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As of January 1 2011 Medicare has mandated that all Medicare patients receiving hospice care in the home be seen by a doctor or Nurse Practitionerat each recertification period prior to being recertified.

As a case manager for a non profit company providing hospice care in the home my first thought… what an extra burden on the company already stretched financially. Then my thought was, why doesn’t Medicare trust the nurses…. We KNOW if the patient meets criteria or not. So I ignored the idea and waited to see what might happen.

Yesterday just before leaving the house I received a call from a woman who said ”Hi I’m so-and-so I am about to go to your patient’s house for a “face-to-face”. At first I had no idea who she was nor what she was talking about, that expression had not yet become part of my new knowledge. After some back and forth I finally got the picture. This was a Nurse Practitioner about to make a visit for my company in order to keep up with the new mandate.

We met at Mr. P’s house, entered with the lockbox and announced our arrival. Mr P is very shy, very private and not open to new faces but the NP was very personable right from the start, she was warm and compassionate, took her time and did not rush anything.

The visit lasted an hour and I had questions that she had answers to and the patient had questions that she also answered. It was wonderful having a little support to complement and enhance the work being done. It may sound like I am unsure of myself in my professional practice, I am not, but support and running ideas around help justify the practice being given.

I love this woman! It was the best visit and I now think this is a great idea! I’m not sure every 3 months is necessary, maybe every other certification period (ever 6 months) as there are a lot of people to see, but hey, let’s put these wonderful practitioners to work in the field for support sharing their medical knowledge and let the medical director oversee the multitude of patients under his/her care.

This is a good idea!

by: Gigi Trabant RN CHPM

Home hospice case manager

This Post Has 8 Comments

  1. It IS a wonderful idea, but there's no extra reimbursement to support it. Many people think it will put small hospices out of business.

    The visit is intended to be administrative, not medical, so it's not really a good use of an NP or a physician. (kind of like working for an insurance compamy, reviewing charts. That's not why most NP's or physicians went to school.)

    Of course, Medicare says we can bill for a portion of the visit, if it includes medical management, but we've been warned that we'll face extra scrutiny if we start billing for these visits, so we get the message not to bill.

    I think it will have an overall negative impact on hospices, and I wonder if data will support its continuation.

  2. Great post. My understanding is that this new medicare "face to face" regulation is intended to confirm and document continued appropriateness for hospice. Resources are tight everywhere. Personally, I think the use of NPs (or PAs)in hospice settings would add much to the care of home hospice patients as well as assist with RN case manager education. Ultimately, the barrier, as I see it, is the ridiculously low medicare per diem rates hospices receive in the setting of increasing higher costs and expectations of hospice services.

  3. Indeed, what a great post! Many years ago, I too was a hospice nurse case manager. I went back to school to become an NP with a goal of returning to hospice as an NP, with the advanced training, in order to provide the level of care that I thought that hospice patients could truly benefit from. I saw that no MDs or NPs were out seeing these patients to support the nurses and that many of these patients need advanced level clinicians to assist with symptom control. Imagine my surprise when I got the education and then learned that hospices in my town don't use NPs- at all! They are too expensive, we are all told, even when the hospices are profit making entities that are bought and sold as money making ventures and some even have executives on the Forbes list! (Yes, I do read the business pages) Really, no money for NPs?

    I will support any venture that will bring advanced practice NPs to the bedside of the dying, I just wish that is was in a position that would enable us to use our clinical skills to the fullest potential. Maybe in a land, far away, there is a hospice patient that gets to have a full complement of team members that includes advanced practice nurses, all working together, to manage the emotional, spiritual, psychosocial, and medical aspects of dying. I just hope it is an idea that catches on and spreads to my hometown!

  4. I see FTF visits as a quality improvement tool; albeit a blunt instrument. No disrespect at all to my RN colleagues, who are the foundation of hospice practice, but it's forcing a higher level of multidisciplinary collaboration and it's providing an additional role for NP's at our agency, both good things.
    As an NP that mostly does hospital consults, I relish getting to do FTF home visits and the opportunity to have more contact with our hospice patients.
    It's taking some organizational learning, but we seem to be on it. Very do-able.

  5. While the new face to face rule is a bit of a challenge financially to the smaller companies I think it is a smart move by Medicare. I have been in hospice for many years, I have worked as an RN Case Manager, Patient Care Coordinator and now am a Director for a hospice. We hired a Nurse Practitioner to help our Medical Director with these face to face vists so that we can stay in compliance. She not only does these face to face visits but carries a case load of patients for the doctor and will do admissions and RN visits as needed. She is paid a very good salary so it is important that we utilize her. I will tell you she is a wonderful addition to our team. The Medicare benefit is a wonderful service but I have seen it abused over and over by companies who are so census driven that they will admit anyone who is referred. Anyone is hospice for any length of time can tell you the pressure they felt at one time of another to admit or to keep on service a patient that is not medically eligible. I have left jobs over it. It is helpful for the RN Case Manager to have the NP assess these patient's. The NP will help the field nurse to improve their skills in evaluating patients and they will be a support for them when the NP agrees that the patient no longer qualifies for hospice services.

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