End of life care is member-centric care that includes Advance Care Planning, and the delivery of appropriate health care services and practical supports. The goals of end of life care focuses on providing treatment, comfort, and quality of life for the duration of the member's life.
The end of life concept of care strives to ensure members achieve quality of life through the provision of services such as:
1) Physical and/or behavioral health medical treatment to:
a) Treat the underlying illness and other comorbidities;
b) Relieve pain; and
c) Relieve stress.
2) Referrals to community resources for services such as, but not limited to:
a) Pastoral/counseling services; and
b) Legal services.
3) Practical supports are non-billable services provided by a family member, friend or volunteer to assist or perform functions such as, but not limited to:
a) Housekeeping;
b) Personal Care;
c) Food preparation;
d) Shopping;
e) Pet care; and
f) Non-medical comfort measures.
Members aged 21 years and older who receive end of life care may continue to receive curative care
until
they choose to receive hospice care.
Members under the age of 21 may receive curative care concurrently with end of life care and hospice care.
Advance Care Planning
Advance Care Planning is initiated by the member's qualified health care professional for a member at any age that is currently or is expected to experience declining health or is diagnosed with a chronic, complex or terminal illness. For the purposes of Advance Care Planning, a qualified health care professional is a MD, DO, PA, or NP. Advance Care Planning is meant to be an ongoing process for the duration of the member's life.
Advance Care Planning often results in the creation of an Advance Directive for the member.
Providers must perform the following as part of the end of life concept of care when treating qualifying members:
a). Conduct a face-to-face discussion with the member/guardian/designated representative to develop Advance Care Planning;
b) Teach the member/guardian/designated representative about the member's illness and the health care options that are available to the member to enable them to make educated decisions;
c) Identify the member's healthcare, social, psychological and spiritual needs;
d) Develop a written member centered plan of care that identifies the member's choices for care and treatment, as well as life goals;
e) Share the member's wishes with family, friends, and his or her physicians;
f) Complete Advance Directives;
g) Refer to community resources based on member's needs; and
h) Assist the member/guardian/designated representative in identifying practical supports to meet the member's needs.
i) refer to MCP/Mercy Maricopa/MCPLTC Care Management team to assist with coordination of care.
Mercy Care Plan (MCP) and Mercy Maricopa Integrated Care (Mercy Maricopa) shall provide care/case management to qualifying members and coordinate with and support the member's provider in meeting the member's needs. In addition, the care/case manager will assist the member/guardian/designated representative in ensuring practical supports and community referrals are maintained or revised to meet the member's current needs.
Advance Care Planning is a covered, reimbursable service when provided by a qualified health care professional. The provider may bill for providing Advance Care Planning separately during a well or sick visit.
Hospice Services
Training
MCP and Mercy Maricopa requires that providers and their staff must be educated in the concepts of end of life care, Advance Care Planning and Advance Directives.
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