Hospice Admission Nurse....appreciate any advice and tips

nutella, MSN, RN · Dec 28, 2016

Just got accepted a position for hospice Admission Nurse....appreciate any advice and tips!!! So happy to be leaving bedside!!!

I hope you have some experience in hospice nursing or home care!

Will you be admitting in the home setting only or facilities like longterm care/ assisted living or both?

Depending on where you will be admitting mostly - be prepared to accept that your car will turn into a vehicle with no place for groceries or such as your trunk will be full with supplies you need.

- I highly recommend you join the HPNA

- get a good book - for example the core curriculum that is specific for palliative and hospice nursing

- you need to be super organized - no joke - I highly recommend that you get a car charger with cable for your phone if you use that also as your GPS, once you start orientation find out if you get a company cell phone - if yes, make sure that all contacts are loaded. No matter what phone you use (company or your own with reimbursement) make sure that you sit down and put in all relevant contact info organized including all longterm care and assisted living facilities main numbers that you frequent- add the address in contacts as well in case you need it for GPS use. Add phone numbers of your fellow hospice nurses and the on call coverage number, manager number, supervisor and so on. Make sure that when you orient you find somebody you can relate to and you get along with and ask them if they could be some kind of mentor / if it is ok to call them if you have questions - because it will happen in the first year when you are on your own that you encounter problems and really need to talk to somebody. Make sure you have all the numbers for the medical directors /physicians from hospice who give you orders, number for the pharmacy including after hour number, number to order hospice supplies including beds, oxygen and such, number for the large MD offices in your area. Most hospices have lists for you to use or you may have to get several lists. Also, make sure you have the phone and fax numbers for your company intake. oh - and the non emergency number for the fire dept in case you need non emergency lifting help. And the numbers and addresses for the funeral homes in the area.

It is best to get 2 binders with pockets. One for relevant information regarding your company, policies, phone numbers, work flows, and other information - make sure you have instructions on how to program a CADD pump.... . The second one for forms - which you probably will have many despite computer use. Make sure that you put a copy of the standing orders right into the front. Also you need pronouncement forms, forms to order supplies, forms for referrals, fax cover sheets, teaching sheets for a variety of things (may be available at the company but if you become a HPNA member you also have access to a bunch of teaching sheets and handouts you can use), medication grids ! Highly recommend those so you can write down your initial medication recommendation that is based on assessment and usually covered by the standing orders. You might want to consider some kind of plastic box or folder in which you throw in a bunch of admission packages and extra forms. There are usually folders that are available for admissions that include the benefit election form, consent, and so on - make sure you have extras because you will be called to do "another" admission that was not planned...

- Admitting in hospice is a lot of paperwork and depending on your company and computer software there will be an expectation of how long one admission should take. Make sure you understand the expectations. After you visit and have done the initial teaching you still need to make sure that you input all the data. You can do some while you do the visit directly into the laptop like vital signs and part of your assessment - but a lot of times the situations are charged - you will only be able to input a certain amount in the house. You need to write a narrative and select an initial care plan and so on - it take longer in the beginning as you find out to navigate the software and the requirements.

Make sure you have different languages available and the number for phone interpretation and in person interpretation.

What you absolutely need handy ( laminate or put in a sleeve) is this:

http://geriatrics.uthscsa.edu/tools/Hospice_elegibility_card__Ross_and_Sanchez_Reilly_2008.pdf

http://www.nhpco.org/sites/default/files/public/regulatory/GIP_Tip_GIP_Sheet.pdf

Equivalency Table

there is also a really great table with explanations in the core curriculum that I like better but the above is for free

Get some apps for your phone that are helpful including fast facts, HPNA app, infusion conversions, drug formulary, symprom management guide.

- You never know what you will run into at home - be prepared to insert foleys, provide initial symptom control, start CADD pumps, you may have to access ports (make sure you got trained and know how to access port a caths ),

- Make sure you know what "comfortable " means if you are new to hospice care, acknowledge the family needs as well.

- Learn some lingo about how to explain and re-assure families. It is your job when you admit the patient to be confident and emanate confidence that they will be able to provide care at home - give real life advice that applies in home care and use common sense when explaining stuff.

A lot of decisions for home hospice are also financially motivated meaning that the family does not really feel they can care for the patient but do not have the finances for nursing home care with hospice. They may be in panic or crisis initially when realizing that it gets real now and they will have to provide the care - use language like "think of it as it was 50 years ago - people died at home - no special education needed ..."

- Make sure they understand who to call during the day and after hours, that they understand the on call system - if your company has stickers available or magnets make sure you point that out. I usually wrote the on call number in large letters with a sharpie on the folder and recommended to the family to place a sticky note at the phone or if cell phone only to take a picture of the number or program it in

- Make sure you know what to do if you get to a house for admission and you find out that the family is unable to care for the patient - usually the pre-screening detects those situations and potential situations and they will not be considered for an admission. But once in a while it happens that you go home for an admission and you realize that the patient is not safe. Know who you call to discussed those situations.

