As your health deteriorates with age, you may lose interest in feeling ‘better’ and instead want to feel comfortable. Hospice is a medical intervention that provides care but not cures, and can be offered at a nursing home.
Some people who pursue hospice care through nursing homes do so after a period of skilled nursing care, whereas others move to a nursing home in direct pursuit of hospice. However you time your transition, initiating hospice is a big decision.. To make sure you or your loved one is ready to make the change, consider the differences between how nursing homes provide hospice treatment and skilled nursing care, and how you’ll fund the transition.
[READ What Is Palliative Care, and Can You Get It at Home?]
Hospice at a Nursing Home
If you or your loved is considering hospice care at a nursing home, they’re likely experiencing — or witnessing — a decline in health and seeking medical care that provides comfort but not a cure.
Hospice care remains an active form of medical treatment, involving ongoing clinical assessment, medication management and interdisciplinary support aimed at preventing distress and maintaining comfort. Hospice care can be beneficial for patients who are terminally ill. For these people, hospice can actively manage pain and suffering, offer a sense of control over their body and prevent undesired hospitalizations. However, not everyone in a nursing home is qualified to pursue hospice care, or will be approved to have hospice care funded by insurance. For personal and financial reasons, it is important to have thorough, educated conversations about the patient’s health status before starting hospice.
To receive hospice coverage, it must be actively elected by the patient or their legal representative and hospice cannot be forced against someone’s will. Lori Schoener, nursing home administrator at Landis Homes Retirement Community in Lititz, Pennsylvania, says that before a resident transitions to hospice, the staff facilitates thoughtful conversations with nurses, doctors and family members. Schoener previously worked as the administrator of skilled nursing at Brethren Village, a neighboring retirement community and nursing home in Lancaster, Pennsylvania, where she says the protocol was almost identical.
“If a resident does not have decision-making capacity, does not understand their health condition or has brain changes such as various dementias, we would be talking with their family or their power of attorney,” Schoener says.
She adds that conversations tend to be productive and, for those who elect hospice, making the transition can be a “pretty smooth process” too.
[READ: How Do You Comfort a Dying Parent?]
Does Medicare Cover Hospice at Nursing Homes?
Medicare will cover most hospice services at a nursing home through its Medicare hospice benefit. Before a nursing home resident can qualify for this benefit, a doctor must certify that the resident has six months or less to live. This doesn’t mean death is inevitable within six months, however, and many people may continue receiving hospice for longer than six months.
[READ: How to Prepare for End of Life: Medical Care and Planning]
What hospice services does Medicare cover?
According to Medicare.gov, some examples of hospice supports that Medicare may fund at nursing homes include:
— Aide and homemaker services
— Dietary counseling
— Doctors’ services
— Medication for pain and symptom management
— Medical equipment for pain relief and symptom management
— Occasional inpatient respite care for up to five days, arranged by your hospice provider
— Medical supplies, like bandages or catheters
— Nursing and medical services.
— Occupational therapy services
— Physical therapy services
— Short-term inpatient care for pain and symptom management
— Social services
— Speech-language pathology services
— Spiritual and grief counseling
— Physical supports like specialty chairs and mattresses are also commonly provided for hospice patients as part of a location’s daily rate, Schoener says.
Physical supports like specialty chairs and mattresses are also commonly provided for hospice patients, Schoener says. This can be especially helpful for patients who were previously paying out of pocket and unable to fund such things, she adds.
What hospice services does Medicare not cover?
Medicare’s hospice benefit does not cover treatments intended to cure a resident’s underlying condition or prolong life. While Medicare pays for hospice-related medical care delivered in a nursing home, it generally does not cover the cost of room and board for residing in the facility. In limited, short-term circumstances, such as inpatient hospice care for symptom management or respite, room-and-board costs may be temporarily covered. Outside of these situations, families are typically responsible for nursing home housing costs while hospice services are provided.
Some hospice services that Medicare does not cover include:
— Treatment or medications to cure the terminal illness
— Care from a separate hospice provider, other than the specific provider you chose
— Room and board, with some exceptions for short-term stays
— Outpatient hospital care, like ER visits
— Inpatient hospital care
— Ambulance transportation, unless arranged by your hospice team or unrelated to your terminal illness
[SEE: Advance Directives: Your Complete Guide to Living Wills & Health Care Power of Attorney]
[READ: How to Pay for Nursing Home Costs.]
How to Pay for a Nursing Home Stay on Hospice
Figuring out how to fund hospice care at a nursing home can be challenging for some patients. The good news is that there are other ways to pay for hospice care at a nursing home.
Some payment options include:
— Your state’s Medicaid program
— Private insurance
If you are transitioning to hospice care from custodial care, you may already be financially equipped to make the change, or even discover a financial incentive.
Does Medicaid Fund Hospice at a Nursing Home?
Nursing home residents on Medicaid may be able to fund hospice through Medicaid if they specifically elect to do so by filling out a statement with their hospice. Medicaid coverage for hospice can vary state by state.
[READ: Taking Over Affairs for an Aging Parent in Mental Decline.]
Who Pays for Hospice Patients to Stay at a Nursing Home?
Medicare will pay for hospice services delivered in a nursing home, but Medicare typically does not cover room and board costs, which may instead be funded through Medicaid, veterans’ benefits, hospice subsidies in limited circumstances,or private payment.
This is different from how Medicare handles skilled nursing care. If receiving skilled nursing, the insurance will pay for you to stay in a nursing home for up to 100 days, after a three-day inpatient stay at a hospital.
