I have been a nurse for a long time, and 17 years in Hospice. Even in a not for profit Hospice, I have found that the expectations for admissions and "making them fit" is somewhat overwhelming. I am leaving my last job, disappointed that I never found a hospice I could totally believe in. I have found multitudes of wonderful hospice nurses!
If we go back to when hospice really began in this country, we see a different mindset. We were doing something that felt right. We went to a person's house, sat down and really communicated. We made sure that they understood what we do, and don't do. We let them know we would "be there". That medications that would ease their symptoms would be available to them, and that it was our priority to make sure the rest of their days would be as comfortable and peaceful as we could make them. That we would be there for the family, significant other, children, and friends. we would help family and pt to reconcile themselves to the terminal disease, and make the best of the time they had left. We would be facilitators in this, their last journey.
It wasn't about the numbers. the amount of visits you could get through in a day, and how quickly you could get your notes or documentation in so they could bill. Sure, income is necessary for out go, but we were not a money-driven machine.
I believe in rules and regulations, because they keep us organized and productive, but not to the extent that we lose track of the original purpose of our business. Patients and families should be able to count on us to always do what is in their best interest, based on their goals, not ours. Such as; a DNR not being done. Ever. Because that is how they feel about it. And then not every discipline reminding them that they don't have one, and should get it done. Oh we don't cross the rule line, but we do hover over it. (a hospice cannot require a DNR for admission) Our job should be to let them know from the beginning that they have the option to have an OOHDNR, but it is not required. It is not up to us to make the decision for them, and I believe that our repeated mention of it tends to harass them into it.
Medicare has criteria that we are supposed to meet. I always hear, "well the doctor is the one who makes the decision". Yes, he is, but he is depending on our information most of the time, and we are responsible for that information. It is not ok to lean toward one disease or another in order to get the one you want, so the patient will qualify. I think when the powers that be at medicare made the absolute criteria, then meant it. So if the patient can carry on a conversation, they are not qualified for a dementia diagnosis, no matter if they have stage 1 or 2 cardiovascular disease. And then you can't make the cardiovascular disease look worse than it is. I really don't get how these decisions are made on the medicare end. Do we absolutely have to meet criteria? or are they just suggestions? Is the doc truly the only one responsible?
How much time should you spend doing an info, eval, consents and admission to hospice? In my history, there were places that had info and consents done, then the nurse would do eval and admit. That is the only way it makes sense to me. It takes very little time in most cases to find criteria for admission. You find a diagnosis, you check for the criteria, you get history to add comorbs and contributing conditions, and by the time you are done with all that, you have most of your assessment done. I know that sounds ridiculous, but actually, in a pt that has clear cut disease and symptoms, you can get that admission done in just a couple hours. It doesn't make sense to me that the office can add info and consents and think you should still be able to complete it in 2 hours. Some info visits take 2 hours all by themselves. And then you get to consents, and you have questions. It can take over an hour to do that. Why is it impossible to understand that this is one of the most important and difficult things a person or family can ever expect to do? This is emotional and hard for them. It takes time. They are upset, and they have questions. Thanks to some really hard things that have happened over time, they have some serious concerns, like "are we going to just give him morphine so he can die?". If you have worked in hospice for any length of time, you have heard this question. And many more.
I do not intend to ever rush an admission. So comments? Ideas? I have retired, again. I don't expect to ever have this constant reminder of my ineptness again, but it still matters to me. A lot. Hospice was truly my niche in life. I hope this makes sense, and doesn't sound like an old whiny nurse complaining.
Sep 23, '17
So, you've got a lot that you're concerned about. I'll do what I can to help clarify things. I do admissions for the hospice company I work for. That often includes info and consents.
First, Medicare guidelines are just that, guidelines. Each and every situation is unique. If a patient is being considered for Alzheimer's Disease, for example. I look at both PPS and FAST scores. There is no specific PPS given in the guidelines for PPS, but for FAST, the guideline is 7A. This means that the individual is incontinent of bowel and bladder (does not have to be 100% of the time) and cannot speak more than 5 words in a day. The words do not have to be appropriate to the question or attempted conversation, they just have to be words. For example, you may ask the patient what day it is. They may answer "Window." It is a completely inappropriate answer, but it is a word and it counts. Sometimes, I have a patient who can easily say a dozen or more words that make sense. On the surface, it looks as though this patient would not qualify. That is when I need to dig deeper. What else is going on with this patient? One thing I will look at is their appetite and weight. Is the patient eating well? Is the patient loosing weight. I may look back at serial weights over the last 6 months and find they have last 20 or 30 pounds. Their caregiver may tell me they hardly eat anything and it takes a lot of coaxing. I will also consider functional decline. Maybe a few months ago they didn't require much help with ADL's but now can do very little for themselves. Looking a their History and Physical and labs, I may find that they have Class 3 heart disease and require oxygen. They also have renal insufficiency with an elevated Creatinine level. If their serum albumin level was tested I will look at that. In general, Medicare looks for a level less than 2.5. I will gather all the information I can that provides a clear picture of everything going on with the patient before I call and talk to the physician. That way, the physician can make an informed decision about whether or not to admit the patient.
