Hospice and Palliative Care in Nursing Facilities

Hospice and palliative care represent two distinct but overlapping frameworks for managing serious illness and end-of-life needs within nursing facility settings. This page covers the regulatory structure governing both service types, the mechanics of how they operate inside long-term care environments, the clinical and administrative tensions that arise when hospice agencies and nursing facilities share care responsibilities, and the specific classification boundaries that determine eligibility and coverage under federal programs. Understanding these frameworks is essential for anyone navigating end-of-life care decisions within the skilled nursing and long-term care sector.

• Definition and scope
• Core mechanics or structure
• Causal relationships or drivers
• Classification boundaries
• Tradeoffs and tensions
• Common misconceptions
• Checklist or steps (non-advisory)
• Reference table or matrix

Definition and scope

Hospice care is a federally defined benefit under Medicare Part A, governed by the Medicare Conditions of Participation for Hospice (42 CFR Part 418), that provides comfort-focused services to patients certified as having a terminal prognosis of six months or fewer if the illness runs its normal course. Within a nursing facility, the hospice benefit layer sits on top of — but does not replace — the facility's core obligations as a licensed provider. Palliative care is a broader term without a discrete federal billing category of its own; it refers to specialized interdisciplinary support focused on symptom relief, functional comfort, and goals-of-care alignment that can begin at any stage of serious illness, including alongside curative treatment.

The Centers for Medicare & Medicaid Services (CMS) regulates both the hospice benefit structure and the nursing facility's participation in that arrangement. The scope of hospice in the nursing facility context is defined in 42 CFR § 418.112, which establishes mandatory written agreements between the hospice and the nursing facility, coordination of care planning, and the division of clinical responsibility between the two entities.

Palliative care services in nursing facilities may be provided by the facility's own interdisciplinary team, consulting palliative care specialists, or embedded palliative care programs — none of which requires a terminal prognosis or election of the Medicare Hospice Benefit. The care planning and interdisciplinary team in nursing homes process is the primary structural vehicle through which palliative goals are incorporated into a resident's plan of care, regardless of whether hospice has been elected.

Core mechanics or structure

When a nursing facility resident elects the Medicare Hospice Benefit, the operational structure involves at minimum two licensed entities: the Medicare-certified hospice agency and the nursing facility itself. The hospice agency assumes responsibility for the palliation of the terminal diagnosis and related conditions. The nursing facility retains responsibility for room and board, personal care, nursing services related to non-hospice conditions, and overall facility compliance.

The hospice interdisciplinary team (IDT) — required by 42 CFR § 418.56 to include at minimum a physician, registered nurse, social worker, and pastoral or counseling professional — develops and maintains a patient-specific plan of care. This plan must be coordinated with the nursing facility's own care plan. Under 42 CFR § 418.112(c), the hospice and facility are required to hold joint care conferences at least every 14 days, or more frequently as clinical need dictates.

The four Medicare hospice benefit periods are structured as two 90-day periods followed by an unlimited number of 60-day periods. Each period requires physician re-certification of terminal prognosis. The hospice per diem payment — which covers nursing, aide services, medical social services, physician services, counseling, medications related to the terminal illness, and medical equipment — is paid to the hospice agency, not the nursing facility. The facility separately bills Medicaid (or private pay) for room and board. CMS publishes annual hospice payment rate updates through the CMS Hospice Center.

For pain management protocols in nursing homes, the hospice agency takes primary clinical accountability for symptom control related to the terminal diagnosis, while the nursing facility nursing staff administer medications and document responses under the hospice plan.

Causal relationships or drivers

The prevalence of hospice use in nursing facilities is driven by a convergence of demographic, regulatory, and clinical factors. Approximately 28 percent of Medicare hospice enrollees receive care in a nursing facility setting, according to the Medicare Payment Advisory Commission (MedPAC). This concentration reflects the fact that nursing facility residents already have functional impairment and a care infrastructure in place, making the transition to comfort-focused care logistically feasible.

