Hospice-Veteran Partnership Toolkit : About the Hospice-Veteran Partnership Program : 8. Working Together to Build Solutions

As a system, the Department of Veterans Affairs (VA) Veterans Health Administration (VHA) needs to consistently and reliably use community hospice resources to help meet the hospice and palliative care needs of veterans. This document provides guidance to VA staff and community hospice agency staff on how they can work together to honor veterans' preferences for care through the end of life.

A. Summary of Veteran Eligibility and VA Policies Relating to Hospice Care

1. Hospice and palliative care is a covered benefit for all enrolled veterans (§17.38 Medical Benefits Package). VA must offer to provide or purchase hospice care that VA determines that an enrolled veteran needs. (38 Code of Federal Regulations (CFR) 17.36 and 17.38) A veteran in need of hospice services has a right to choose whether such services are to be provided through the VA or Medicare.
2. If a veteran in need of hospice services is not eligible for hospice care through Medicare, Medicaid or private insurance, or chooses to have hospice services provided through VA, then VA is responsible for providing or purchasing the needed services.
3. VA Medical Centers have authorization to purchase needed hospice and palliative care services, with all purchases going through the fee file system. (Contract Home Care and Hospice Directive, 2003)

B. VHA Definitions of Hospice and Palliative Care

1. The VHA defines hospice and palliative care as all care in which the primary goal of treatment is comfort rather than cure in a person with advanced disease that is life-limiting and refractory to disease-modifying treatment; this includes bereavement care to the veteran's family.
2. The term hospice, as differentiated from palliative care, is used within the VHA to denote care in the terminal phase of illness. This distinction is important, because veterans are exempt from the extended care co-payment when hospice care is being provided in a VA Nursing Home Care Unit (NHCU) or in a contracted Community Nursing Home (CNH). The VHA defines hospice care as all care provided to veterans who meet four criteria:
• Diagnosed with a life-limiting illness
• Treatment goals focus on comfort rather than cure
• Life expectancy is determined by a VA physician to be six months or less if the disease runs its normal course, consistent with the prognosis component of the Medicare hospice criteria
• Accepts hospice care
NOTE: Recognizing that prognosis cannot be predicted with certainty, physicians are advised to use the National Hospice and Palliative Care Organization's "Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases, Second Edition" (http://aspe.hhs.gov/daltcp/reports/impquesa.htm#appendixC). While these prognostic guidelines are useful in determining eligibility for the Medicare hospice benefit, they are to be used as a guide, not a rigid requirement. Some patients appropriate for hospice will survive longer than six months. Periodic reevaluation of patients, their prognoses, and their expected benefit from hospice care needs to be documented in the care plan.

C. VA Process for Making Referrals to Community Hospice Agencies

1. VA primary care and specialty care providers, members of the interdisciplinary team (physicians, nurses, physician assistants, social workers, chaplains), or the patient and family may identify the need for hospice services. In addition, the VA treatment team (inpatient, outpatient, Home Based Primary Care, or Adult Day Care), community hospital treatment teams, or contract nursing home teams may also identify the need for hospice services. A VA physician must make the determination of need for hospice, and make the referral contact or sign the referral form to the hospice agency.
2. If community hospice referral is appropriate, the following information should be provided to the community hospice agency:
• Name and contact number of the person making the referral
• Demographic and insurance information and payment source
• Name and telephone numbers of the legal decision maker
• Brief medical summary (history and physical exam, recent progress notes, list of medications and treatments, scan/X-ray and lab reports related to the advanced illness)
• Name, telephone number, and fax number of the physician who will follow the patient
• Any information and documentation about discussions relating to advance directives or the resuscitation status of the patient
3. The Community Health Nurse Coordinator or designee will identify community hospice agencies in the patient's geographical area, assist the veteran and family in choosing the hospice, and contact the hospice to initiate the referral.

D. Community Hospice Agency Process for Making Referrals to the VA

1. Community hospices are advised to make a practice of asking all potential patients if they are veterans. If a veteran is already enrolled in and receiving care through the VA, the community hospice agency is encouraged to call the veteran's preferred VA Medical Center and ask for the Community Health Nurse Coordinator or designee, or speak with the veteran's primary care provider or social worker. Some VA facilities may have a VA Home-Based Primary Care (HBPC) or a Palliative Care team coordinator. To find the local VA Medical Center, visit www.va.gov. Click on Health Benefits & Services and then select Locate a VA Medical Center.
2. If a veteran is not enrolled in or receiving care through the VA-and is not eligible for hospice care under Medicare, Medicaid or private insurance-then the hospice is advised to contact the closest VA Medical Center to initiate the enrollment process. It may be helpful to ask for a social worker, the Community Health Nurse Coordinator or designee, or VA Palliative Care team coordinator to assist in the enrollment process.

