White Paper on Hospice in Long Term Care

Issued August 11, 2000

Introduction

Over the last decade, the role of the medical director has become increasingly defined. Federal and state regulations as
well as corporate entities have contributed to this process. AMDA has led the way in developing and refining this role.

All will agree that the administrative responsibilities as well as the liabilities of the long term care medical director have
continued to increase. Yet the need for ancillary and consultative care continues, increasing these responsibilities and
liabilities.

The medical director's role in quality end -of-life care is no exception. The Medicare Hospice Benefit has been identified
within the long term care facilities as a six month entitlement to Medicare patients who meet specific criteria. However,
the multitude of hospice providers has created a variability in the quality of care delivered. Despite the favorable final
Office of Inspector General (OIG) report on Hospice in the Nursing Home released in April, 1998, there are still concerns
of fraud, duplication of services, reimbursement and prognostication dilemmas. Some of these issues have been
addressed, but the concerns of the nursing home medical director have not been covered extensively.

The responsibility of quality medical care throughout the facility rests on the medical director more than ever before. As a
result, the Hospice Subsection has chosen to address the integration of hospice and long term care. The following
concerns were discussed and approved by the Subsection at the 1999 Annual Symposium of the American Medical
Directors. The goal of this document is to enhance the delivery of quality care to nursing home hospice patients by
clearly delineating the role of the medical director.

Quality Assurance

The medical director of a nursing home has to include end -of-life care in the Quality Assurance (QA) process. As a
result, several issues need to be evaluated, measured, and trended. These potential areas are listed to serve as ideas to
be considered. Over a period of time, the data that are reported to the QA committee will help to establish benchmarks.

Pain Management
Pain has been defined as the 5th vital sign and can be measured by several different instruments. The choice of a visual
acuity graph is not as challenging as the accurate assessment of pain. There continues to be a lot of concern on how
best to accurately measure pain and discomfort, especially in the non -communicative and/or demented patient. Better,
more comprehensive evaluation tools have been created, examples of which are included with this paper. (Appendix A)

Another useful measurement is the length of time it takes to control pain symptoms. Also, the utilization of the various
pain medications as well as the various routes of administration could be measured. The committee could measure
separately the management of different types of pain including chronic pain, acute pain, or pain found in actively dying
patients.

A Pain Burden Scale is calculated by dividing the number of patients in the facility in pain by the total number of patients.
(Appendix B) The QA committee could require this information from various hospice providers as well as monitor the
data for their own facility.

Non-pain Symptom Management

Other symptoms can be monitored in much the same way as pain. Constipation, diarrhea, nausea, vomiting, confusion,
depression, shortness of breath or other symptoms can be considered. Visual Acuity Graphs can be developed for
monitoring. (Appendix C) As in pain management, the QA committee could require this information from various hospice
providers as well as monitor the data for their own facility.

Hospice Utilization
Knowing the average length of stay for patients receiving hospice care within the facility, as well as the average length of
stay of the hospice program for the city, state, or region could be beneficial. This would address some of the current
concerns by many regarding the hospice/nursing home integration and the qualification for the patient's six month
entitlement. The QA committee can monitor the percentage of patients on hospice in relation to the facility census.
Furthermore, the number of patients on hospice in the facility can be measured against the total number of facility
patients. The terminal patients are those who are in persistent vegetative state, those who have end stage medical
condition, or whose death is imminent.
Bereavement
Bereavement in the nursing home includes the family, staff, friends, and fellow patients and is ongoing. Bereavement
services includes routine support to those in need as well as memorial services. Documentation for these duties is
needed. Several tools could be utilized to meet the facilities needs. (Appendix D)

Further Documentation
Some surveyors have requested documenting and reestablishing the surrogate's understanding of the patient's advance
directives and the end -of-life care being provided. The issues such as malnutrition, tube feeding, pressure ulcers, or non -
hospitalization needs to be discussed again and documented every 60 days. The hospice provider, nursing facility, and
attending physician need to address these issues.

