Hospice Support: Peace, Comfort


Continuing education online courses in Hospice Support: Peace, Comfort

N20.  Hospice Support: Peace, Comfort, 3 CE-hours, $21

Course Description:

N20.  Hospice Support: Peace, Comfort, 3 CE course hours

Objectives: Hospice care focuses on controlling pain and other symptoms of illness so patients can remain as comfortable as possible near the end of life.

Course Format: Online linked resources and lectures that you can use anytime 24/7. One multi-choice test.

Course Developers and Instructors: R. Klimes, PhD, MPH (John Hopkins U), author of articles on overall End of Life Care topics including Hospice Support – Physical and Spiritual perspectives.

Course Time: About 3 hours for online study, test taking with course evaluation feedback and certificate printing.


Professor Rudolf Klimes, PhD, welcomes you to this online course. Keep going.

START the course here. TAKE the exam at the end. PAY after the exam.


Hospice Support

What Is Hospice?

Hospice is a special type of care in which medical, psychological, and spiritual support are provided to patients and their loved ones when cancer therapies are no longer controlling the disease. Hospice care focuses on controlling pain and other symptoms of illness so patients can remain as comfortable as possible near the end of life. Hospice focuses on caring, not curing. The goal is to neither hasten nor postpone death. If the patient’s condition improves or the cancer goes into remission, hospice care can be discontinued and active treatment may resume. Choosing hospice care doesn’t mean giving up. It just means that the goal of treatment has changed.The hospice team usually includes doctors, nurses, home health aides, social workers, clergy or other counselors, and trained volunteers. The team may also include speech, physical, and occupational therapists, if needed. A hospice team member is on-call 24 hours a day, 7 days a week to provide support. The hospice team will work with the patient on the patient’s goals for end-of-life care, not a predetermined plan or scenario. Hospice care is very individualized.Hospice services may include doctor or nursing care, medical supplies and equipment, home health aide services, short-term respite (relief) services for caregivers, drugs to help manage cancer-related symptoms, spiritual support and counseling, and social work services. Patients’ families are also an important focus of hospice care, and services are designed to give them assistance and support.Hospice care most often takes place at home. However, hospice care can also be delivered in special in-patient facilities, hospitals, and nursing homes.


Who is eligible for hospice care?

 Under most insurance plans in the United States, including Medicare, acceptance into hospice care requires a statement by a doctor and the hospice medical director that the patient has a life expectancy of 6 months or less if the disease runs its normal course. The patient also signs a statement saying that he or she is choosing hospice care. (Hospice care can be continued if the patient lives longer than 6 months, as long as the hospice medical director or other hospice doctor recertifies the patient’s condition.)The hospice team or insurance provider can answer questions about whether specific care decisions, such as getting a second opinion or participating in a clinical trial while in hospice care, would affect eligibility for hospice services.


How can people get help paying for hospice services?

Medicare and most Medicaid and private insurance plans cover hospice services.Medicare is a government health insurance program for the elderly and disabled that is administered by the Centers for Medicare & Medicaid Services (CMS). The Medicare hotline can answer general questions about Medicare benefits and refer people to their regional home health intermediary for information about Medicare-certified hospice programs. The hotline number is 1–800–MEDICARE (1–800–633–4227); callers with TTY equipment can call 1–877–486–2048. The booklet Medicare Hospice Benefits is available on the Medicare website. The Hospice and Respite Care page, also on the Medicare website, has answers to frequently asked questions about Medicare coverage for hospice and respite care.Medicaid, a federal-state partnership program that is part of CMS and is administered by each state, is designed for people who need financial assistance for medical expenses. Information about coverage is available from local state welfare offices, state public health departments, state social services agencies, or the state Medicaid office. Information about specific state locations can also be found online.Information about the types of costs covered by a particular private policy is available from a hospital business office or hospice social worker, or directly from the insurance company.Local civic, charitable, or religious organizations may also be able to help patients and their families with hospice expenses.


What is the difference between hospice and palliative care?

