NAHC Conveys Hospice Concerns to National Nursing Home Commission

WASHINGTON, D.C. (July 21, 2020)—The National Association for Home Care & Hospice (NAHC) is urging the independent National Commission on Safety and Quality in Nursing Homes to ensure that residents of nursing homes have access to hospice care, whether in the form of safe, in-person visits or by telehealth communication.

In response to the ongoing and widespread impact of the COVID-19 public health emergency on nursing home residents throughout the country, the Centers for Medicare & Medicaid Services (CMS) authorized creation of an independent commission that began its work in June. The commission has been meeting regularly over the last several weeks and is expected to conclude work by Sept. 1, 2020, on the following tasks: 

• Identify best practices for facilities to enable rapid and effective identification and mitigation of transmission of COVID-19 and other infectious diseases in nursing homes.
• Recommend best practices as exemplars of rigorous infection control practices and facility resiliency that can serve as a framework for enhanced oversight and quality monitoring activities.
• Endeavor to identify best practices for improved care delivery and responsiveness to the needs of all nursing home residents in preparation for, during and following an emergency.
• Leverage new sources of data to improve existing infection control policies and enable coordination across federal surveyors, contractors and state and local entities to mitigate coronavirus infection and future emergencies.

“NAHC is deeply sensitive to the challenges that have been faced by nursing facilities and other congregate living sites as they work to stem the spread of COVID-19 among what is a very vulnerable population,” says NAHC President William A. Dombi. “At the same time, it is incumbent upon all of us to ensure that patients’ care preferences are honored, and that all of their care needs are met. This is particularly important for individuals who are approaching the end of life, and their loved ones. We bring these issues to the commission in hopes that the deliberative process will result in development of best practices that support collaborative efforts by nursing facilities and hospice agencies to ensure patient-centered care going forward.”

Throughout the pandemic hospice organizations have continued to experience significant challenges accessing patients who are residents of nursing facilities and other congregate living sites. Recently the commission solicited public comment, and the NAHC took advantage of that opportunity to submit a statement summarizing the difficulties hospices have faced and urging the commission to address these concerns as part of its work. The concerns expressed fall into six areas:

Access to hospice services: Hospices have experienced severe limitations in accessing patients, which in turn have limited patients’ access to care. Following are some of the nursing home practices that NAHC’s statement highlighted:

• Imposition of no in-person hospice visits rule
• Refusal to admit hospice staff, even for death visit
• Refused hospice medical director/hospice physician access
• No in-person hospice visits unless the resident is actively dying
• Restriction of hospice visits to RN only or RN and aide only
• Restriction of hospice visits to RN only and only once every 14 days
• Access granted to certain hospice disciplines only if these individuals are assigned exclusively to the facility and do not serve patients in other facilities
• Hospice staff not permitted to connect with patient, only permitted to speak to the facility nurse
• Chaplain/social work visits prohibited even when patient/family requests 
• No visits; drop supplies outside facility
• Requiring that patients who test positive for COVID-19 be discharged from hospice in order to elevate the facility services to the nursing home skilled level of care

Technology-based visits: The comments identified challenges that include nursing facilities’ refusal to help facilitate the use of telecommunications technology for the provision of hospice, citing insufficient resources or time to support such visits. Findings from NAHC’s hospice COVID-19 survey also underscore that despite situations where they are able to use technologies to provide visits, only 4% of hospices have been able to supply all needed visits in facilities using telecommunications technology. It must be concluded that many hospice patients in facilities are not receiving the full hospice benefit due to limitations on access to patients.

Coordination of care: NAHC’s statement conveyed reports from hospice providers of widespread inability to secure information about patient status, the inability to contact the facility’s liaison to the hospice, and failure of the liaison to return calls regarding patient status. Facilities have also reduced access to a single hospice (despite having contracts with multiple hospices and patients on service with them), which impacts the continuity of care for existing patients.

Reduced referrals/Discouraged hospice elections: Also included in the statement were concerns expressed by hospice providers over reduced referrals by nursing facilities and reports of facilities discouraging election of hospice care.

“Skilling” patients/Forced discharge from hospice: The submission also included concerns around widespread shifting of patients who test positive for COVID-19 to the Medicare skilled nursing benefit and forcing discharge from hospice care.

Testing: Despite clarification from CMS that testing of hospice staff that enter facilities is the responsibility of the nursing facility, it is frequently the case that facilities will not supply testing and/or indicate that it is the hospice agency’s responsibility to secure testing.