Just a word about your workflow - most companies will try to push you and often have unrealistic expectations in home care including home hospice. You need to understand the "productivity" that is expected and find out how to achieve it. There is a minimum standard of documentation that is required by Medicare and ties into hospice reimbursement. There is a time frame to submit your documentation.

If you can - document as much as possible in the house and if you have time between admissions, sit in the car and document if there is no other place. It is not good to save all your documentation for the office or home - that usually results in unpaid overtime.

Make sure you have supplies in your care so that you have what you need and the next nurse or HHA brings out more stuff.

I found keeping a bunch of 1 ml syringes with a cap to pre-draw roxanol very helpful - if you admit a patient and they will need some roxanol until they are seen by the case manager or next nurse and you have doubts that the caregiver is comfortable, it can help to pre-draw 2 or 3 syringes (they are specifically for this purpose - ask the company for them) and put them in a safe place.

ALWAYS make sure you talk about medication safety especially when there are children in the house or come to visit - Roxanol can look like liquid candy.... Make sure they understand where to keep the medication and that some has to be in the fridge (liquid ativan for example), talk about oxygen safety.

I made it a rule to teach the comfort kit at home with the main caregiver and had them draw up medication and put the cap on - demonstration is not enough IMO - when you have the do it you know they are able to do so. The same applies to teaching gtube for example or emptying the foley ....

Make sure you know if the caregiver can read - literacy level is low to begin with but there are a lot of people who can not read and you would not know - they compensate well in day to day. But if they cannot read and you say "here are all the instructions about the comfort kit" they will not be able to understand or do it. In that case you may have to use additional strategies.

If there is a DNR form - make sure it is at the fridge when you leave

Admission nurse is not an easy job n hospice - it is easier in facilities if all you have to do is admission though it is more paperwork.

Don't get discouraged - it will take you a long time to get comfortable if you are new to home care / hospice. Most likely you will not be able to finish your documentation within the allowed in the beginning - this is one of the biggest challenges in home care and hospice and one of the reason why people leave.

You should get reimbursed for driving (mileage) - if you are salaried understand productivity. If they ask you to do an "extra admission" and pay you per visit for that admission - do the math. If they pay you for example $ 100 but it takes you 4 hours in total with visit and documentation you get only $ 25/hour! Most agencies take advantage of their employees.

You will also depend on the hospital if you do mostly home admissions - if they are late with discharge and the ambulance is delayed - you may be waiting perhaps hours until the patient comes home. If you go to a facility but the family member who needs to sign the admission is not on time, you may be waiting.... when you get your admission cases for the day make sure that the timing is accurate - you may have to call the hospital to make sure that everything is on time.

I found that making a courtesy call to the family as soon as I know I have an admission to let them know my name and that I will be there at this and that time really helps them as they are usually nervous.

Good luck!!!

taivin · Dec 29, 2016

Just skimmed the above advice. As an "admissions" person you probably won't be putting in foleys, IV's, etc... (that's for the caseworker). I'm not saying you could be doing an admission, and some kind of emergency would come up and some sort of actual bedside nursing skill would be needed, but admissions is more about paperwork, history, reviewing it all, and setting everything in order. Your job is to make sure that the family actually does qualify for hospice, all T's are crossed and I's are dotted; you go through it all. A thorough head to toe on the patient is imperative as well (to check for pressure sores, bruises, IV's, fractures, etc).

Your own baseline is good to start off with. Question yourself as if it was you in the position; do they need a pressure relieving pad, turning schedule understood if bed bound, do they need a bsc if there isn't one ordered already, if patient still ambulatory is the house fall proofed...so much. I'm sure your company has a check list. If they don't; create one yourself.

There are many signatures to get; many, many, questions are asked. You set things in motion such as ordering the comfort kit, the supplies that your hospice can give weekly, do they currently have necessary medications, etc... You are the face that introduces your company and teaches the family your hospices philosophy and services that are available to them. What is covered by the health insurance, etc...

As for posting the DNR on the fridge, I don't do that unless they actually want me to. In many cases the kitchens are open areas visible to anyone entering, walking around, etc... What I do is pick out an area for the family to have a "command center" (cc). My cc idea came about to me one time I was working with this beautiful family when I first started out on my own as a caseworker. The layout of their house was open, so from the front room you could see the fridge directly. The hospital bed was set up in the front room; the person's house was on top of a hill that overlooked a fantastic view. What a view!

Placement of the bed for the patient in the residential home is a critical decision (another topic); this allows for easier access of visitors and family instead of sticking the person away in a back bedroom, unless the patient wants it that way. No one yet that I've journeyed with has wanted to... anyway; the DNR had been posted on the fridge by the admission's nurse.