Regulatory drivers include CMS's Long-Term Care survey process (42 CFR Part 483 Subpart B), which requires nursing facilities to address residents' preferences for end-of-life care through the Resident Assessment Instrument and the Minimum Data Set (MDS). The MDS 3.0 includes Section J items specifically capturing preferences regarding life-sustaining treatments and health care proxies. Facilities that fail to document and honor these preferences risk deficiency citations. The advance directives and end-of-life planning in nursing homes framework is the primary compliance mechanism connecting resident preferences to clinical care delivery.

Clinical drivers include disease trajectory recognition in conditions such as advanced dementia, end-stage cardiac disease, and metastatic cancer, where curative or rehabilitative goals are no longer achievable. The dementia and memory care medical services context is particularly significant: dementia accounts for a substantial portion of nursing facility hospice enrollment because cognitive decline progresses to a point — typically characterized by inability to ambulate, communicate, and maintain nutrition — that triggers the six-month prognosis threshold.

Classification boundaries

Four distinct clinical and billing categories define the boundary conditions in this domain:

Medicare Hospice Benefit (elected): Requires a physician certification of terminal prognosis ≤ 6 months (42 CFR § 418.22), a signed election statement from the patient or authorized representative, and enrollment with a Medicare-certified hospice provider. The patient waives Medicare coverage for curative treatment of the terminal diagnosis but retains Medicare coverage for unrelated conditions.

Palliative Care (non-hospice): No terminal prognosis requirement, no Medicare Hospice Benefit election, and no waiver of curative treatment. Covered through standard Medicare Part A (SNF benefit), Part B (physician and therapy services), or Medicaid, depending on the specific services rendered. No separate palliative care benefit category exists under Medicare.

Skilled Nursing Facility Medicare Part A Stay (concurrent): Medicare Part A covers SNF skilled care — physical therapy, occupational therapy, skilled nursing — but cannot be billed concurrently with the Medicare Hospice Benefit for the same terminal condition. The skilled nursing facility vs custodial care distinctions page addresses the qualifying criteria for SNF Part A coverage in detail.

Medicaid Room and Board for Hospice Residents: Under 42 CFR § 418.112, Medicaid covers room and board costs for nursing facility residents enrolled in the Medicare Hospice Benefit. The hospice agency receives the full per diem from Medicare; the nursing facility receives a separate room and board payment from Medicaid at a rate no lower than 95 percent of the facility's Medicaid daily rate, per 42 CFR § 418.112(g).

Tradeoffs and tensions

The dual-entity structure of hospice in nursing facilities generates documented administrative and clinical friction. The hospice agency bears financial responsibility for all services related to the terminal diagnosis — including hospitalizations, specialized procedures, and medications — creating an incentive to narrowly define what qualifies as terminal-condition-related. The nursing facility, conversely, may face pressure to refer residents with ambiguous prognoses to hospice to shift medication and supply costs off the facility's Medicaid per diem.

Oversight bodies including the Office of Inspector General (OIG) of the Department of Health and Human Services have published audit findings indicating that some hospice agencies enroll nursing facility residents who do not meet the terminal prognosis standard, particularly residents with diagnoses of debility or adult failure to thrive. The OIG Work Plan has flagged hospice in nursing facility settings as a persistent area of review given the financial alignment risk between the hospice agency and the facility.

A second tension involves the continuity of nursing care. When a resident is enrolled in hospice, the nursing home registered nurse staffing requirements at the facility do not decrease — the facility must still provide full nursing coverage — but clinical authority over symptom management shifts partly to the hospice RN case manager, creating potential gaps in handoff communication and medication reconciliation, particularly for nighttime and weekend coverage when hospice staff may not be physically present.

Goals-of-care misalignment also creates tension when families hold competing expectations — one family member pursuing hospice enrollment, another seeking continued curative intervention — in the context of ambiguous or contested advance directives. The resident rights and medical decision making in nursing homes framework governs how facilities navigate surrogate decision-making in these circumstances.