Surveys
Satisfaction surveys from the patients and families are useful and should include information regarding the nursing home
staff, medical director, and attending physician. Performance surveys may be beneficial, where the proposed care plans
can be compared with the care actually given. It is critical that the coordinated plan of care for these patients be written
as specific as possible.

In-Service Education
Coordinated in -services need to be given to meet the specific educational needs of each facility.

Minimum Data Set (MDS) Whether the MDS is the most appropriate assessment tool in the nursing home has
continued to be debated. The patient's care plan is produced from this assessment tool and the MDS triggers that refer
to the appropriate Resident Assessment Protocols. The MDS is now electronically transmitted and it is now used to
determine outcomes. Finally, PPS has utilized the MDS in establishing the reimbursement rate for the skilled units.

However, the MDS has shortcomings. It is designed as a functional assessment tool with expected outcomes for
maintaining or improving function. With good end-of-life care, patients may decline in their ability to function. In addition,
the MDS does not address all of the areas needed for end -of-life care including psychological, social, and spiritual
issues.

The Hospice Subsection recommends that a separate instrument be developed utilizing the MDS format. The hospice
provider should be responsible for the completion and utilization of this separate assessment tool, since the palliative
care plan needs to be determined by those trained in palliative care, and not just acute and rehabilitative care. HCFA has
now requested that such an instrument be developed. Several groups have already started on parts of this project
including the National Hospice Organization and the Hospice Nursing Home Task Force.

Fraud
Several areas of potential fraud need to be addressed. Ethical concerns usually revolve around reimbursement issues.
As a result, a chart has been developed to help answer most of these questions. (Appendix E)

Further reimbursement issues relate to medical director fees. As in any area of long term care, these rates are not in any
way related to ability to refer patients, or tied to any performance clauses. There has been recent concern relating to dual
medical directorships where a physician functions as both a nursing home medical director as well as a hospice medical
director. If the purpose of the dual medical directorship is for referrals, then this remains unethical. If the purpose for dual
responsibility is for education, integration, continuity of care, regulatory compliance, etc. then there are not any ethical
issues.

The OIG has regularly published fraud alerts. Areas pertaining to long term care include concerns over inducements by
hospice providers. Medicare skilled units were targeted because hospices provided free services to these residents in
order for them to contract with the hospice when discharged. However, if a hospice patient has a hospitalization
unrelated to the terminal diagnoses and qualifies for Medicare skilled care, they can remain on hospice related to their
terminal diagnosis.

The National Hospice Organization's development of prognostication guidelines, especially of the non -malignant
diseases has helped defray many of the eligibility concerns. Physicians can utilize these and other similar documents to
avoid non -eligible admissions. (Appendix F)

Medical Directors

Nursing Home
The responsibilities of the nursing home medical director have already been established. However for completeness, a
copy of recommendations by AMDA has been included. (Appendix G) Nevertheless, the involvement of the nursing
home medical director in the hospice program is worthy of mention. The nursing home medical director as well as the
attending physician should stay involved in the patient care.

This can be done in several ways. The attending physician should continue as the primary care provider for his patient. If
the physician is not working for the hospice, they can bill Medicare for their service as usual. A chart demonstrating the
reimbursement issues is attached. (Appendix E) If the attending feels uncomfortable or unsure about the palliative care
needed for the patient, such as appropriate symptom interventions, he can always consult with the hospice medical
director. The nursing home medical director should be in contact with the hospice medical director if any concerns or
problems develop. Attendance at the hospice interdisciplinary team meeting (IDT) might be appropriate, especially if
there are issues to be addressed or discussed concerning the hospice program within the nursing facility. The nursing
home medical director may need to explain and train the hospice on certain nursing home regulations and needs or how
simple grievances or concerns could be addressed. A good working relationship is always encouraged.