E. VA Guidelines for Purchasing Hospice Care

1. If a veteran in need of hospice services is not eligible for any of the coverage options described below, then the VA is responsible for purchasing or providing the needed services.
• Medicare Hospice Benefit: Veterans can access the Medicare hospice benefit if they have Medicare Part A and meet the following criteria:
  • Certified by their physician and the hospice medical director as terminally ill with a life expectancy of six months or less if the disease runs its normal course
  • Sign a statement choosing hospice care using the Medicare hospice benefit, rather than curative treatment and standard Medicare-covered benefits for their terminal illness
  • Willing to enroll in a Medicare-approved hospice program
• Private insurance: Veterans with private insurance may have a hospice benefit. VA staff and the community hospice can work together to inquire about benefit coverage.
• Medicaid: Veterans with Medicaid may be able to access a Medicaid hospice benefit, depending upon state-specific criteria and availability. VA staff may need to assist the veteran in applying for Medicaid.

F. VA Process for Purchasing Community Hospice Agency Services

1. The VA may purchase hospice services through VA funding in the following ways, with all purchases entered through the Fee File system:
• Contract for services
• Basic Ordering Agreement
• Bid
2. Hospice is to be purchased as a comprehensive package of bundled services, and paid at a per diem rate. VA will pay the Medicare per diem rate for that locale.

G. Medicare Hospice Coverage

1. The Medicare hospice benefit covers four levels of care:
• Routine home care
• General inpatient care
• Respite care
• Continuous care
2. Medicare Hospice Benefit services include all care needed for comfort and palliation of symptoms related to the terminal diagnosis, including, but not limited to:
• Physician services
• Nursing care
• Social work services
• Chaplain services
• Home health aide and homemaker services
• Medications for symptom control and pain relief related to the hospice diagnosis, including infusion pumps or intravenous therapy, if necessary
• Medical equipment (such as hospital bed, wheelchair, oxygen, and oxygen equipment)
• Medical supplies (varies by agency).
• Short-term inpatient care, including respite care
• Continuous care at home during periods of crises
• Physical and occupational therapy
• Speech therapy
• Volunteer services
• Dietary counseling
• Counseling to help the veteran and family with grief and loss
• Radiation or chemotherapy if necessary for the control of a symptom related to the terminal diagnosis.
• Transportation to and from facilities for necessary treatments
3. The Medicare Hospice Benefit does not cover:
• Care unrelated to the terminal diagnosis
• Long-term custodial care
• Services not included in the hospice plan of care
4. Reference: Medicare Hospice Manual, Publication 21, Chapter II (230).
5. The fee-for-service approach may be used to purchase additional community services needed to supplement care provided by the Medicare hospice agency. For example, VA Medical Centers may purchase additional needed home health aide care that is beyond the scope of Medicare coverage.
6. VA staff are to follow these steps relating to authorization for purchase of bundled services:
• The request for hospice services should be initiated through the primary care or specialty care provider and the veteran's health care team based on a clinical assessment.
• Each facility must designate an official to approve and authorize hospice services.
• Authorization should included what care will be provided and for what frequency and duration and method of reimbursement.
• Completed authorizations should be forwarded to the fee file unit for final processing and payment.
• If care is required beyond the current authorization period, follow these same steps for reauthorization.
7. Invoices must include:
• Full name and address of the community hospice
• Veteran's name, social security number, and diagnosis code
• The number of days or services billed
• The level-of-care category, per diem rate or fee for service

H. Hospice Coverage in a Community Nursing Home (CNH)

1. If a veteran is eligible for Medicare nursing home care, then needed hospice services will likely be available through Medicare as well. A patient may have long-term coverage of nursing home care by Medicaid.
2. If a veteran is residing in a nursing home, needs hospice care, but is not eligible for Medicare hospice services, then VA is to assure that the veteran is able to get those needed hospice services. VA may pay for hospice services as long as they do not overlap with services covered by the Medicaid nursing home provision.
3. Veterans are free to elect their Medicare benefit. VA is obliged to ensure that there is no double-billing for medications related to the terminal diagnosis. VA does not recognize any substitution by hospice staff for NH staff and therefore does not reduce its per diem rate, other than for meds, as above.
4. For CNH patients with no Medicare coverage, but needing and requesting hospice care, VA will add a flat, consultation amount, presently $60 per diem for hospice care. The CNH makes the arrangements.