Hospice agency shutting down - help!

[mslavender1982]

The hospice agency in my small remote town is shutting down next month.  They stopped taking new admissions a month ago.  I am a nurse case manager at our hospital, and we are trying to come up with a short-term solution for our end-of-life patients until we can put together a more long-term solution.  (I was a home health and hospice nurse for 10 years, so I'm coming at this with a little bit of a knowledge base.)  Any ideas or advice from this group would be much appreciated!

Some things we are working on so far:

- Palliative packet for patients discharging home - education sheets on symptoms (pain, dyspnea, constipation, anxiety/agitation), medication instructions in plain English, basic skin care, short booklet about the dying experience and what to expect, important contacts (physician, pharmacy, mortuary); our SW team and chaplain are also contributing to this packet

- Doc-to-doc handoff between hospital physician and patient's PCP

- Post-discharge - a couple of phone calls from an RN within the first week to make sure they picked up their meds from the pharmacy and understand how to use them

- Community partners - we have a small mobile integrated health team that consists of an LVN, an EMT, and a paramedic that can offer check-ins and limited assistance

Some concerns:

- The physicians in our community are worried about the burden this will put on them and the clinic staff

- There is no nighttime or weekend coverage for these patients/families

- Hospital admissions and hospital lengths of stay will increase; our facility only has 40 medical beds that service our town and the surrounding villages

Some questions:

- Is hospice/palliative services via telemedicine an option? 

- Is there some sort of phone-triage service that can offer support or advice during the night and weekend?

[LVN_IAM]

mslavender1982 have you tried to reach out to surrounding counties to see if there is any Hospice agencies that can pick them up? When my company closed in 2018 they were responsible for getting each patient assigned to a new company. 

[mslavender1982]

Our town is landlocked and you can only enter by boat or plane (Juneau, AK).  So there are no surrounding counties that could formally pick them up on their service.  Our team has pondered seeing if other hospices in our state could be a remote resource for our end of life patients. 

[LVN_IAM]

Wow that's a tough one. Yes even remote/telemeds maybe an option. Wishing you the best. 

[sleepwalker, MSN, NP]

On 9/17/2022 at 8:22 PM, mslavender1982 said:

Our town is landlocked and you can only enter by boat or plane (Juneau, AK).  So there are no surrounding counties that could formally pick them up on their service.  Our team has pondered seeing if other hospices in our state could be a remote resource for our end of life patients. 

Have you reached out to the Public Health Service regarding options, information, etc.  Can the village health clinic provider assist?

[pmabraham, BSN, RN]

As a visiting hospice RN case manager, I don't know how much I would trust cameras in order to be able to properly see the condition of the patient.  While vital signs, in my experience, are often not the main factor for me to determine estimated end of life, most family members are not trained on how to properly take vital signs... and while this part can be easier if the patient is at a facility, there is still the issue of not being able to properly see the patient (more often than not, I know if a person has <= one month based on visual presentation).

[NRSKarenRN, BSN, RN]

Check out these resources to consider for your discharge packets:

Barbara Karnes RN series of booklets on  end of life education so helpful as written in plain language using every day terms average person understands.  I first used her book " Gone from My Sight",  part of admission packet while working hospice in 1994; purchased in 2019 for my sons to read when husband terminal and agreed to DNR at home.  Booklets cost $3.00

Titles include:

• Gone from My Sight: The Dying Experience
• The Eleventh Hour: A Caring Guideline for the Hours to Minutes Before Death
• Pain at End of Life: What You Need to Know About End of Life Comfort and Pain Management
• The Tree of Life: End of Life Education, A Coloring Booklet and Family Tree -for children

Hospice and Community Care Online Serious Illness Support series of videos. Unable to provide advice re securing  Hospice services in Alaska. 

Hospice Telehealth CAN be provided under new medicare regulations:

See Hospice Telehealth Flowchart | NHPCOhttps://www.nhpco.org › wp-content › uploads  

Quote

Under 42 C.F.R. § 418.304, non-administrative, direct patient care services provided by a hospice physician or nurse practitioner serving as the patient’s designated attending physician (“NP”) may be billed to Medicare when (I) the services are reasonable and medically necessary for the palliation and management of a Medicare hospice patient’s terminal prognosis or related conditions and (ii) the physician/NP is employed by or under arrangement with the hospice (“Billable Physician/NP Visit”). Under the federal 1135 waiver issued in response to the COVID-19 pandemic, patients now can receive Medicare telehealth services in any location, including at home, for the duration of the pandemic. Further, on a March 31, 2020 National Stakeholder Call, CMS confirmed that Billable Physician/NP Visits can be performed via telehealth.

  Your organization may want to reach out to the National Hospice and Palliative Care Organization for advice.

Thanks for caring about this issue, hope it was bumped up to administration as a  community issue ....

..which falls back on discharge planning staff in my prior experience as Intake manager for 5 county home health agency.  

 

[Kelly77marie, RN]

I would also encourage Hospice and end-of-life education for your physicians. I have found many providers lack knowledge about how to properly prescribe/deprescribe at end of life. 

[SunDazed, BSN, RN]

Vynca out of Palo Alto, CA bought the remote palliative care company started by Dr Fratkin here in Northern California. It involves a lot of remote care. I have heard that the caseloads are quite high for nurse case managers, so it is likely more palliative based than hospice...