Although hospice and palliative care share the same principles of providing comfort and support for patients, palliative care is available throughout a patient’s experience with cancer, whereas hospice is offered only toward the end of life. A person’s cancer treatment continues to be administered and assessed while he or she is receiving palliative care, but with hospice care the focus has shifted to just relieving symptoms and providing support. The NCI fact sheet Palliative Care in Cancer has more information about palliative care.




Options for Care of Terminally Ill Patients

Questions and Answers About Palliative Care, Hospice, and the Palliative Care Information Act

Question: The law is intended to ensure that terminally ill patients are fully informed about their options for care. What types of options should be considered, and how should I frame them?

Answer: Therapeutic options include treatments for the serious illness and comorbidities—so-called disease-modifying therapies—and treatments and services that may be considered under the broad approach known as palliative care. Disease-modifying therapies may be undertaken to prolong life, reduce the complications of the disease, or aid in symptom control. Palliative care is a model of care that aims to reduce illness burden and suffering, support coping and adaptation, and maintain quality of life.  Some key considerations are:

  • Deciding among options should be guided by prognosis, the availability and medical appropriateness of disease-modifying therapy, and the patient’s goals for care. For some patients, these decisions may also be guided by religious or cultural considerations concerning end-of-life care. Although studies have shown that prognostication is difficult, many patients value the knowledge that “time may be limited” or “people with this disease often have months, but not years.”  To communicate about the medical appropriateness of specific therapies, physicians must have information about treatment availability, the evidence in support of effectiveness, and the risks or burdens that should be anticipated.
  • The specific treatments or services that constitute palliative care may be provided alone or in conjunction with disease-modifying therapies.  Specialist palliative care may be available for selected patients through consultation with a palliative care service, or if appropriate, referral to a hospice agency.  For those illnesses with advanced disease-modifying therapies, such as cancer, congestive heart failure and chronic obstructive pulmonary disease, there often is a prolonged period during which the best therapeutic approach is one that simultaneously offers aggressive treatment for the disease and aggressive palliative care.
  • The “palliative plan of care” should be sensitive to cultural and religious considerations and may target:
    • Pain and other symptoms
    • Psychiatric disorders or psychological concerns
    • Family disruption or distress, caregiver burden, or social isolation
    • Spiritual distress
    • Problems in coordinating care among many professionals or sites
    • Poor communication leading to uncertainty about the goals of care or to a lack of advance care planning (e.g., no living will, no Medical Orders for Life Sustaining Treatment (MOLST), no health care proxy)
    • Need for practical help at home.
  • Patients (or if the patient lacks medical decision-making capacity, his or her authorized health care decision-makers) must consent to treatment.  Informed consent requires that the patient or his or her decision-maker be given appropriate, accurate information about the risks and burdens and likely benefits of each treatment option.  Consent to treatment, whether disease-modifying or palliative, should be informed by weighing risks and burdens against benefits.
  • A discussion of options when patients are very ill should help the patient or his or her health care decision-maker understand that individuals vary in how they judge the balance between risks/burdens and potential benefits. Some patients prioritize comfort and support, and unless the benefits of treatment are very likely or very substantial, do not want down-sides like side effects or time away from home to compromise quality-of-life. Other patients choose substantial risk or burdens for even a small chance of benefit. The preferences and values of patients are critical in establishing treatment goals, and patients should be encouraged to communicate them to their physicians and other health professionals.

Discussions about options, therefore, must be individualized and guided by the availability and appropriateness of disease-modifying therapy; the need for palliative treatments and services; and an understanding of the patient’s values, preferences and goals.  It should be framed by a broad understanding of prognosis, gently shared with the patient and/or decision-maker as appropriate, and as accurate an analysis of risk/burden versus benefit as is possible, given the complexities of the situation. Discussion about options often requires multiple conversations.





The Hospice Association of America (HAA) has received notification of comprehensive new guidelines from the Health Care Financing Administration (HCFA) on providing hospice care in skilled nursing facilities (SNFs). The guidelines, reprinted here in their entirety, were sent from the Director of the Office of Survey and Certification at HCFA’s central office to all of their regional bureaus. They have been made available to HAA for distribution among HAA members. HAA applauds HCFA’s efforts in directly addressing the issues surrounding hospice care in SNFs and is grateful for the opportunity to assist in distributing the following information to ensure the quality of hospice care.