Hospice
The hospice medical director should embrace a multitude of duties and responsibilities. Since many nursing home
medical directors are considering hospice medical director positions, the Hospice Subcommittee has chosen to delineate
some recommendations.

Admission And Certification

1. Confirm the diagnosis and prognosis for each newly admitted patient.
2. Visit patients as indicated.
3. Recertify patients for each benefit period

Education

1. The hospice medical director should be trained and well versed in palliative care. Education in these areas can be
obtained at the AMDA annual symposium, the American Academy of Hospice and Palliative Medicine (AAHPM)
meetings, National Hospice Organization (NHO), Hospice Association of America (HAA), as well as other national
organizations.
2. The hospice medical director should develop and present educational materials at in -services for hospice, nursing
home and hospital staff. Topics are to include but not be limited to:
a. Pain management
b. Symptom management
c. End -of-life decision making
d. Medical ethics
e. Hospice Medicare regulations
f. Palliative care

Marketing
The hospice program can be represented to physicians, medical community, medical facilities, and the community
through articles, presentations, or videos.

Utilization Review & Quality Assurance

Exercise medical leadership in CQI by chart audits and review and monitoring of the clinical practice of attending
physicians.

Administration

1. Direct medical interventions consistent with palliative care protocols.

2. Act as liaison with the attending physician, consultants, and medical directors of hospitals, nursing homes, and
managed care programs.
3. Be able to assume temporary responsibility for patient care on an emergency basis if the attending physician or
designee is not available.
4. Monitor physician performance in interdisciplinary meetings.

Clinical Duties

1. Be available to serve as a consultant expert in palliative care. These duties may include:
a. In -patient rounds
b. Nursing home rounds
c. Home visits
d. On call
e. IDT meetings
 Frequently Asked Questions

1. How can you tell when a patient has six months or less to live in order to qualify for the Medicare hospice
benefit?

The regulations state that a patient can qualify for hospice if the patient is in the last six months of life "if the terminal
disease runs it's normal course."

No one has a "crystal ball". Therefore, HCFA has revised the benefit periods for recertification of the patient's terminality,
if a disease does not run it's "normal course".

To help with prognostication of non -malignant terminal disease, the National Hospice Organization (NHO) published the
GUIDELINES FOR PROGNOSIS OF SELECTED NON -MALIGNANT TERMINAL DISEASES. (Appendix F) These
guidelines are available to address end-stage prognostication of Dementia, Heart Disease, Pulmonary Disease, Liver
Disease, Renal Disease, Coma, HIV, ALS, and Stroke.

2. What are hospice benefit periods?

In the past there were four benefit periods, (90, 60, 30 days, then a fourth period that was unlimited). At each period the
physician recertified that the patient had 6 months or less to live. Many patients had entered their 4th benefit period and
were in fear of losing their hospice benefits, if they were to remain on hospice till they died.

Since the end of 1997, the benefit periods have been revised. Now the patient has 90, 90, then continuous 60 day
benefit periods for physician recertification of terminality. For example, if a patient improves and is not felt to be terminal
at the end of the 2nd benefit period, then the patient can come off of hospice care and be restarted when the patient's
prognosis worsens again.

3. How is the attending physician reimbursed?

If the attending physician is not salaried by the hospice that is caring for that patient, Medicare is billed for the level of
service provided.

If the physician is employed by the hospice caring for that patient, the hospice is billed for the level of service provided.

If the physician is salaried by a different hospice , and not by the hospice caring for the patient, Medicare is billed for the
level of service provided.

If an associate sees the patient, he/she must bill Medicare or the hospice under the primary care physician (attending
physician of record) name and provider number and then be reimbursed by the physician. HCFA receives a record of the
name of each attending physician for each hospice patient.