On my first visit the son approached me, and asked if we couldn't be a little more discreet, and post the DNR somewhere where it wasn't so glaringly obvious. He told me that they all knew their mother was a DNR, but they didn't need to be reminded of it every hour of every minute (ours are bright green). So the cc idea came to me, and I posted it at the end of their kitchen island on the overhanging kitchen cabinet, along with putting all supplies, binders, medication documentation, etc... all right there in one place (including the 24 hour hospice phone line). I believe the family is entitled to privacy rights concerning the placement of the DNR as well. Posting it in areas visible to visitors and the like who do not have authority to have access to the patient's records appears to be a violation of their privacy rights.

The DNR needs to be in the patient's possession (in the house) and available for review by authorized health care staff and family.

As RNs, one of the more important hats we wear are as educators. Patient and family must understand why the DNR is in place, and what to do in case of any emergencies. In my state at the hospice I worked last, a correct DNR must be in place to qualify for hospice services paid for by CMS. It's not enough just to have a DNR, but that the DNR not have life supporting measure checked (as many do). It's often when admitting the person at their home, that you find life supporting choices have been checked. This is a much debated subject.

This area can be a tricky one, since I'm usually shocked that whatever doctor/nurse didn't teach about why we don't check the box to give fluids for lifesaving measures, and some of the other ones that should be for the full/partial CPR area only. That's why as an admissions RN you need to make sure you go over the DNR carefully. If a change needs to be made, you do it right there as you should have DNR forms that can be redone with the family and then delivered to the doc for signature. (in my state anyway)...every state has different laws and then there's CMS rules, regulation, requirements. Also, many hospice companies have p/p that supplements the regulations for the facilities and the familie's convenience.

In my experience it's two box that that are always checked; give antibiotics (Abs) can be given for blah, blah and supplemental nutrition via g-tube for life sustaining measures. I reassure the family and patient that checking the comfort care box can includes Abxs if a urine infection or cold presents to make the person comfortable (which we do if family wants), but that the two boxes can't be checked to qualify for hospice in the company I was with. Perhaps others can comment on this aspect from their experience and state'/CMS regulations/standing/rules. l

Now I see how the previous poster's post turned out to be long...as I start explaining one thing, other things pop up in my head, as everything is related. Back to the posting of the DNR. It's important for the family to understand the DNR. I tell them call us not 911 if anything happens. Along with the DNR posted in the cc area, I also tape up the 24 hour hospice phone number for the family/patient to call for help/advice/anything. The DNR can also be put as the first page in the medication binder or what ever tool your hospice uses for record keeping at the house. The regulation in my state is that the DNR must be with the patient in the residence (accessible to all interested parties able to view patient's records). Now when the patient goes from hospital to home the DNR must be reviewed. If the DNR is changed, then it will become active after a doc signs off on it, which usually isn't a big hurdle...usually. It's not enough for the family or patient to sign off on it; a doctor must sign for the DNR to be active.

Passing away at your home is a journey that should be taken with pride and dignity. Usually people have built their homes for many years and it's the very foundation where their children were raised; where they went through the stages of their lives. It is only fitting to take the biggest journey of your life at home. I am a huge advocate of passing at home.

Review many of the questions and discussions on this site for hospice; lots of good reading.

Good luck to you... :up:

nutella, MSN, RN · Dec 31, 2016

Talvin - it has been my experience that it depends a lot on the company's set up what the admissions nurse has to do.

And it really also depends a lot on the location - facility vs home.

I have inserted a fair amount of catheters upon admission, accessed ports, and so on and forth - if there is an urgent need you can not wait for the case manager to come next day .....

It is very interesting how different the areas are. In my area, the fridge is the designated place in the community for the POLST / DNR form and all emergency personnel looks for it there. Unfortunately, I do see patients in the hospital who got resuscitated although it was not the wish, because the nerve wrecked relative could not remember if there is a form or where...

Nurseismade RN · Dec 31, 2016

Talvin and Nutella!!! Thank you for the in depth answers and tips!!! This was very informative and helpful!!!!

samoanluver · Jan 26, 2017

please familiarize yourself with medicare hospice criteria/guidlines, can't stand it when a nurse admits to hospice saying patient is non ambulatory, eating bites, nonverbal and when i do my initial the next day the patient is walking, walking and eating like a bear. i think managers will pressure you for admissions and these poor families don't need the emotional roller coaster of getting the hospice talk then the case manager comes and says 'it looks like you are not appropriate, we will have to discharge you' i've been a hospice case manager since 2012 and it makes me mad when admission nurses stretch the truth just to admit someone and it doesn't help that the hospitalist don't know much about hospice other than 'oh you don't want to go back to the hospital? here's hospice.' memorize hospice criteria, be very organized, i heard admissions is a lot of work. good luck!!

StJohnRiver · Jan 27, 2017

I get the admissions, and I have quickly learned who I can trust to bring in appropriate and, more importantly, appropriately educated patients/families. You don't want the RNs who take report from you cringing when they hear your name because you have passed along inappropriate patients, or painted too rosy a picture of what awaits them in hospice. No, there will not be a nurse with them 24/7 -- that is very different than a nurse being on-call 24/7, for example. Be clear with your admissions and honest with the RNs who will be doing the work caring for that patient, and all will be well.