Plan of Care
“When a resident of a Medicare participating skilled nursing facility (SNF) or nursing facility (NF) elects the Medicare hospice benefit, the hospice and the SNF/NF must coordinate, establish, and agree upon one plan of care for both providers which reflects the hospice philosophy and is based on an assessment of the individual’s needs and unique living situation in the SNF/NF. The plan of care must be written in accordance with 42 CFR 418.58, and include the individual’s current medical, physical, psychosocial and spiritual needs. The hospice must designate a registered nurse from the hospice to coordinate the implementation of the plan of care (42 CFR 418.68(d)).

This coordinated single plan of care must identify the care and services which the SNF/NF and hospice will provide in order to be responsive to the unique needs of the patient/resident and his/her expressed desire for hospice care. The plan of care must include directives for managing pain and other uncomfortable symptoms and be revised and updated as necessary to reflect the individual’s current status.

The SNF/NF and the hospice are equally responsible for the content of the single plan of care and for ensuring that it is implemented according to accepted professional standards of practice.

In addition, all covered hospice services must be available as necessary to meet the needs of the patient. Substantially all core services must be routinely provided directly by hospice employees and cannot be delegated to the SNF/NF (42 CFR 418.80). Drugs and supplies must be provided as needed for the palliation and management of the terminal illness and related conditions. Drugs must be furnished in accordance with accepted professional standards of practice (42 CFR 418.96).

The plan of care should reflect the participation of the hospice, SNF/NF, and the patient to the extent possible. The hospice and the SNF/NF must communicate with each other when any changes are made to the plan of care and each provider must be aware of the other’s responsibilities in implementing the plan of care.

The surveyor should expect to see evidence of this coordination and single plan of care in the clinical records of both providers. All aspects of the plan of care should reflect the hospice philosophy.

Professional Management:

As with any patient, when the hospice accepts a nursing facility resident as a hospice patient, the hospice must assume full responsibility for the professional management of the hospice patient’s care related to the terminal illness; ensure that all hospice services are provided in accordance with the plan of care at all times in all settings; make any arrangement necessary for inpatient care in a participating Medicare or Medicaid facility.

SNF/NF Requirements:

Even though the SNF/NF is the hospice patient’s residence for purposes of the hospice benefit, the SNF/NF must still comply with all requirements for participation in Medicare or Medicaid. This means that the resident must be assessed using the information contained in the Resident Assessment Instrument (which includes both the Minimum Data Set and the Resident Assessment Protocols), have a plan of care, which in this case will be jointly developed with and agreed upon by the hospice, and be provided with all services contained in the plan of care. The plan of care must be consistent with the hospice philosophy of care.

SNF/NF Services:

The SNF/NF services must be consistent with the plan of care developed in coordination with the hospice. The hospice patient residing in a SNF/NF should not experience any lack of SNF/NF service or personal care because of his/her status as a hospice patient. The plan of care must include directives for managing pain and other uncomfortable symptoms and be revised and updated as necessary to reflect the individual’s current status. The SNF/NF must offer the same services to its residents who have elected the hospice benefit as it furnishes to its residents who have not elected the hospice benefit. However, it must be remembered that the patient/resident has the right to refuse any services.

The professional services usually provided by the hospice to the patient in his/her home should continue to be provided by the hospice to the resident in a SNF/NF, or other place of residence. This includes furnishing any necessary medical services to those patients that the hospice would normally furnish to patients in their homes.

Core Services:

Substantially all hospice core services (physician services, nursing services, medical social services and counseling) must be routinely provided directly by hospice employees and cannot be delegated (42 CFR 418.80).

A hospice is considered to provide a service “directly” when the person providing the service for the hospice is a hospice employee. For the purpose of meeting 42 CFRReprinted from Hospice Forum, December 15, 1993. 418.80, an individual who works for the hospice on an hourly or per-visit basis may be considered a hospice employee if the hospice is required to issue a form W-2 on his/her behalf.