4. Is hospice care and nursing facility care a duplication of services, ('double -dipping')?

Hospice began as caring for the dying patient at home. The family would provide the daily care for the patient, bathing,
feeding, toileting, giving medicine, etc. Hospice would provide specialized services of pain management, non -pain
symptom management, psychosocial, spiritual, and bereavement care for up to one year. Literature has established the
value -added benefit of hospice to improve the quality of end -of-life care in this setting.

In 1986, the nursing home/facility was recognized as a surrogate home for America's elderly, and that hospice care was
a patient right in this new home setting. Now the nursing facility provides the daily care for the patient, i.e., bathing,
feeding, toileting, giving medicine, etc. Hospice would provide the same service as in any other home setting. The affects
on the quality of end-of-life care in this setting have not been published.

5. What CPT codes should a physician use when seeing a hospice patient in the nursing facility setting?

According to the Health Care Financing Administration and American Medical Association's CPT Information Services,
"there are no specific CPT codes for evaluation and management services provided by a physician to a patient receiving
hospice care in any location. When a Medicare beneficiary elects the hospice benefit, Medicare pays the hospice for all
services related to the terminal illness through four set per diem rates. The exception to this is physician services.
General supervisory services and participation in the establishment, review, and update of plans of care provided by the
hospice medical director or a physician member of the hospice interdisciplinary team are included in this hospice per
diem. This would include evaluation and management services provided by a physician employed by, or providing
services under arrangement with, the hospice."

"Medicare hospice regulations, at 42 CFR 418.304(c), state that services of the patient's attending physician, who is not
employed by the hospice or providing services under arrangements with the hospice, are not considered hospice
services. These services are billed directly to Medicare Part B according to procedures established in 42 CFR 405
subparts D and E. When provided by an attending physician, as described above, evaluation and management services
provided to hospice patients would be billed in the following manner:

n If the evaluation & management services are provided to a hospice patient that is residing in a nursing facility,
then the subsequent nursing facility care codes are billed (99301-99316 series).
n If the evaluation & management services are provided to a hospice patient in their private residence, then the
home services codes are billed (99341-99350 series). The physician must provide the evaluation & management
services in the patient's home in order for these codes to be billed.
n If the evaluation and management services are provided to a patient in a board and care type facility, including a
hospice residential facility, then domiciliary/rest home codes are billed (99321 -99333 series). Again, these
services must be provided in the facility in order for the domiciliary/rest home codes to be billed."
 End-of-Life Care Resources for Additional Information

American Academy of Hospice and Palliative Medicine

11250 Roger Bacon Dr., Suite 8
Reston, VA 20190 -5202
703/787 -7718
703/435 -4390 fax
www.aahpm.org

American Hospice Foundation

1130 Connecticut Ave., NW
Suite 700
Washington, DC 20036 -4101
202/223 -0204
202/223 -0208 fax
www.americanhospice.org

Choice in Dying
1035 30th Street, NW
Washington, DC 20007
202/338 -9790
202/338 -0242 fax
www.choices.org

Hospice Foundation of America

2001 S Street, NW, #300
Washington, DC 20009
202/638 -5419
202/638 -5312 fax
www.hospicefoundation.org

National Association for Home Care

228 Seventh Street, SE
Washington, DC 20003
202/547 -7424
202/547 -3540 fax
www.nahc.org

Hospice Association of America

228 Seventh Street, SE
Washington, DC 20003
202/546 -4759
202/547 -9559 fax
www.nahc.org/HAA/

National Hospice and Palliative Care Organization

1700 Diagonal Road, Suite 300
Alexandria, VA 22314
703/837 -1500
www.nhpco.org

American Medical Directors Association

10480 Little Patuxent Parkway, Suite 760
Columbia, MD 21044
(800) 876-2632 or (410) 740 -9743
Fax (410) 740 -4572
www.amda.com
 AMERICAN MEDICAL DIRECTORS ASSOCIATION
HOUSE OF DELEGATES
RESOLUTION I99

