Palliative care is specialized medical care designed for individuals living with a serious illness. Its primary focus is providing relief from the symptoms and stress associated with that condition. The overarching goal is to improve the quality of life for both the patient and their family. This care is delivered by an interdisciplinary team and is appropriate at any stage of a serious illness, including within a skilled nursing facility or long-term care setting.
Palliative Care vs. Hospice Care
Palliative care and hospice care are often confused, but they represent two distinct phases of care for serious illness. Palliative care can begin immediately upon diagnosis of a serious condition, such as cancer or dementia. It can be administered simultaneously with treatments intended to cure or slow the disease’s progression, focusing on comfort and the patient’s overall well-being.
Hospice care is a specific type of palliative care reserved for patients whose prognosis is six months or less. To elect the Medicare Hospice Benefit, a patient must agree to forego curative treatments for the terminal illness and focus exclusively on comfort. While all hospice care is palliative, not all palliative care meets the strict regulatory requirements of hospice. This distinction is important because many nursing home residents could benefit from palliative care long before they become hospice-eligible.
Models of Palliative Care Delivery in Nursing Homes
Palliative care services are provided to nursing home residents using a few primary logistical models.
Consultation Model
The most common approach is the Consultation Model, where an external specialist palliative care team visits the resident at the nursing home. This team, often based at a local hospital, provides expert recommendations for symptom management, goals-of-care discussions, and psychosocial support. This supplements the care already provided by the facility staff.
Integrated Model
In the Integrated Model, the nursing home staff receives extensive training to provide “primary palliative care” themselves. This includes basic symptom management, communication skills, and advance care planning. Specialist palliative care teams remain available for complex cases.
Regardless of the model, palliative care is delivered by an interdisciplinary team. This team typically includes a specialized physician or nurse practitioner, a social worker, a chaplain, and other therapists. The nursing home coordinates the resident’s primary care with the palliative care team to ensure a seamless plan.
Initiating Palliative Care Services
Accessing palliative care services typically begins when the need for specialized support is recognized. This recognition often comes from the primary care physician, a specialist, or the nursing home staff observing the patient’s increasing symptom burden or functional decline. Once the need is identified, the next step is obtaining a physician referral to a palliative care provider.
The palliative care team conducts a comprehensive initial assessment to understand the resident’s medical, psychological, social, and spiritual needs. This assessment focuses on clarifying the patient’s goals of care and personal values, which determines the direction of treatment. Following the assessment, the team collaborates with the patient, family, and the nursing home staff to create a personalized care plan. This plan details specific interventions for pain and symptom management and outlines strategies for psychosocial support.
Understanding Coverage and Costs
Payment for palliative care in a nursing home differs significantly based on whether the resident is receiving non-hospice palliative care or hospice care.
Non-Hospice Palliative Care
Non-hospice palliative care can be received concurrently with curative treatments and is generally billed like any other specialized medical service. Physician and nurse practitioner consultations are typically covered under Medicare Part B or private insurance. The patient is responsible for applicable deductibles, copayments, and coinsurance. Medications for symptom control are usually covered under the resident’s Medicare Part D prescription drug plan.
Hospice Care
Hospice care is covered under the comprehensive Medicare Hospice Benefit (Part A). This benefit bundles nearly all services related to the terminal illness, including:
- Physician services
- Nursing care
- Social services
- Medical equipment
- All medications for symptom management
This results in minimal to no out-of-pocket costs for the patient. However, the hospice benefit does not cover the resident’s room and board costs in the nursing home. These costs must be paid by the patient or through other means like Medicaid or private funds. Medicaid may also cover palliative care services for eligible residents, but specifics vary by state.