Hospice nurses charting on facility forms

[oomalava2]

I work as an Admissions Nurse for a small hospice in an area where there is ferocious competition between the local hospices. I was told recently by one of the nursing homes we have patients in that the nurses there don't like to work with our hospice because 'you're the only one that won't write med orders out on our forms or chart in our EMR."

Whaaaaaaaat?

Of course, I chart extensively on my hospice agency EMRs and make sure meds are written on agency medication forms.... because I work for the hospice agency, not the nursing home. As I understand it, it's not legal for a hospice nurse to write orders on nursing home (or any other facility) forms. I'd risk my license if I did this, and the nursing home would face fines and possibly a suspended license if they were audited and it was found that the unit nurse was allowing the hospice nurse to be doing this.

Am I crazy? Has anyone else gotten this feeback? What's the best response?

[Jensmom7, BSN, RN]

The Hospice I work for is owned by the same company that owns the facilities where many of our patients live.

It's an ongoing challenge to educate the staff that I am employed by Hospice, and not the facility, even though we have the same name.

When I write orders, I write them on Hospice order sheets, make a copy to be scanned into the facility system, and I give another copy to the nurse.

I'm always being asked why I don't put in my own orders. I explain that our Hospice is considered an outside vendor, just like any of the other agencies that have patients there. They can't put in their own orders, either.

I get eye rolls from new staff, but it is what it is. I can't put in orders. I CAN, however, access their EMR on a read-only basis. So, if they get lazy and blow off orders, I know about it.

[Pbrown1414]

We are allowed to write orders in facility charts as long as we write them appropriately. This is usually in the contract with the facility. You should have a meeting with the facility DON/Admin, and find out what the rules are for their facility. It should specify what they expect from the case manager visiting the hospice patient. It is in the COPS that Hospice and facility coordinate care and that hospice keeps records at the facility and has records in the agency that match. When the hospice contracts with the facility, it is probably stipulated that the hospice is responsible for 'vetting' their own staff and that the facility allows and expects certain things. Your consent packet as well as your admit packet should have something stating what the responsibilities are for each entity. That way there can be no confusion. I would leave a copy of that document in the facility hospice section of the chart or in the separate chart that the hospice keeps in the facility. It would be good if your marketers could come up with a directive for each facility that you visit, that will give you their requests. Some require that the case manager always stops by the Social Workers office, some the DON, some both when they visit, just to check in. Most require that they at least check in with the charge nurse. This is South Central Texas, so I am not sure how it would work for other states, just suggestions.

[nutella, MSN, RN]

Medicare requires facilities and hospice agencies to show evidence on how they communicate and conduct business with each other. The initial agreement should be in the contract but since Medicare worded this requirement (I think it has been effective since 2012 fall), the hospice has to get together with longterm care facilities and discuss this in detail. There should be a discussion about how the both entities communicate, educate, and how patient information is shared.

The medical orders have to be written by the patient's physician but hospice recommends. I used to write me recommendations on the hospice recommendation sheet and flag it in the chart for the nurse to call the physician. Also, you need to print out and place a copy of your assessment, care plan and the IDT for facility review into the chart if you do not share the EHR. Perhaps somebody prints it out for you, in my area the nurses print it out once a week or so and place it in the chart under the hospice tab. Some facilities have their own binders for hospice.

I think because of competition some facilities like to work with certain hospice providers. It is up to hospice management to address and educate the facilities and to find a way that works for both sides and the patient.

[vampiregirl, BSN, RN]

This may be another area where the laws vary from state to state. Then you add in the policies and procedures from your hospice organization AND the policies and procedures from each individual SNF. It can get really confusing at times!

Any orders we get come from the patient's physician or are implemented from our hospice protocol. We can write them on the facility's order form so they get implemented and give it to the patient's nurse. We also make a brief note in the facilities EHR, we have our own logins. Yes, double charting which I despise, but this way the SNF staff has easy access to see our assessment info.

One thing I've found that makes it a little easier is collaborating with the SNF nurses. One, when I assess a patient we are just getting a "snapshot" view of the patient; the nurse from the facility can give me so much more information so I really address all that needs to be addressed. Also, the patient care is a collaborate effort - the hospice patient is "their" patient too, which is so important to remember. (Disclosure - former SNF nurse here, so I also have been on the other side of this.)