Hospice Challenges with SNFs/ALFs?

HazelnutCream · Apr 24, 2016

Some of our challenges:

-ALFs that refuse to allow ANY PRN medications

-ALFs that do not allow hospital beds or oxygen

-SNFs that expect hospice to perform ALL treatments (e.g. daily wound care)

-SNFs (and some ALFs) that contact their attending MD for orders without notifying or updating hospice of the concern or the new orders.

Not one I've personally faced, but have heard from other providers:

-ALFs requesting continuous care any time a patient has ANY symptoms

I'm sure there are more that will come to mind but these are the biggest ones that I can think of. Interested to hear what others are facing and what is working for you.

Thanks! :)

nutella, MSN, RN · Apr 25, 2016

To get a better understanding of the challenges you need to understand the differences in culture and work flow.

While LTC and AL appreciate hospice commonly as a vehicle to get an additional CNA for care as well as equipment (low airloss mattress, broda chair, hoyer...) they do not necessarily appreciate the involvement of the hospice nurse. I know, that sounds weird but is a fact. Some AL and LTC that have a lot of dementia pat try to get them on hospice for the additional "perks" - not necessarily because the love hospice, hospice philosophy and want to decrease suffering and end of life. That might be a motivator as well but the desire to get a broda chair, air mattress and the CNA is definitely high up on the wish list.

Facilities do not appreciate hospice nurses coming in and be "gung ho" about anything. They can be very protective or territorial and are very sensitive about any RN coming in and "telling them what to do". There is a lot of dynamics going on that I am not going to write about but basically while they might appreciate hospice, end of life is not their priority and the sense of urgency that a hospice nurse has towards relieving suffering does not reflect their sense of urgency in most cases - leading to conflict.

Here are some pointers to get a better relationship with facilities:

- Make sure you have all the contracts updated / in place and review the contracts periodically with administration to ensure you are on the same page.

- Facilities like consistency - the same liaison and nurses for one facility helps

- Assign nurses who like that environment. If a nurse who is just fine at home hospice but despises facilities goes in there you will have problems and they will give referrals to somebody else.

- Hospice nurses who behave like guests and are respectful do better in facilities

- It is all about collaboration and communication. The hospice nurse needs to talk to the primary nurses and aids who take care of the resident to get a full picture and tell them they appreciate the input.

- Never teach with an attitude. This is huge in facilities. Some hospice RN are upset when a nurse does not understand the importance of pain medication/different medication/ not giving meds. Teaching needs to be done without blame and be positive and constructive.

- Clear recommendations and scheduled meds instead of PRN if nurses are not giving meds that the pat needs.

- Facilities see hospice as a service providers - acting like one with quick response to referrals/equipment helps.

- make sure the pat is seen as often as the pat would be seen at home.

- don't create drama in the facility.

The market has become tight as pat in facilities tend to stay on longer leading to more "profit" with less "needs". Some hospice agencies specialize in this segment and market aggressively. I know of places where companies "follow" resident's weight for example and make a call to the family once the pat appears to meet hospice criteria to take them on asap. This is usually within a tight relationship of a facility with a specific hospice that is already in the facility.

Although pat have a choice when it comes to hospice, the nurses and administration certainly influence who gets referrals.

If you want to create a better relationship offer education in facilities, talk to nursing director about the specific needs/problems/concerns.

Have the hospice nurses go into facilities that enjoy that environment and collaborate well with positive communication skills.

Thinking about this - perhaps I should write an article ....

Good luck!

MunoRN, RN · Apr 25, 2016

I don't work in an SNF or ALF, I help coordinate care between a hospital and nursing facilities, so I'm by no means an expert on hospice billing, but from what I understand here's how it works; Prior to transitioning to hospice, the nursing home bills for room and board as a base charge, and then all other treatments, short term more frequent medications, etc are often separately billable. The room and board cost essentially covers 'simple' medication administration. When the patient becomes hospice, the nursing home can now only bill for room and board, all other treatments, medication administration costs, etc fall under an all inclusive hospice reimbursement. So if the hospice is now the one receiving payment for everything beyond room and board, I can certainly see why they would expect hospice to provide those services.

nutella, MSN, RN · Apr 26, 2016

I don't work in an SNF or ALF, I help coordinate care between a hospital and nursing facilities, so I'm by no means an expert on hospice billing, but from what I understand here's how it works; Prior to transitioning to hospice, the nursing home bills for room and board as a base charge, and then all other treatments, short term more frequent medications, etc are often separately billable. The room and board cost essentially covers 'simple' medication administration. When the patient becomes hospice, the nursing home can now only bill for room and board, all other treatments, medication administration costs, etc fall under an all inclusive hospice reimbursement. So if the hospice is now the one receiving payment for everything beyond room and board, I can certainly see why they would expect hospice to provide those services.

The way it works in SNF is like this:

Room and board is paid privately or Medicaid.

Medicare pays for hospice via the hospice benefit. Other insurances also have a hospice benefit (most of them ..).

A patient can not be getting care under the skilled nursing benefit and receive care under the hospice benefit at the same time.

Financially, it can be difficult if a person does not qualify for Medicaid. Room and board can easily add up to 12,000 - 14,000 dollars a month in my area.

