Or. Admin. Code § 410-141-3846

Current through Register Vol. 64, No. 1, January 1, 2025

Section 410-141-3846 - Palliative Care Program

(1) Definitions.

(a) "Assessment" means procedures by which a qualified practitioner of the healing arts identifies strengths, weaknesses, problems, and needs to determine a member's need for palliative care services.

(b) "Palliative care interdisciplinary team (PCIDT)" means a team of individuals working together in a coordinated manner to provide palliative care services, which may include the family-patient unit. An interdisciplinary team is composed of the following core team members who are trained or certified in palliative care:

(A) A registered nurse;

(B) A social worker; and

(C) A physician or primary care provider, or specialty care provider;

(D) In addition to (a-c) above, the interdisciplinary team may include one or more of the following palliative care program personnel:

(i) Licensed practical nurse;

(ii) Certified nurse's aide;

(iii) Home health aide;

(iv) Hospice aide;

(v) Community health worker;

(vi) Occupational therapist;

(vii) Physical therapist;

(viii) Trained volunteer (faith or community based);

(ix) Spiritual care professional;

(x) Advanced practice clinicians; and

(xi) Licensed or credentialed mental health professionals including:

(I) Licensed psychiatrist;

(II) Licensed psychologist;

(III) Psychiatric nurse; and

(IV) Qualified Mental Health Professional.

(c) "Palliative care services" means comfort services that focus primarily on reduction or abatement of physical, emotional, social, functional deficiency and spiritual symptoms of serious illness.

(d) "Primary caregiver" means the person designated by the patient or the patient's representative to assume responsibility for care of the patient as needed. If the patient has no designated primary caregiver and is unable to designate one, the interdisciplinary team may designate a primary caregiver.

(e) "Portable Orders for Life-Sustaining Treatment (POLST)" means the formal written medical orders for life sustaining treatment signed by a physician, naturopathic physician, nurse practitioner or physician assistant that helps identify the types of medical treatment a patient shall receive during their palliative care.

(f) "Prognosis" means the probable outcome of a disease over a given period of time.

(g) "Residential care facility" has the meaning given that term in ORS 443.400.

(h) "Serious Illness" means a disease, injury, or other physical, cognitive or mental condition that is life-limiting.

(i) "Skilled nursing facility" has the meaning given that term in ORS 442.015.

(j) "Symptom management" means assessing and responding to the physical, emotional, social, functional and spiritual needs of the patient and their family.

(2) System of Care.

(a) A Coordinated Care Organization (CCO) shall maintain a network to provide a community or home-based Palliative care benefit for its members.

(b) A residential care facility or a skilled nursing facility is not subject to these rules for the Palliative Care Program established for CCOs in providing or arranging palliative care services for residents of the facilities.

(c) A provider of palliative care services under the program and a CCO shall determine the reimbursement paid for services by mutual agreement.

(3) Eligibility for the Palliative Care Program.

(a) A patient qualifies for palliative care services under the program if they:

(A) Have been diagnosed with a serious illness that has a negative impact on the patient's quality of life or the quality of life of their primary caregiver; and

(B) Palliative care is ordered by the patient's primary care, specialty care or hospital-based provider.

(b) If Medicare or other insurance is available it must be billed before billing Medicaid.

(4) Plan of Care.

(a) A written plan of care must be established for eligible member electing palliative care and maintained for each patient eligible for palliative care services, and the care provided to a patient by the PCIDT must be provided in accordance with the plan of care.

(b) The plan of care is developed and updated at minimum every year or whenever there are significant changes in the patient's condition or patient's service choices, and as directed by the patient accessing palliative care services or the patient's representative, in collaboration with the members of the PCIDT.

(c) The plan of care must include the following:

(A) A comprehensive palliative care assessment by a core PCIDT member, to include physical, psychological, social, spiritual needs, and functional status. The PCIDT must also perform on-going assessments of the need for community-based palliative care services;

(B) An assessment of caregiver needs by a core PCIDT member, including providing to the caregiver appropriate referrals to community-based services such as support groups, caregiver respite, and grief or bereavement services;

(C) A documented plan to manage the patient's symptoms and coordinate care in accordance with the patient's needs and goals; and

(D) An ongoing assessment of pain, other physical symptoms, functional status, and psychological symptoms.