SUBJECT: END-OF-LIFE CARE PLANNING IN NURSING FACILITIES

INTRODUCED BY: HOSPICE SUBCOMMITTEE

INTRODUCED IN: MARCH 1999

WHEREAS, 20 percent of all deaths in America occur in nursing facilities, and

WHEREAS, one-third of all residents entering a nursing facility will die within 12 months
of admission, and

WHEREAS, studies have indicated significant opportunities to alleviate pain, suffering,

and grief at the end-of-life, and

WHEREAS, the care planning process for residents dying in nursing facilities require
coordination of resources, and

WHEREAS, medical directors are responsible for implementation of resident care

policies and coordination of end-of-life medical care in the facility, and

WHEREAS, the medical director’s involvement extends to all services provided in the
facility related to end-of-life care, therefore be it

RESOLVED, that AMDA recognizes the significance of end-of-life care planning. And,
that all residents in nursing facilities should have access to appropriate end-of-life care.
The expected outcomes are respect for patient advanced directives, safe and
comfortable dying, and effective grieving, and

RESOLVED, that medical directors should be provided with sufficient training, education,
and institutional involvement to assess and improve end-of-life care in the facility.

______________________________________________________________________

RESOLUTION RESULTS: Passed by HOD and Board of Directors. Board of

Directors directed Program and Education Committees to work with Hospice
Subsection on end-of-life planning issues.
 APPENDIX A
PAIN/DISCOMFORT EVALUATION TOOLS

Visual Analog Scale

Numeric Rating Scale
Verbal Descriptor Scale
Verbal Numeric Analog Scale
Pain Assessment - Initial/Quarterly
VISUAL ANALOG SCALE

The Worst Imaginable Pain

No pain
NUMERIC RATING SCALE

20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
VERBAL DESCRIPTOR SCALE

_____ The most intense pain imaginable

_____ Very severe pain

_____ Severe pain

_____ Moderate pain

_____ Mild pain

_____ Slight pain

_____ No pain
VERBAL NUMERIC ANALOG SCALE

Subject is asked:

On a scale of 0 to 10,

with 0 being no pain

and 10 being the worst pain imaginable,

what you rate your current pain?

 Pain Assessment
Initial/Quarterly

Resident________________________________________ Room_______________

Date__/__/____

Pain Medication __Routine __PRN __None

Medication / Dose / Interval_________________________________________________

Diagnosis________________________________________________________________

Allergy_________________________________________________________________

Circle best response

Alert and oriented

0=No 1=x1 2=x2 3=x3

Verbalize pain

Y=yes N=no

Intensity A=No Pain

B=Mild Pain
C=Moderate Pain
D=Severe Pain
E=Horrible or Excruciating Pain

Nursing Observations (Circle all that apply)

A=Complaining L=Frightened appearance

B=Crying M=Wincing
C=Moaning N=Guarding
D=Fidgeting O=Tense finger
E=Restless P=Withdrawal
F=Muscle rigidity Q=Sleep
G=Agitation R=Insomnia
H=Resistiveness S=Anger
I=Wrinkled brow T=Depression
J=Facial grimacing
K=Sad/Worried look
 Pain Assessment
Initial/Quarterly

Pain Site / Location

A=Upper back pain F=Incision pain

B=Lower back pain G=Joint pain (where)__________
C=Chest pain H=Upper abdominal pain
D=Headache pain I=Lower abdominal pain
E=Hip pain J=Other (specify)___________

Description

A=Achy F=Stabbing
B=Dull G=Throbbing
C=Sharp H=Radiating
D=Upon movement I=Burning
E=Upon touch J=Itching

Frequency of Pain

A=Daily
B=Pain less than daily

Time of Pain

A=Morning E=Bedtime
B=Afternoon F=All times
C=Dinnertime G=Intermittent
D=Evening H=Night

What causes or increases pain?

