FAQs: Providing Community-based Palliative Care

The Provision of Non-Hospice Community-based Palliative Care

As hospices and other providers work to meet the needs of seriously ill individuals and carve out a niche in the post-acute care space, they are faced with a unique set of challenges. Hopefully this will be helpful and I look forward to receiving your questions and answering them here.

Q:    Do state laws prohibit hospices from providing non-hospice palliative care?

A:    In most states licensure regulations utilize the federal standards for non-hospice services provided by the hospice organization.  Hospices should ensure that non-hospice services do not “over shadow” the hospice services.  Specifically: “This requirement does not preclude provision of non-hospice services to terminally ill individuals who are not hospice patients or services to individuals, who are not terminally ill, so long as the primary activity of the hospice is the provision of hospice services to terminally ill individuals.”

Q:    Do hospices providing non-hospice palliative care need to follow the hospice Conditions of Participation (CoPs)?

A:    No, the hospice CoPs states “Hospice means a public agency or private organization or subdivision of either of these that is primarily engaged in providing hospice care… .” Legal analysts have concluded that there is support under federal law for hospices to provide non-hospice palliative care and that they are not required to follow hospice CoPs.

Q:    Do we need a separately incorporated entity for our non-hospice palliative care program?

A:    Many experts believe a separate entity is a good idea, depending upon your current organizational structure.  Regardless of whether or not you incorporate, it is vitally important to maintain separate and distinct records for each service line (e.g. financial, clinical, and policies and procedures). In addition, be sure that marketing and clinical education materials list a separate phone number.  These precautions help you avoid potential fraud and abuse concerns related to federal anti-kickback regulations.  

Q:    Can we use hospice staff in our palliative care program?

A:    As stated above, co-mingling staff could create confusion for surveyors, so experts recommend segregating systems and processes as much as possible.  Keeping that in mind, there are pros and cons to using hospice staff in a palliative care program:  

Pros:

• Increases the ability to flex staffing from hospice to palliative care as you launch and grow a palliative care program, thus affording patients with the benefits of interdisciplinary palliative care

  • E.g.  A new palliative care program hires an advanced practice nurse as the only new full-time employee and allocates .25 of a hospice RN and .5 of a social worker

• Enhances a “core” palliative care team with additional staffing based on individual patient needs

  • E.g.  A palliative care team might engage a hospice chaplain when palliative care patients express a spiritual goal or concern or a hospice aide for short-term assistance with an ADL that could prevent a hospitalization

• Improves continuity of care if / when patients transition to hospice

  • E.g.  A palliative care patient transitioning to hospice would have a rapport with the chaplain who visited them

Cons:

• Offers the potential for surveyors to see “blurred lines” between hospice and non-hospice services

• Transitions between hospice and palliative care patients because of the different approach, policies and procedures, and documentation requirements could be difficult for staff

• Skills-building training is needed to teach hospice clinical staff how to care for palliative care patients pursuing curative treatments

Q:  What is California's SB 1004?  

A:  This legislation requires Medi-Cal managed care plans to provide palliative care services to eligible recipients and affords fee-for-service Medi-Cal beneficiaries to receive palliative care too. The Department of Health Care Services developed a comprehensive policy paper outlining the eligibility criteria and other information to guide the Medi-Cal Managed Care Plans as they prepare to implement this new benefit for the state's Medicaid recipients.  In addition to the policy paper, DHCS published their Beneficiary Utilization Analysis, which provides interesting background information. 

• Eligibility

  • Cancer, congestive heart failure, chronic obstructive pulmonary disease, or liver - the policy paper outlines both disease specific and general eligibility criteria

• Services

  • ​DHCS outlines 8 core services and 1 recommended service:

    • ​Advance care planning

    • Palliative care assessment and consultation

    • Plan of care

    • Pain and symptom management

    • Mental health and medical social services

    • Care coordination

    • Palliative care team

    • Chaplain services

    • 24/7 telephonic palliative care support (recommended)

•  Care settings

  • ​Home

  • Outpatient

  • Inpatient

• ​Care providers

  • Hospices

  • Hospitals

  • Long-term care facilities

  • Clinics

  • Home health agencies 

  • Other community-based providers

Read more about SB 1004 at the DHCS website.

What questions do you have regarding palliative care? Let me know in the space below, tweet, or email me and I’ll add them to the FAQs!