(d) Plan of care must be kept in patient's file.

(5) Provider Qualifications for Palliative Care Program.

(a) Core PCIDT members must be credentialed and recredentialed per CCO requirements in OAR chapter 410, division 141.

(b) Core members of the PCIDT must be:

(A) Certified in palliative care; or

(B) Have documentation of a minimum of sixteen (16) hours of palliative care training.

(i) Training topics must include, but are not limited to:

(I) Advance care planning conversations of POLST and Advance Directive;

(II) Palliative care assessment, including patient assessment; social needs screening; home safety assessment; caregiver assessment; spiritual assessment; functional assessment; and risk assessment;

(III) Basic pain and symptom management;

(IV) Expected disease trajectory for physicians, naturopathic physicians, nurse practitioners, physician assistants and registered nurses.

(ii) Additional training topics may include:

(I) Trauma informed care;

(II) Social determinant of health issues;

(III) Professional boundaries;

(IV) Motivational interviewing.

(c) It is recommended that other members of the PCIDT also receive palliative care training.

(6) Palliative Care Team and Services.

(a) The Palliative Care Program maintained by CCO's must designate an Interdisciplinary team who provide or supervise the care and services offered to the patient. Members of the PCIDT team interact on a regular basis and have a working knowledge of the assessment and care of the patient/family unit by each member of the team. The core members of the PCIDT must:

(A) Develop the plan of care;

(B) Provide or supervise palliative care services;

(C) Review and update the plan of care for each patient receiving palliative care services; and

(D) Follow policies governing the day-to-day provision of palliative care services established by the CCO's Palliative Care Program.

(b) Palliative care services shall include:

(A) Palliative care assessment;

(B) Advance care conversations including a discussion of POLST and Advance Directive;

(C) Case management and care coordination provided by a registered nurse or other qualified member of the interdisciplinary team;

(D) Symptom assessment and management;

(E) Transitional care management;

(F) Behavioral health and social work services;

(G) 24-hour clinical telephone support;

(H) Spiritual care services;

(I) Education with the patient and their caregivers, including:

(i) Aspects of in-home care, including the safe use of medications, and storage and disposal of medications in the home setting;

(ii) Goals towards the patient being more self-reliant and when to seek higher level of care;

(iii) When to contact Emergency Medical Services (EMS);

(iv) Hospice services availability and eligibility;

(v) Bereavement support and services availability.

(c) The palliative care services, as determined and provided by an interdisciplinary team, must be provided in the patient's choice of residence.

(7) Requirements for Coverage. To be covered, palliative care services must meet the following requirements:

(a) A referral from a patient's primary care or other specialty care provider must be given for palliative care services;

(b) The patient or the patient's representative must elect palliative care services;

(c) The services provided must be consistent with the patient's plan of care.

(d) Providers must not submit encounter claims for a palliative care and hospice service for the same dates of service.

(8) Patients are no longer eligible for community-based palliative care services under the Palliative Care Program if the patient:

(a) Enrolls in hospice;

(b) Dies;

(c) Is no longer enrolled in Medicaid;

(d) Experiences improvement of their condition or functional status as documented by a qualified provider's assessment that causes them to no longer meet eligibility criteria within this rule;

(e) Chooses to disenroll from the Palliative Care Program;

(f) Moves out of a palliative care provider's service area;

(g) Engages in behavior that is disruptive, abusive, or is considered a health and safety concern to the patient or a member of the PCIDT, to the extent that delivery of care to the patient, or the ability of the agency to operate effectively, is seriously impaired;

(h) Lives in a home where others engage in behavior that is disruptive, abusive, or is considered a health and safety concern to the patient or a member of the PCIDT, to the extent that delivery of care to the patient, or the ability of the agency to operate effectively, is seriously impaired.

Or. Admin. Code § 410-141-3846

DMAP 142-2024, adopt filed 12/12/2024, effective 1/1/2025

Statutory/Other Authority: Oregon Laws 2021 Chapter 462

Statutes/Other Implemented: ORS 413.042