Just because a patient does not meet the qualifications for one diagnosis, that does not mean they are not appropriate for hospice. Medicare understands that comorbidities play a factor in overall health and prognosis. It's up to us to paint the full picture. You do not have to ignore other diagnoses. They do play a factor in the decline of the patient's health. Diseases do not act on the body in isolation. Likewise, the decision to choose one diagnosis over another is based on the severity of each diagnosis and what will most likely be the deciding factor in the patient's death. If the doctor feels the patient is appropriate for hospice, he or she will take all the information you provide, including all diagnoses, to determine which one to use. It requires a good working relationship with the doctor to do what is best for the patient.
As far as time is concerned. Yes, there is a lot of pressure to complete everything in as little time as possible. What I have found personally, is that as I have done more info, consents, and admissions that faster I get. I've found that I can identify what issues are most problematic for a patient and family and address those in detail. I find that often, they have a basic knowledge of hospice and I just need to fill in the gaps and correct any wrong ideas. I am clear about what we can and cannot do. As I go through the consents, I go over each section and remind them of what we talked about already. That helps connect the discussion with the paperwork. Time varies considerably with some taking 30 to 40 minutes and others taking an hour or more. Once consents are done, I complete the admission. Much of the information I need, I already have by this point. I complete the assessment, go over medications and make any changes needed (after discussing with the physician of course). If I am doing the whole thing from info to admission, I will usually take 3 1/2 hours or so. If info and consents are done and I am only doing the admission, it usually takes about 2 1/2 hours. Of course this varies from one situation to the next.
I have found that my supervisors are pleased with my admissions because they are thorough and done correctly. That goes a long way in having some leeway with time. I do what I can to keep things as quick as possible, but will not sacrifice quality. It has taken time to build up the reputation I have at work, but it was worth it. They know that patients I admit are appropriate for hospice and the documentation will represent that. When the pressure is on, I am careful to truthfully tell them what I can and cannot do. I work hard and they know that. When I say I can't do something, they believe it.
I hope this helps. Please don't let someone with unrealistic expectations make you feel inept. It is their problem, not yours.
Sep 28, '17
I am not new to Hospice or admissions, having worked on and off for 17 years in hospice and 37 in nursing. I find that I am taking longer than most anyone else with the full admission when eval, info, consents, and admission are needed. I am somewhat OCD regarding info and consents, making sure that patients and family understand what hospice is and is not. As I have said, this is probably the most important and emotional time in a persons life, and it is important to me that they have the right information to make an informed decision. Some evals take no time at all, considering an obviously terminal patient or disease process. And it was telling to me that ("Much of the information I need, I already have by this point") you do your documentation after the visit. I have been 2 hours driving to a patient, the full admission done, and then an hour to the next and a full admission and expected to have every little bit of the admission and documentation done. That includes calling for supplies and equipment, and medications with difficulties with ordering on tablets and with reception in the outlying areas. I have been expected to do all of this and then another if it comes up during the day. I had to leave them, even though it seemed a good place to start with, because I couldn't keep up the pace. That is what happens to us 'older' nurses. I also felt that I was being 'laughed' at because i couldn't keep up. So now i go on to other things. Maybe part-time, maybe full retirement, who knows? It is hard to give up doing hospice care. Once a hospice nurse, always a hospice nurse.
Nov 20, '17
I've been away from this site for awhile. But I would like to clarify. I do not do my documentation after the admission visit. I do it on-site. But, I do a thorough evaluation of the patient to determine whether or not they are appropriate for hospice. By this time, I know much of their medical history as well as what is going on with them now. During the admission assessment, I am required to document on each system (cardiovascular, respiratory, etc.). When doing a thorough evaluation, I gather information such as cardiovascular disease and symptoms the patient is experiencing at that time as well as over time. So, when I get to that portion of the admission assessment, I already know that the patient has an irregular heartbeat, they require O2, experience dyspnea with exertion. All this is information I obtained during the evaluation portion of the visit. I do not need to re-assess the patient in front of me just because it's been 30 minutes or so. It's the same visit and information is still valid. I would document if the patient had taken any medication since I got there and what the effect was, or if their symptoms had changed in that short time. Typically, however, they are not in an acute care setting and are not experiencing such rapid changes to their condition. All our admissions include an evaluation as that is not done before hand.