Physician Services:

The hospice must provide physician services to the hospice patient. The patient’s attending physician may
continue to be involved in the care of the patient if this care is consistent with the plan of care and the expressed wishes of the patient.

Medical Social Services and Counseling:

Medical social services and counseling must be provided by hospice employees and cannot be delegated or contracted to SNF/NF personnel.

Nursing Services:

The hospice may not contract with the SNF/NF to provide the nursing services. However, the hospice may involve the SNF/NF nursing personnel in assisting with the administration of prescribed therapies included in the plan of care only to the extent that the hospice would routinely utilize the services of a hospice patient’s family/caregiver in implementing the plan of care. (For example, SNF/NF staff who are permitted by the facility and by law may assist in the administration of medication as established by the plan of care developed by the hospice interdisciplinary group (IDG) in coordination with the SNF/NF.)

Attending Physician:

While the attending physician may participate in the development of the plan of care and provide care under it, the hospice IDG, the attending physician, and the patient will have to reach an agreement regarding treatment before services are provided. If a patient prefers the type of care proposed by the attending physician and the hospice’s IDG proposes a different mode of care, the patient may revoke the hospice election and accept treatment from the physician outside the hospice benefit. Alternatively, the patient may choose to remain in the hospice benefit. Alternatively, the patient may choose to remain in the hospice program and refuse the suggestions of his/her attending physician.
Non-core Services:

The hospice may arrange to have some non-core hospice services provided by the SNF/NF if the hospice assumes professional management responsibility for these services and assures that these services are performed in accordance with the policies of the hospice and the patient’s plan of care (42 CFR 418.56). In this situation, the key to surveying the adequacy of SNF/NF services for hospice patients is to review the assessment and note the implementation of the plan of care in conjunction with the facility’s documented agreement with the hospice.

Medicaid Patients and the Hospice Benefits

When the beneficiary is also eligible for Medicaid and the facility is being paid for the beneficiary’s NF care by Medicaid, the Medicare hospice benefit may be elected if the hospice and the facility have a written agreement under which the hospice takes full responsibility for the professional management of the individual’s hospice care and the facility agrees to provide room and board to the individual. The hospice patient must remain in a Medicaid certified bed while residing in the NF.

In states that offer the Medicaid hospice benefit, if an individual is eligible for Medicare as well as Medicaid, the hospice benefit must be elected and revoked simultaneously under both programs. The state Medicaid agency pays the hospice the amount determined as payment for room and board while the patient is receiving hospice care, and the hospice pays the facility. Room and board services include: performing personal care services; assisting with activities of daily living; administering medication; socializing activities; maintaining the cleanliness of a resident’s room; and supervising and assisting in the use of durable medical equipment and prescribed therapies.


The hospice is precluded by the regulation at 42 CFR 418.24(c) from involuntarily discharging a Medicare beneficiary from hospice care once the beneficiary is accepted for care. A hospice may not discharge a Medicare beneficiary at its discretion, even if the beneficiary’s care promises to be costly or inconvenient. The election of the Medicare hospice benefit is the beneficiary’s choice rather than the hospice’s choice. A beneficiary whose circumstances cause him or her to desire a different type of care may choose at any time to revoke the hospice election. The only time that a hospice would be unable to recertify a Medicare beneficiary would be if the hospice finds that the beneficiary is no longer terminally ill, in which case the beneficiary would no longer be eligible for the hospice benefit. A hospice may also discharge a patient if he or she moves out of the hospice’s service area. HAA urges members to familiarize themselves with these guidelines and apply them when providing hospice care to nursing facility residents.




Medicare & Hospice

Medicare pays Hospice agencies a daily rate for each day a patient is enrolled in the Hospice benefit. The daily payments are made regardless of the amount of services furnished on a given day and are intended to cover costs that the Hospice incurs in furnishing services identified in the patient’s POC, including services provided directly or arranged by the Hospice. Payments are made based on the level of care required to meet patient and family needs.

The levels of care are:

  • ™™Routine home care
  • ™™Continuous home care
  • ™™Inpatient respite care
  • ™™General inpatient care

Additional Resources


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