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________
 APPENDIX B
PAIN BURDEN SCALE

Number of Patients Reporting Pain

Total Number of Patients

Example
40/100=0.4

08/17/00
 APPENDIX C
SYMPTOM ACUITY GRAPH
PATIENT:_________________________ MR#________________
Month________ Year_____
Rank severity from 1 to 10, filling in the number of boxes
Date
10
9
8
7
6
5
4
3
2
1
Initials

Date
10
9
8
7
6
5
4
3
2
1
Initials

Date
10
9
8
7
6
5
4
3
2
1
Initials
Symptoms (Record symptom and rank 1-10)
1. Pain 2. Nausea 3. Dyspnea 4. Constipation 5. Sleep 6. Edema
7. Confusion 8. Depression 9. Other________________
 SYMPTOM ACUITY GRAPH
PATIENT: Jane Doe MR# 107925
Month Feb Year 2000

Date 2/1 2/2 2/3 2/4 2/5 2/6 2/7

10
9
8
7
6
5
4
3
2
1
Initials K K J J K J J
C C T T C T T

Date
10
9
8
7
6
5
4
3
2
1
Initials

Date
10
9
8
7
6
5
4
3
2
1
Initials
Symptoms (Record symptom and rank 1-10)
1. Pain 2. Nausea 3. Dyspnea 4. Constipation 5. Sleep 6. Edema
7. Confusion 8. Depression 9. Other________________
 APPENDIX D
BEREAVEMENT SERVICES DOCUMENTATION

Assessment Comments From Team Member(s)/Bereavement

Involvement
Tracking Schedule
Bereavement Contact Notice
Patient Name:________________________ MR#__________________
Bereaved:___________________________ Relationship:___________________
Primary Language: ___________________ Significant Team Member: _____________

ASSESSMENT COMMENTS FROM TEAM MEMBER(S)/BEREAVEMENT

INVOLVEMENT

Survivor believes his/her support system is adequate: Yes___ No___

Team believes the survivor’s support system is adequate: Yes___ No___
Survivor expresses desire for intensive bereavement support Yes___ No___
Attempted Calls _____ _____ _____ _____

Circle one item in each category. Leave blank if unknown.

A. Children under 17 in home B. How will bereaved cope C. Clinging/Fawning

Name/Age 1. Low-normal grief & 0. Low - Never
None:____ recovery w/o special help 1. Moderate - Seldom
One:____ 2. Moderate-Doubtful – may 2. High - Constant
Two or more:____ need special help
List children with grief issues: 3. High – requires special help
_________________________ 4. Mental diagnosis with no
_________________________ active treatment or has
suicidal ideation.

D. Anger E. Self Reproach F. Financial Status

0. None (or Normal)
1. Low – irrational
2. Moderate, occasional
outburst
3. High - Severe
4. Extreme, always bitter
G. Relationships now
0. Close intimate
relationships
1. Warm supportive family
permitting expression of
feeling
2. Family supportive but
live at distance
3. Doubtful
4. None of the above
0. None
1. Low-vague and general
2. Moderate-some clear
self reproach
3. High – Severe-
preoccupied with self-
reproach
4. Suicidal
H. Faith Community
0. Yes – active faith or
positive self image
1. PCG has extensive
spiritual questions
2. Spiritual distress
1. Low – financially stable
2. Moderate – Financial
hardships
3. High – Financially
unstable
Add one point for each:
a. Untimely death
b. Socially unacceptable
death
c. Several loss issues

TOTAL SCORE – Plan of Care

Level I Level II Level III
______ < 12 (Low Risk) ______ = or > 12-14 (Moderate Risk) ______ => 15 (High Risk)

EXPECTED OUTCOME: For the survivor to be knowledgeable of Bereavement services and,

when needed, to use bereavement services to achieve more positive grief outcome.
Comments:_____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Signature and Discipline: ______________________________________________
Tracking Schedule

