Mont. Medicaid Hospice Policy Manual, Policy 003

For purposes of this Policy Manual the following definitions apply:

ATTENDING

PHYSICIAN

➢A doctor of medicine or osteopathy who is legally authorized to

practice medicine or surgery by the State of Montana, a nurse

practitioner, or physician assistant, and is identified by the member,

at the time he or she elects to receive hospice care, as having the

most significant role in the determination and delivery of the

member’s medical care.

BEREAVEMENT

COUNSELING

A service that provides emotional, psychosocial, and spiritual

support and is provided before and after the death of the member

to assist with issues related to grief, loss, and adjustment.

CAP PERIOD

The twelve-month period ending October 31, used in the

application of the cap on overall hospice reimbursement.

CLINICAL NOTE

Is a notation of a contact with the member and/or the family that is

written and dated by any person providing services and that

describes signs and symptoms, treatments and medications

administered, including the member’s reaction and/or response,

and any changes in physical, emotional, psychosocial or spiritual

condition during a given period of time.

COMPREHENSIVE

ASSESSMENT

A thorough evaluation of the member’s physical, psychosocial,

emotional and spiritual status related to the terminal illness and

related conditions. This includes a thorough evaluation of the

caregiver’s and family’s willingness and capability to care for the

member.

DIETARY

COUNSELING

The education and interventions provided to the member and family

regarding appropriate nutritional intake as the member's condition

progresses. Dietary counseling is provided by qualified members,

which may include a registered nurse, dietitian or nutritionist, when

identified in the member's plan of care.

EMPLOYEE

A person who:

1. Works for the hospice and for whom the hospice is

required to issue a W-2 form on his or her behalf;

2. If the hospice is a subdivision of an agency or

organization, an employee of the agency or

organization who is assigned to the hospice; or

3. Is a volunteer under the jurisdiction of the hospice.

HOSPICE

A public agency or private organization or subdivision of either of

these that is primarily engaged in providing hospice care as defined

in this section.

HOSPICE CARE

A comprehensive set of services identified and coordinated by an

interdisciplinary group to provide for the physical, psychosocial,

spiritual, and emotional needs of a terminally ill member and/or

family members, as delineated in a specific member plan of care.

INITIAL

ASSESSMENT

An evaluation of the member's physical, psychosocial and

emotional status related to the terminal illness and related

conditions to determine the member's immediate care and support

needs.

LICENSED

PROFESSIONAL

A person licensed to provide member care services by the State.

MULTIPLE

LOCATIONS

Medicaid-approved locations from which the hospice provides the

same full range of hospice care and services that are required of

the hospice issued the certification number. A multiple location

must meet all of the conditions of participation applicable to

hospices.

NURSE PRACTITIONER

➢A registered nurse who performs such services as legally

authorized to perform in accordance with State law and who meets

training, education, and experience requirements described in 42

CFR 410.75.

PALLIATIVE CARE

Member and family-centered care that optimizes quality of life by

anticipating, preventing, and treating suffering. Palliative care

throughout the continuum of illness involves addressing physical,

intellectual, emotional, social, and spiritual needs and to facilitate

member autonomy, access to information, and choice.

PHYSICIAN

A doctor of medicine or osteopathy legally authorized to practice

medicine and surgery under the state medical practice acts, to

practice medicine or osteopathy.

PHYSICIAN’S

ASSISTANT

➢A professional who has graduated from an accredited physician

assistant educational program who performs such services as he or

she is legally authorized to perform in accordance with State laws

and who meet the training, education and experience required by

42 CFR 410.74 (c).

PHYSICIAN

DESIGNEE

A Physician designee is a doctor of medicine or osteopathy

designated by the hospice who assumes the same responsibilities

and obligations as the medical director when the medical director is

not available.

REPRESENTATIVE

A member who has the authority under State law (whether by

statute or pursuant to an appointment by the courts of the State) to

authorize or terminate medical care or to elect or revoke the

election of hospice care on behalf of a terminally ill member who is

mentally or physically incapacitated. This may include a legal

guardian.

RESTRAINT

1. Any manual method, physical or mechanical device,

material, or equipment that immobilizes or reduces the ability

of a member to move his or her arms, legs, body, or head

freely, not including devices, such as orthopedically

prescribed devices, surgical dressings or bandages,

protective helmets, or other methods that involve the

physical holding of a member for the purpose of conducting

routine physical examinations or tests, or to protect the

member from falling out of bed, or to permit the member to

participate in activities without the risk of physical harm (this

does not include a physical escort); or

2. A drug or medication when it is used as a restriction to

manage the member's behavior or restrict the member's

freedom of movement and is not a standard treatment or

dosage for the member's condition.

ROUTINE HOME

CARE (RHC) RATE

A rate in which a level of care day will be paid by one of two RHC

per diem payment rates. The RHC level of care will be paid

depending on the timing of the day within the patient’s episode of

care. Days 1 through 60 will be paid at the RHC “High” rate while

days 61+ will be paid at the RHC “Low” rate.

SECLUSION

The involuntary confinement of a member alone in a room or area

from which the member is physically prevented from leaving.

SERVICE

INTENSITY ADD-ON (SIA)

RATE

A payment for skilled visits (provided by a registered nurse and/or a

medical social worker) during the last seven days of life during a

hospice election. The SIA payment will be paid in addition to the

current per diem rate for the RHC level of care.

TERMINALLY ILL

A member has a medical prognosis that his or her life expectancy is

six months or less if the illness runs its normal course.