Daughter doesn't want hospital to know Patient on hospice

Whispera, MSN, RN · Feb 24, 2009

Medicare won't pay for both hospice and hospitalization. It's one or the other. I would say if the patient hadn't said she was finished with hospice and signed the appropriate papers, her hospitalization will not be paid for by Medicare. The family could be in for a BIG financial surprise.

caliotter3 · Feb 24, 2009

Also I would be concerned about what the hospice nurse will do when she goes out for her regular visit and finds out the patient is in the hospital. Surely the family doesn't think the nurse will just let this slide. Don't have any other input. I know hospice allows for hospitalization, but that discharges and readmits are involved and families usually cooperate with the process.

AtlantaRN, RN · Feb 24, 2009

Strange situation continues. I went to the hospital today, as is protocol. I needed to find out if admission was related to her diagnosis (it was not). Daughter was there and said" I TOLD you that we would call when she was discharged from the hospital." I educated her as patient is still under hospice care (unless she revokes). Daughter again stated "I don't want you all up here....the last time she was here (with chest pain), they didn't want to treat her" (not true, she got a VQ scan, 3 sets of enzymes that were found to be negative, an echo, and a thallium scan...all protocol when a patient comes in with chest pain).

So, I asked my manager what is the normal process when something like this occurs. She told me to make daily calls to family to keep in contact. ((i'm going to call the daughter that lives with patient, at least she is nice)).

linda

SuesquatchRN, BSN, RN · Feb 25, 2009

Linda, you have a problem of education and the lack thereof here. Obviously, Daughter is frightened that Mother will be neglected because of her hospice status. Well, there I go, stating the obvious.

I don't know how to fix that.

AtlantaRN, RN · Feb 25, 2009

Excellent observation. I work that way to, what I can fix, and what I can't...

Manager said that when she gets out of the hospital, it's major education for sister and patient. Patient basically does what the daughters tell her to do.

I just feel so bad that she had diarrhea, nausea and vomiting from Friday until Monday and they didn't call the on call service! She HAS a comfort kit in her home with phenergan, compazine, etc.

They had called the service in the past, but I don't know why they didn't this time.

linda

rnboysmom · Feb 25, 2009

What you have here, folks, is a daughter that wants desperately to maintain control of the situation. Medicare will pay for hospice and a hospitalization as long as the hospice diagnosis and the reason for hospitalization are completely unrelated. However, the daughter need to understand that neglecting to notify the hospital that mom is on service potentially makes mom responsible for the bill in the event the ER sticks the hospice diagnosis anywhere on the bill (which they frequently do as they list every diagnosis that will guarantee payment).

Medicare always takes the path of least resistance and pays for the least costly service (hospice always versus ER if there is ANY question of the visit being related). The daughter may be able to hide the fact that the patient is on hospice from the physicians at the hospital, but she sure won't be able to hide it from the patient's insurance (usually Medicare) and they may very well bill the patient for the stay.(You may want to mention this to the patient as people of this age group are usually very concientious about paying their debts).

Even more important are the following issues 1. The patient prefers to remain passive but is able and capable of making her own decisions and 2. the daughter is obviously not ready to explore a palliative course of treatment for her mother. An IMMEDIATE family conference is required to unravel this issue. Are they on hospice to pay for medications or for extra services in the home? In the event the patient refuses to make her own decisions, she would need to appoint someone to do that on her behalf or we would not be able to continue to care for her on our service. If we could not get the family on board with the palliative care concept, we would counsel the family on their right to revoke the benefit and would inform them that the IDT has not approved this hospitalization and may not likely approve future hospitalizations r/t non-compliance with the plan of care. The fact that this family is not accepting and wished to aggressively treat may change their elibility status for hospice services. i would make sure that the patient receives an ABN notice in the event Medicare decides not to pay the hospital bill.

The frequency of hospice nursing visits while a patient is in the hospital is set by your company (and sometimes, by the hospital contract). GIP patients should receive daily visits for proper case management. Patients in the hospital on a non-related stay are not required by regs to be visited daily, but it is a good idea for the whole core team to rotate visits on a daily basis and nursing needs to make regularly scheduled visits for case management with the goal being toward working on discharge planning for the patient. It is a good idea to make daily visits to ensure that the stay REMAINS unrelated. Sometimes, patient stays start out as unrelated, but the hospcie diagnosis ends up on the bill because of some complications. Say your patient starts out in the hospital with nausea and vomiting (unrelated) but picks up a dysrhythmia r/t dehydration or fluid volume excess from IV's--now the hospital has to have a diagnosis code to put the patient on telemetry and viola, your hospice diagnosis ends up on the bill--now the stay IS related to the terminal diagnosis only you don't know because you didn't visit and keep track of the patient's progress. (sigh) :bowingpur