Patients Name:_____________________________ DOD:_______________________________

Bereaved Name:____________________________ Relationship:_________________________
Home Number:_____________________________ Work Number:________________________

Due Done
Standard Care – Level One – Low Risk
Bereavement Services Declined: __________________________
Bereavement Card (Completed 1 week after DOD by IDG team) _________ _________
Not able to contact letter sent _________ _________
Transfer to Bereavement (Completed by RN after death) _________ _________
Bereavement Assessment/Plan of Care (1st month after death) _________ _________
Introduction letter and satisfaction survey (1st month after death) _________ _________
Quarterly Newsletter Refer to Bereavement Notebook
Invitation to Grief Group Refer to Bereavement Notebook
Invitation to Memorial Service Refer to Bereavement Notebook
Other:__________________________________ _________ _________

Level Two – Moderate Risk (in addition to Level One)

1st Follow-Up Call _________ _________
2nd Follow-Up Call _________ _________
3rd Follow-Up Call _________ _________
Further Calls when deemed appropriate _________ _________
_________ _________

Visits Offered _________ _________

Further Visits when deemed appropriate _________ _________
_________ _________
_________ _________

Referral to Community Service when appropriate _________ _________

Other:____________________________ _________ _________

Level Three – High Risk (In addition to Level One and Level Two
Further Follow-Up Calls when deemed appropriate _________ _________
_________ _________
_________ _________
_________ _________

Further Visits when deemed appropriate _________ _________

_________ _________
_________ _________

Other: _______________________________ _________ _________

Other: _______________________________ _________ _________

Change in the Level of Care or Special Comment: _____________________________________

______________________________________________________________________________
______________________________________________________________________________

Date of Discharge: ___________ Signature of Bereavement Coordinator: ________________

Bereavement Contact Notice

Patient/Deceased Name: ______________________ MR# ______________ Date: ___________

Bereaved Relationship: __________________________________________________________
Significant Others: ______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Telephone After Service 6 Weeks 1 Year

Questionnaire
Personal Visit Sent ______ 3 Months 13th Month
Funeral/Wake Initial 6 Months Bereavement Satisfaction
Survey
Note/Literature 3 Weeks 9 Months

Comments/Observations/Interventions _______________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

_______________________________________________________ _____________________
Staff Signature Length of Visit
 APPENDIX E
Billing Guidelines

Care Care provided Care provided Care provided by Care provided Care Care Care
provided by by non- by non- physician who has by a physician provided provided by provided by
primary hospice hospice provided a performing by hospice the hospice physician
physician primary primary second opinion to diagnostic/ physician physician’s taking call
who is not a physician’s physician’s on- the patient therapeutic associate for the
hospice associate call associate procedures hospice
physician physician
Care Bill Medicare Bill Medicare Bill primary Bill hospice after Bill hospice Bill hospice Bill hospice Bill hospice
related to under primary physician, who authorization after physician,
the physician’s in turn bills given authorization who in turn
terminal name Medicare given bills hospice
illness
Care Bill Medicare Bill Medicare Bill Medicare Bill Medicare Bill Medicare Bill Bill Medicare Bill Medicare
unrelated Medicare
to the
terminal
illness
 APPENDIX F
NHO PROGNOSTICATION GUIDELINES

MEDICAL GUIDELINES FOR DETERMINING

PROGNOSIS IN SELECTED NON-CANCER DISEASES
SECOND EDITION

TABLE OF CONTENTS

Introduction and Overview 2

General Guidelines for Determining Prognosis 6
Heart Disease 8
Pulmonary Diseases 10
Dementia 12
HIV Disease 14
Liver Disease 17
Renal Disease 20
Stroke and Coma 22
Amyotrophic Lateral Sclerosis 24
References 27
Appendices:
I. Type, Strength and Consistency of Evidence 35
II. Karnofsky Performance Status Scale 36
III. New York Heart Association Functional Classification 37
IV. Functional Assessment Staging (FAST) Scale: Dementia 38
V. Typical Time Course of Alzheimer’s Disease 39
VI. Diagnostic Imaging Factors Indicating Poor Prognosis After Stroke 40
Worksheets 41

