Hospice in LTC.................

Katillac, RN · Oct 10, 2005

question for all ya hospice nurses out there...............our hospice has several ltc patients. on for things such as dementia and chf. my question is.... do you take over complete care for that pt? let me give an example. my chf patient in the nursing home fell yesterday and got a laceration to the head. the nursing home called and we went out to assess and cleanse the wound. the fall really wasn't chf related but do you still go out to assess or would you let the nursing home handle it? or the dementia pt that also has diabetes and their blood sugars are out of control. is it hospice's responsibility to get the blood sugars under control or is it the nursing home's since they are the primary care givers? just curious and needing some input.
thanks

i look at the delegation of care of patients in an ltc much the same as i do patients in our hospice residence. the primary nurse in the case functions as the case manager, while the staff nurse delivers the care. if a resident gets a skin tear, for example, the staff nurse assesses and does the documentation, including filing the incident report. he or she also dresses the tear per palliative care protocol/standing orders. the primary nurse is notified and may make adjustments in the care plan (and must at least change it to include skin integrity after doing a wound assessment on the next visit), but we don't see a need for the pn or the on call to immediately respond. we want to be notified when there are status or order changes, but it's up to the staff nurses in an ltc or our residence to do the hands-on part.

as far as unstable bgs in the demented patient, i would expect the staff nurse to assess and note a bg outside perameters and respond appropriately per orders, and notify the hospice if it was an acute issue, but the pn would need to collaborate with staff nurses and the pmd to develop a plan to keep the bgs within a more appropriate range. it would be the staff nurse's responsibility to notify the pn if it was a chronic issue, but also up to the pn to review the chart to look for this. the bg issue is part of the care plan, and she needs in her weekly assessment to review the care for an appropriate response to the problems noted in the care plan.

it can be challenging, especially with the varying skill levels of clinicians, to get the best care possible delivered. but we prefer to teach and support good decision making on the staff nurses' part rather than attempt to have the pn do all of the care. not only would that be unworkable in terms of care load, but it would not foster very good collaborative relationships with the snf staff or our residence staff nurses.

doodlemom · Oct 10, 2005

I don't agree with managing a dementia patient's diabetes in the nursing home. The nursing home is ultimately still the primary caregiver who spends the majority of the time with the patient. Of course in the home I would take care of the diabetes or any other problem that arises. Because they are in the home and have no round the clock medical staff to take care of their needs. JMO

We don't go out and give the injections, but if the facility calls us and reports high blood sugars, we do call the doctor for them and get an order. Most of the time, the facilities don't call us about this kind of stuff but if they do we take care of it for them. They appreciate that we do things like this for them and that's why they give us so many referrals - as opposed to giving them to all of the for-profit sharks swimming around. Again, they are paying the same amount for our care as the home patient and deserve the same care. I worked for a for profit for a short time and I remember that a patient in a SNF had fallen and broken her hip. When called by the facility, the on-call nurse told the facility nurse to call the doctor and get an order for an x-ray instead of calling the doc herself and calling in mobile xray and getting it all set up. This was viewed as an OK thing to do at the hospice, but the hospice I now work for would not think this is OK. The facilities have around the clock care, but I view part of role to be helping the facility staff as much as possible. Why else would they want to have us in their facility?

webblarsk · Oct 11, 2005

We don't go out and give the injections, but if the facility calls us and reports high blood sugars, we do call the doctor for them and get an order. Most of the time, the facilities don't call us about this kind of stuff but if they do we take care of it for them. They appreciate that we do things like this for them and that's why they give us so many referrals - as opposed to giving them to all of the for-profit sharks swimming around. Again, they are paying the same amount for our care as the home patient and deserve the same care. I worked for a for profit for a short time and I remember that a patient in a SNF had fallen and broken her hip. When called by the facility, the on-call nurse told the facility nurse to call the doctor and get an order for an x-ray instead of calling the doc herself and calling in mobile xray and getting it all set up. This was viewed as an OK thing to do at the hospice, but the hospice I now work for would not think this is OK. The facilities have around the clock care, but I view part of role to be helping the facility staff as much as possible. Why else would they want to have us in their facility?

You have giving me some things to think about. I am always gathering opinions and things that other hospice's are doing to make my hospice the best it can possibly be. I know the nursing homes that we are in love us and prefer us to the non-profit hospice in the area simply because we give better care and do help the nursing staff out when needed.

webblarsk · Oct 11, 2005

i look at the delegation of care of patients in an ltc much the same as i do patients in our hospice residence. the primary nurse in the case functions as the case manager, while the staff nurse delivers the care. if a resident gets a skin tear, for example, the staff nurse assesses and does the documentation, including filing the incident report. he or she also dresses the tear per palliative care protocol/standing orders. the primary nurse is notified and may make adjustments in the care plan (and must at least change it to include skin integrity after doing a wound assessment on the next visit), but we don't see a need for the pn or the on call to immediately respond. we want to be notified when there are status or order changes, but it's up to the staff nurses in an ltc or our residence to do the hands-on part.
as far as unstable bgs in the demented patient, i would expect the staff nurse to assess and note a bg outside perameters and respond appropriately per orders, and notify the hospice if it was an acute issue, but the pn would need to collaborate with staff nurses and the pmd to develop a plan to keep the bgs within a more appropriate range. it would be the staff nurse's responsibility to notify the pn if it was a chronic issue, but also up to the pn to review the chart to look for this. the bg issue is part of the care plan, and she needs in her weekly assessment to review the care for an appropriate response to the problems noted in the care plan.
it can be challenging, especially with the varying skill levels of clinicians, to get the best care possible delivered. but we prefer to teach and support good decision making on the staff nurses' part rather than attempt to have the pn do all of the care. not only would that be unworkable in terms of care load, but it would not foster very good collaborative relationships with the snf staff or our residence staff nurses.

i totally agree, thanks for your input! very informative and goes along with what i have been thinking.