Hospice in a nursing home

Can you get hospice in a nursing home?

Yes. For a person who lives in a nursing home, the facility is home, so hospice comes to them there. Many residents on hospice stay in the same room, with the same facility staff, until the end of life.

Before a hospice can care for residents of a nursing facility, the hospice and the facility must sign a written agreement (42 CFR 418.112). Many facilities already have agreements with several hospices. If the facility does not have one with the hospice you want, ask whether it will sign one. We care for people wherever they call home, including nursing facilities, residential care facilities for the elderly (RCFEs) and board-and-care homes, in coordination with facility staff.

Who does what when a nursing home resident is on hospice?

The nursing home keeps doing what it did before hospice: the room, meals, personal care, help with daily activities, giving medicines and 24-hour nursing. The hospice adds its team, takes charge of the plan for the terminal illness, and brings the medicines, equipment and supplies for it.

These duties come from the federal rules for hospices that serve nursing home residents (42 CFR 418.112). The hospice and the facility write them into their agreement and into a shared plan of care. Medicare requires a hospice to offer bereavement services for up to 1 year after a death (42 CFR 418.64); the 13 months is Beta's own program.

What the rules for hospice in a nursing home require

The federal rule for hospice in a nursing facility is 42 CFR 418.112. In plain words, it requires a few things. The hospice and the facility sign a written agreement before care starts. The hospice is in charge of the plan for the terminal illness, including any change in the level of care. The facility keeps giving 24-hour room and board, personal care and nursing at the same level as before hospice. The hospice gives the same care it would give if the resident lived in a private home.

The two teams write and follow one hospice plan of care together. The facility must tell the hospice at once about a significant change in the resident's condition, a need to move the resident, or a death. Beyond the nursing care the facility already gives, the hospice may ask facility nurses to help give treatments in the hospice plan only where state law and the facility allow it, and only as far as it would ask a family member to help at home (42 CFR 418.112(c)(7)).

The resident or their representative chooses the hospice. A facility may work only with hospices that have signed its agreement, so ask early which hospices it works with.

Does hospice pay for a nursing home?

No. Medicare pays the hospice for hospice care related to the terminal illness. Under Medicare, most people pay nothing for hospice care itself. There can be a copay of up to $5 per prescription for symptom medicines. Medicare does not pay room and board where you live, and in a nursing home that is the bed, the meals and the daily care.

Room and board is paid the way it was paid before hospice: by the resident or family, by long-term care insurance if the policy covers it, or by Medi-Cal for residents who are eligible for Medi-Cal nursing facility care. In California, when Medi-Cal pays room and board for a resident on hospice, the Medi-Cal plan pays the hospice and the hospice pays the facility (DHCS All Plan Letter 25-008). Any share of cost the resident already pays continues.

The details are on two pages: does hospice pay for a nursing home? and Medi-Cal and hospice.

How to start hospice in a nursing home

Anyone can start the conversation: the resident, family, the facility's social services staff, or a doctor. The steps are the same as at home, plus one check on the facility's agreement.

1. Step 1

   Ask for a hospice evaluation

   Tell the facility's social worker or director of nursing, the resident's doctor, or call a hospice directly. You do not need the facility's permission to ask a hospice a question.

2. Step 2

   Check the facility works with the hospice you choose

   Ask whether the facility has a signed agreement with that hospice. If not, ask whether it will sign one. The choice of hospice belongs to the resident or their representative.

3. Step 3

   A hospice nurse visits the resident

   The nurse reviews the records, talks with facility staff and the family, and explains what hospice would change. A hospice doctor, and the resident's own doctor if they have one, certify that the person is eligible.

4. Step 4

   The resident or representative signs the election

   This is the form that starts hospice. Tell the hospice about every kind of coverage, including Medi-Cal, so room and board is handled correctly from the first day.

5. Step 5

   The two teams make one plan

   The hospice writes the plan of care with the facility staff. Medicines and equipment for the terminal illness come from the hospice. See how to start hospice.

Hospice at home or in a nursing home?

The hospice care itself is the same in both places. What changes is who gives the daily care and who pays for the place to live.

Respite and continuous home care rules: CMS Medicare Benefit Policy Manual, chapter 9, sections 40.1.5 and 40.2.1. See levels of care.

What to ask the nursing home about hospice

• Which hospices do you have a signed agreement with? Will you sign one with the hospice we choose?
• Who on your staff is the contact for the hospice, day and night?
• How will your staff and the hospice share changes from shift to shift?
• Will the room and board rate change when hospice starts? (It should not change because of hospice.)
• If the resident has Medi-Cal, who handles the room and board billing with the hospice?
• Can family stay late or overnight near the end?
• What happens if the resident needs a short inpatient stay for symptoms?

Common questions about hospice in a nursing home

Related guides

Hospice in assisted living, does insurance cover hospice?, how to choose a hospice, and, for facility staff, hospice in skilled nursing facilities.