PUBLISHED BY THE NATIONAL HOSPICE ORGANIZATION

National Hospice and Palliative Care Organization
1700 Diagonal Road, Suite 300, Alexandria, VA 22314
(703) 243-5900
 APPENDIX G
MEDICAL DIRECTOR’S ROLES AND RESPONSIBILITIES

AMERICAN MEDICAL DIRECTORS ASSOCIATION (AMDA)

Medical Director’s Role and Responsibilities

The physician medical director should establish a job description, after consulting with a facility’s
administrator and director & nursing.

1. In collaboration with the nursing director, the administrator, and other health
professionals develop formal patient care policies for the facility that:

• provide for the total medical and psychosocial needs of the resident, including
admissions, transfer, discharge planning, range of services available to resident,
emergency procedures, and frequent of physician visits, in accordance with resident
needs;

• help enhance residents’ rights as identified by the federally-mandated Patient Bill of

Rights.

The medical director should help the facility ensure that these patient care policies are carried out,
as reflected and documented in a facility’s drag regimen review and quality assurance committee
activities.

2. Act as liaison between the attending physicians and other health professionals caring for
residents.

3. In an emergency, be prepared to assume temporary responsibility for the care of a

resident, if the resident’s own attending physician or the designated alternate physician is
not available.

4. Develop, amend, recommend and implement appropriate clinical practices and medical
care policies that help insure that each patient’s medical regime is incorporated
appropriately into the plan of care.

5. Exercise medical and clinical leadership in a multi-disciplinary approach to resident care

and care planning within the long term care setting, and interact with the attending staff
as a colleague and a peer.

6. Monitor the clinical practices of attending physicians, and intervene as needed on behalf
of patients or the facility’s administration.

7. In cooperation with the administration and with the approval of the governing body,
represent the medical staff in developing rules, regulations and policies for the attending
physicians who admit their patients to the facility.

8. Review recommendations and reports of drug regimen review and quality assurance
activities, and take appropriate and timely action as needed to implement
recommendations.

9. Meet periodically with nursing and other professional staff to discuss clinical and
administrative issues, specific patient care problems and professional staff needs for
 education or consultants, offering solutions to problems and identifying areas where
policy should be developed.

10. Help obtain the services of qualified professionals to serve as consultants to help meet
residents' special needs, such as dentistry, podiatry, dermatology, or orthopedics.

11. Help the facility administrator and professional staff ensure a safe and sanitary
environment for residents and personnel, by: reviewing incidents and accidents,
identifying hazards to health and safety, and advising about possible correction or
improvement of the environment.

The Medical Director may also:

1. Attain and provide information about federal, state and local regulations and codes
applicable to long term care facilities, applicable of the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO), and the professional service and
administrative requirements and expectation of third party payers.

2. Help develop in-service and other education programs and materials for attending
physicians and professional staff within the institution, in cooperation with the director of
nursing and the administrator.

3. Provide current information and advice about patient care, new treatment modalities, and
the pathophysiology of illness.

4. Prepare a periodic report for administration summarizing his/her actions, concerns and
recommendations as medical director.

5. Represent the facility in discussions and meetings with other institutions or agencies on
issues relevant to medical care.

6. Help the facility develop an ongoing program to evaluate and manage the health of the
facility's employees, by 1) establishing policy and procedures, and 2) direct physical
examination of employees, emphasizing freedom from significant infection, pre-
employment physical examinations and reexaminations, and compliance with local and
state health regulations.

7. Help manage review and respond to federal, state or local surveys and inspections.

This document is a recommended job description for a medical director. It can be used as a guideline for
administrator and physician, provided the terms and provisions of the document are modified to apply to
the specific scope and resources of each individual situation.