Common misconceptions

Misconception 1: Hospice enrollment means the nursing facility stops providing nursing care.
Correction: The nursing facility's obligation to provide 24-hour nursing supervision, personal care, and non-hospice-related medical management does not terminate upon hospice election. 42 CFR § 418.112 explicitly requires the facility to continue providing services not covered by the hospice benefit.

Misconception 2: Palliative care and hospice are the same thing.
Correction: Hospice is a specific Medicare benefit with eligibility requirements and an election mechanism. Palliative care is a clinical philosophy and practice model applicable at any disease stage. A resident receiving chemotherapy for cancer can simultaneously receive palliative care; a resident cannot simultaneously receive the Medicare Hospice Benefit and curative treatment for the terminal diagnosis.

Misconception 3: Medicare Part A covers everything for a nursing facility resident on hospice.
Correction: Medicare Part A does not pay room and board for nursing facility residents on hospice. Medicaid covers room and board under the arrangement described in 42 CFR § 418.112(g). Residents who are not Medicaid-eligible pay room and board from private resources.

Misconception 4: A hospice patient cannot be discharged from hospice.
Correction: Hospice enrollment can be revoked at any time by the patient or authorized representative, and the hospice agency may discharge a patient who no longer meets eligibility criteria or who is determined to have a life expectancy exceeding six months. Upon revocation or discharge, Medicare coverage for the terminal diagnosis resumes under standard Medicare rules.

Misconception 5: The facility's medical director has no role once hospice is elected.
Correction: The nursing home medical director role and responsibilities include oversight of care quality for all residents regardless of hospice status. The facility's attending physician (or medical director in the attending role) collaborates with the hospice physician on the plan of care and may serve as the certifying physician for the hospice benefit.

Checklist or steps (non-advisory)

The following sequence describes the administrative and clinical process flow for hospice enrollment within a nursing facility, presented as a reference framework:

1. Clinical eligibility assessment: Attending physician and hospice medical director evaluate whether the resident meets the terminal prognosis threshold of six months or fewer if the disease runs its natural course, per 42 CFR § 418.22.
2. Goals-of-care conversation: The interdisciplinary care team, which may include a social worker and the nursing facility's attending physician, documents a goals-of-care discussion with the resident and/or authorized representative.
3. Advance directive review: Existing advance directives, POLST (Physician Orders for Life-Sustaining Treatment), and DNR status are reviewed and reconciled with the proposed hospice plan. See the advance directives and end-of-life planning in nursing homes framework for applicable state-level variation.
4. Hospice election statement: The resident or authorized representative signs the hospice election statement, which includes acknowledgment of the Medicare waiver for curative treatment of the terminal diagnosis.
5. Written agreement execution: The hospice agency and nursing facility execute the written agreement required by 42 CFR § 418.112, specifying services each entity will provide, communication protocols, and emergency procedures.
6. Hospice plan of care development: The hospice IDT develops the initial plan of care within 48 hours of enrollment, with the plan incorporating input from the nursing facility's care team.
7. MDS documentation update: The nursing facility updates the Minimum Data Set to reflect hospice enrollment status; Section J of the MDS 3.0 captures care preferences and life-sustaining treatment preferences.
8. Joint care conference: The hospice and nursing facility teams convene the first joint conference, establishing the schedule for ongoing 14-day conferences as required by 42 CFR § 418.112(c)(7).
9. Ongoing recertification: At the end of each benefit period, the certifying physician re-evaluates and re-certifies the terminal prognosis, or initiates discharge planning if the resident has stabilized or improved beyond the eligibility threshold.
10. Revocation or discharge process: If the resident or family elects to revoke hospice, the hospice agency documents the revocation, and standard Medicare or Medicaid coverage for the terminal diagnosis resumes; any remaining benefit periods are preserved for future use.

Reference table or matrix

Hospice vs. Palliative Care vs. Standard Nursing Facility Care: Key Distinctions

Medicare Hospice Benefit Period Structure

| Period | Duration | Recertification Required |