People who are receiving hospice typically aren’t receiving skilled nursing care, or are not receiving it under the same criteria for billing. Medicare typically won’t pay for nursing home boarding for hospice patients, and it typically won’t cover custodial care at a nursing home, if this is the only care a person needs, either.
Due to the loss of bed and board coverage, patients who are staying at a nursing home for skilled nursing support may feel financially unable to pursue hospice care, even if they are physically and emotionally ready for the switch, for financial reasons, says Dr. Brian Madden, a primary care physician and medical director of palliative care at Providence Saint John’s Health Center in Santa Monica, California.
He adds that facilities can be hesitant to fill hospice beds or invest in quality hospice programs for patients, too. That’s because nursing homes can receive higher Medicare reimbursements for skilled nursing patients than they do for hospice and custodial patients, Madden says. So, while many nurses and doctors try their best to meet patients’ needs, money can influence how many hospice beds a nursing home facility will fill at a time.
“There is a financial loss to the facility going from skilled to custodial,” Madden says. “They get paid more for skilled, so there can be more resistance to converting them.”
There are some loopholes in the rules, however. For instance, Madden says that depending on a resident’s health status when they transition from skilled nursing to hospice, the hospice program may help subsidize the cost of room and board at your nursing home. This can be relevant if the resident qualifies for an inpatient level of care, and needs supports such as a intermittent treatments or a bedside nurse to provide them with medication, he adds.
Who Pays for Hospice in a Nursing Home? Cost Breakdown
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Difference Between Hospice, Skilled Nursing and Custodial Care
Receiving hospice care at a nursing home is different than receiving skilled nursing or custodial care at a nursing home.
What is skilled nursing care at a nursing home?
At a nursing home, skilled nursing services may include treatments for chronic illnesses and services like rehab and post-surgical recovery treatments after a hospital stay.
What is custodial care at a nursing home?
At a nursing home, custodial care services may include non-medical services like changing soiled sheets and providing meals. While these are typically available for residents who receive skilled nursing services, in some places, residents live in nursing homes solely for custodial services. Residents who live in a nursing home for hospice care should also receive custodial services.
Skilled nursing treatments vs. hospice treatments
Skilled nursing treatments are medical care and therapies focused on getting a patient better, whereas hospice centers focus on comfort-focused medical treatments with the goal of achieving or allowing for a peaceful end-of-life experience.
While skilled nursing treatments are typically provided by nurses and doctors on staff, hospice treatments will likely be offered by a separate hospice team — which may be outsourced or have a contract with the nursing home.
Schoener says both Landis Homes and Brethren Village have contracts with a few hospices in the area — which residents can choose from when they are ready for hospice. If a resident prefers a different hospice provider, she adds that the facilities can generally make arrangements for this, too.
Madden explains that the goal of skilled nursing is often to “restore” a patient’s health, whereas hospice care aims to reduce pain and increase comfort through tools like oxygen, pain medications and special chairs.
Hospice treatments don’t just differ from skilled nursing treatments in design, but in their payment methods. Because hospice care offers comfort, whereas skilled nursing fights for a cure, insurance companies — including Medicare and Medicaid — fund the programs differently. In some cases, hospice patients may not receive funding for support that skilled nursing patients receive, or vice versa.
[READ Understanding the Different Eldercare Options]
When to Transition to Hospice Care in a Nursing Home
It’s important to understand your financial situation and future payment options if you are helping a loved one transition into hospice. It’s also important to ensure that they are physically and emotionally ready to pursue this kind of care first.
Schoener encourages people to have educated, group conversations before starting hospice. She adds that your loved one may or may not be active in these conversations, depending on their cognitive state. At Landis Homes and BV, if the resident still has “decision-making capacity,” they will be involved in conversations about hospice and group meetings with their family and medical provider, Schoener says.
According to Shoener, some signs of decline that could warrant a family-doctor conversation include:
— Loss of appetite accompanied by significant weight loss
— Residents becoming more easily fatigued
— Loss of ability swallow easily — in particular for residents with Alzheimer’s or other forms of dementia
— For residents with chronic conditions, an increase in symptoms that are becoming more difficult to treat
In addition to signs of health decline, some signs that hospice care at a nursing home may be appropriate include that your loved one is experiencing or has received:
— A terminal illness diagnosis
— Certification by a medical doctor as having six months or less to live
— Preference of comfort over medical treatments trying to improve health
— Comfort with or readiness to accept the possibility of dying
— Discussions regarding declining health and the possibility of hospice care at the nursing home
After much thought and conversation, you and your loved one can make a confident decision about if you want to pursue hospice. From there, you’ll choose a hospice provider to work with.
“There are a lot of benefits to hospice service and the support that they can provide,” Schoener says. While it can be difficult to watch a loved one enter hospice care, “It also brings peace to families when everybody understands that this is the point we’re at.”
[READ: How to Pay for a Nursing Home With No Money.]
What to Do If You Can’t Receive Hospice at a Nursing Home
Some nursing homes have limited space for hospice patients and may have fewer hospice beds than they do beds for skilled nursing patients. If you can’t receive hospice care at a nursing home — for financial reasons, spatial reasons or other — there are other ways you can get care. If you have a home to return to or loved ones to host you, you could receive hospice care at home. You could also consider a board and care home, a lower-level residential facility for older adults that can be more economically friendly.
Ultimately, Madden says that the decision to receive hospice care in or out of a nursing home should come down to what’s reasonable and comfortable for you.
“You can’t let perfect become the enemy of what’s feasible,” Madden says.
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Who Pays for Hospice Care in a Nursing Home? originally appeared on usnews.com
