 12p. doi:10.1093/geronb/gbv109 18 HOSPICE REFERALS Figure 1: Number of Referrals per facility 8 7 6 5 Pre Intervention 4 Post Intervention 3 2 1 0 Facility 1 Facility 2 Facility 3 19 HOSPICE REFERALS Table 1. Hospice Knowledge, Facilitator/Barrier Survey Demographic Questions: Length of time working in the skilled nursing setting: ☐0-6 months ☐6-12 months ☐1-2 years ☐3-4 years ☐>5 years Age: ☐20-29 ☐30-39 ☐Male ☐Female ☐40-49 ☐50-59 ☐60-69 ☐70-79 Gender: Race: ☐African American ☐Hispanic ☐Asian American ☐Caucasian/white Hospice Questions: 1. Hospice is for people who only have a few days to live ☐True ☐False 2. Hospice is for a resident with any terminal illness ☐True ☐False 3. Hospice is only for people with cancer ☐True ☐False 4. Hospice "dopes" people up" so they become addicted or sleep all the time ☐True ☐False 5. Hospice care requires that all medical treatment is stopped ☐True ☐False ☐ Other 20 HOSPICE REFERALS 6. Hospice in the facility cost the facility more money ☐Strongly agree ☐Somewhat agree ☐Neutral ☐Somewhat disagree ☐Disagree 7. Having a resident on hospice requires me to do more work ☐Strongly agree ☐Somewhat agree ☐Neutral ☐Somewhat disagree ☐Disagree 8. Having a resident on hospice decreases work load ☐Strongly agree ☐Somewhat agree ☐Neutral ☐Somewhat disagree ☐Disagree 9. Having a conversation about hospice makes me feel uncomfortable ☐Strongly agree ☐Somewhat agree ☐Neutral ☐Somewhat disagree ☐Disagree 10. Having the extra support staff from hospice makes it harder for the SNF ☐Strongly agree ☐Somewhat agree ☐Neutral ☐Somewhat disagree ☐Disagree 11. I am unsure whom in the facility I should speak with if I think a resident needs hospice ☐Strongly agree ☐Somewhat agree ☐Neutral ☐Somewhat disagree ☐Disagree 12. What are any barriers you have to referring to hospice [Free Text] 13. What are reasons to referring to hospice [Free Text] Table 2. Post Education Survey Demographic Questions: Length of time working in the skilled nursing setting: ☐0-6 months ☐6-12 months ☐1-2 years ☐3-4 years ☐5 years Age: ☐20-29 ☐30-39 ☐Male ☐Female ☐40-49 ☐50-59 ☐60-69 ☐70-79 Gender: Race: ☐African American ☐Hispanic ☐Asian American ☐ Caucasian/white ☐Other Was this education helpful? ☐Strongly agree ☐Somewhat agree ☐Neutral ☐Somewhat disagree ☐Disagree What addition information, in any would have been beneficial to include in this education? Please provide us with any other comments you would like to share regarding this education