What hospice agencies need to cover is determined by Medicare. Of course hospice covers hospice diagnosis related medications (example : somebody come on to hospice for ovarian cancer - all the pain meds, nausea med and so on are covered by hospice but NOT expensive inhaler for COPD!).

Hospice always covers equipment needed to take care of a patient like hospital bed, air mattress, hoyer lifter, recliner and so on and forth - also transport wheelchairs. The hospice rents those things from a company that delivers to the patient.

The nursing home does not need to bill hospice for the hospice benefit as the hospice will provide the hospice covered items/meds.

If a patient has Medicaid it gets complicated. In that case, Medicaid will pay the amount for room and board to the hospice. The nursing home bills the hospice agency and the hospice agency pays the nursing home with the money from Medicaid. I have never understood why Medicaid is not paying directly to the nursing home once a pat has signed up for hospice but that is how it is.

If a person pays privately - the nursing home bills directly for room and board to the patient/family.

So - it is not correct that all other treatments and medications fall under the hospice benefit. Only diagnosis related medications... and there is no PT/OT/speech and swallow etc. unless for a one time teaching for example...

Pbrown1414 · Apr 30, 2016

1. the facility is paid for basic care and medications, wound care, procedures, tube feeding maintenance, via the room and board payment by the patient or Medicaid/other insurance. that would mean that the hospice nurse would not be responsible in the nursing home setting, for passing meds and other daily or multiple daily meds or procedures. The hospice nurse is, just like at home, responsible for the education of the patient, family, and caregivers, (the nursing home nurses and aides, as well as family members providing care for the patient). The hospice nurse is responsible for the assessment and direction of care under the orders and direction of the attending physician whether it be the facility physician or the hospice medical director. That would mean, that the hospice nurse should assess wounds at least once weekly and when the facility nurse notifies her that there is a change. She should direct the wound care based on the orders and the hospice policies and procedures.

2. problems with nursing facilities are many, and there are different reasons/causes. Most assuredly, nurses that have a negative opinion of hospice, will likely be hard to win over. Hospice nurses must always remember that the facility is our client, just like the family when a patient is at home. When the family member truly knows the procedure and the medication and its dosing, we don't usually mess with them. Same should apply in a facility. The only issue I see frequently, is the reluctance on the part of the caregivers to give prn medications when they are needed. The old adage, "pain is what the patient says it is", is taken seriously by hospice nurses, but not so much by others. We must educate. I think a pain management course should be offered to the facility by the hospice, with more than one session, just like what is offered in Relias or other such educational companies.

We could offer a post session discussion group with a meal or snacks and coffee, drinks etc. This would help tremendously and could be given twice a month maybe. Other facility nurses could be invited, especially affiliated facilities. Expensive? Probably. Worth it? Definitely.

3. Facility nurses can and do contact the facility physician or the attending for orders many times, without contacting the hospice nurse, or notifying her/him of the symptoms or changes that they call about. We can only continue to let them know that we need to be aware of changes and increased symptoms in order to correctly coordinate the patients care. We can also at that point, increase our visits to increase the possibility of catching these changes prior to the need for the facility nurse to address them, or call the facility daily to ask if there are any issues or problems that need attention. Increased time on our part at the beginning can help to decrease total time as care continues. Also makes for a better communication and care for the patient, which is our goal anyway. Right?

4. Medicare has stopped the use of continuous care in a skilled nursing facility with the answer that it is "duplication of services". In many cases, more frequent visits by all members of the hospice team, and possibly utilizing your volunteers more frequently as well as utilization of what some hospices call "11th hour volunteers" to provide support both physical and emotional for the pt and family can help to alleviate some of the "time intensiveness" on the part of the facility staff. Educating family in a tactful and understanding way as to the roles of the nurses and aides in the facility can also help. Normally when a pt really requires continuous care, they are at or near the active stage of dying, and the time spent is both our responsibility and our pleasure as hospice staff, No?

The one thing I do know, is that attitude begets attitude, and positive is always better than negative. Whether we choose to acknowledge it or not, most people that work in nursing homes and assisted living facilities do so because they enjoy working with this population of people and they do become attached. We absolutely must treat them as family!

jeannepaul, BSN · May 13, 2016

I usually take out pens, sticky notes, they tend to be a bit friendlier in answering questions.

electronic records are a big problem for me. The understaffed nurses are usually busy so they have to stop everything to help me. I usually try to find the answers in the chart first before bothering them.

BerryhappyRN, MSN, RN · May 30, 2016

AAAGGGHHH! Thanks for asking! I used to be an ALF hospice nurse, I am now a LTC hospice nurse. The greatest thing that is lacking on both sides is COMMUNICATION! Somehow, someone has GOT to figure out how to better communicate: Changes in condition, new orders, new wounds, falls, ER visits, family concerns, BMs, intake, weights, etc...

Now that so many facilities are electronic I think communication has gotten worse! Instead of being able to read a facility POC on paper, I have to bug an overloaded floor nurse to print it off the computer. Instead of looking in the weight book for current weights, I have to bug an overloaded floor nurse. I want to see a copy of a MAR/MOR, ask the overloaded floor nurse! I have patients who are sent to the ER without notifying hospice. I find out about falls, 3 days after the fall. I went to complete my weekly assessment just to find out my patient DIED the day after my previous weekly assessment! C'mon man, he died and no one called HOSPICE??!!!

ahem, so what I am ranting about boils down to communication.

Thank you for asking!