I don't thnk these patients are appropriate

[Raviepoo]

I see a number of patients who have mid-stage Alzheimer's. Some are pleasantly confused Some have behaviors. Some are sundowners. When they are ambulatory, able to feed themselves, continent on and off, memory impaired but still able to hold a conversation and appear just a wee bit forgetful to people who don't know them well, I just don't see them as hospice appropriate. I have no trouble with the Alzheimer's patient with a sporifice vocabulary who has lost the ability to feed themselves and forgets to eat. These patients are sliding into death, whether it takes 6 months or 6 years. The patient I have trouble thinking of as hospice appropriate are the ones who are still finding some joy in life; still able to do things for themselves, still able to recognize loved ones (even if a daughter become "that lady who takes care of me"). I look at these patients and I don't see a dying person. I see a person living with chronic illness.

What do the rest of you think? When is a person with Alzheimer's truly appropriate for hospice? I have my own ideas but I want to hear from seasoned hospice nurses.

[chopwood carrywater]

I am not going to debate which AZ pts are qualified under CMS control criteria.

But there is obviously a need for increased care for these pts and their families. The only palliative program in my area is self funded and provides consultation from an Rn and MSN, and to be reviewed at IDT. So often more is needed.

And, even for the pt who truly qualifies for hospice, there is often a family pleading for help in getting the pt ready at bedtime.

Do I have an answer? No. And if anyone knows of any programs or practices out there that are working, please get the word out.

Thanks.

[nutella, MSN, RN]

Very good discussion ....

OP - I did evals and hospice liaison work. Because I believe that the CMS guidelines need to be followed I will not recommend admission to hospice for AZ patients and that was backed up by the Medical Director of the hospice agency as well as the hospice manager. I think there needs to be an understanding within the agency to follow criteria. I always called the hospice medical director to discuss each AZ eval because when I had to tell the staff or relatives that a patient does not meet criteria and the agency will re-evaluate I can also say that this was discussed with the MD.

I do not want to see my name somehow related to admissions that do not meet criteria.

I did a lot of education in facilities to educate nurses about the CMS criteria. Granted the agency is on the conservative side but actually a lot of other agency also stopped admitting AZ patient without being at least FAST 7 something with other problems because Medicare will not pay if inappropriate and also I think if this happens regularly it could be seen as fraud.

With education of nursing home staff inappropriate referrals for Alzheimers decreased. Of course there are still PCP in the community who will make inappropriate referrals because they just want the families to get the support. Or the patient is in a bundled payment like a Medicare Advantage plan or similar and is racking up bills because of repeat admissions to the hospital / ER -- in that case they sometimes try everything to get the pat onto hospice to get them off their roster (because they use too much money so to speak).

Which brings us to palliative care and the needs of the elderly population in general.

There are options for low income patient to receive extra services through elder services and you can make referrals for an evaluation.

Palliative programs exist in the community but every program is different.

The agency I worked for has a true palliative home program, which also means the pat needs to be home bound. The visiting nurse is a hospice and palliative nurse, the pat can have a HHA for 3 times a week up to 2 hours.

I work for an inpatient palliative program that also has an outpatient palliative clinic and will start to make home visits / visits in nursing home to follow up on palliative care needs after they are D/C from the hospital. Who finances it? The MD can bill the insurance. Some of the program is funded with federal money.

People with low income qualify for a lot of help to stay at home including CNA services and such. The problem is for people who have some assets - not necessarily doing financially well but have too much to qualify for services. Those are the ones who often do not get the care they need.

[Pbrown1414]

Well, as the original comment suggests, we are under the auspices of the medicare conditions of participation, and there are specific guidelines for the diagnosis of Alzheimers dementia. Fast of 7a or lower, and documentable decline, wt loss, non ambulatory, etc. It isn't that we don't understand that more care is needed for the Alzheimer's patient that is way above this level on the Fast, but we have to meet the guidelines, or admit to Medicare fraud. I understand too, that the addition of comorbidities can increase the likelihood of death in less than 6 months, and sometimes pts are admitted with a higher fast score. If a pt is able to communicate clearly and remembers your name, they are not appropriate as a dementia diagnosis for hospice. So you have to work harder to find a diagnosis that fits, or wait. We all know that it is hard to have a family member with this disease and the need is great for assistance with daily care and supervision. That is why we should be part of the push to get Palliative Care and Hospice together in a graduated care type of system. That way maybe we could help them sooner.

[Kijana]

If they can feed themselves they are not appropriate, Also, pts on hospice should have some sort of change every 2 weeks when we do IDG meeting. If they are not changing, they should be discharged. You also have to be careful because if someone reports this to medicare and they infact investigate and find pt not appropriate to hospice, you as a RN can be in trouble with my license.

[Raviepoo]

You also have to be careful because if someone reports this to medicare and they infact investigate and find pt not appropriate to hospice, you as a RN can be in trouble with my license.

That is my chief concern. I'm not looking to take services away from families who need them, but I do want to keep my license.

[nutella, MSN, RN]

That is my chief concern. I'm not looking to take services away from families who need them, but I do want to keep my license.

Yes - play by the rules. If your agency gives you a hard time and expects you to admit pat who are not appropriate look for a different agency that plays by the rules. Also, make sure that if a pat is admitted but not declining that the team knows as well as the hospice medical director so they can be discharged ...

[vampiregirl, BSN, RN]

Assessing an Alzheimer's patient for eligibility under the CMS guidelines is the most challenging type of patient to accurately assess, at least for me. Often times I end up consulting with another member of my IDT team if I not entirely comfortable as to whether they fit the criteria. All to often though, I've seen these patient's not be eligible until they are actively dying. At this point we've missed the window to provide support and education through the early stages of grief related to a long disease process and find ourselves with family members in a "crisis" situation.

Several other posters have already identified that these patients are kind of "stuck" in between levels of care. Often the families have no desire for any further testing/ treatment, and just really want/need hospice for the support/ education. Hopefully we will see expansion of palliative care. At least where I am, this is one area that services are really lacking.

[Pbrown1414]

YOu know, getting Hospice paid for was a struggle, surely we can find a way to pay for graduated care within the Hospice framework. It would hopefully include the dme, hha and nurse visit in just a different framework. Many of our Home Health nurses already do that kind of thing. Wish we could find enough volunteers to do some of the "extras" that these patients and families need. Whoops! I forgot psycho-social people!

[softrbreeze]

The ENTIRE picture must be taken into consideration. Does this person have frequent UTIs or falls? Does he/she have a lot of comorbidities? Lost any weight recently? Any change in ADLs? Careful documentation of any issues can make your case including things we might consider minor such as chronic constipation or periodic episodes of bradycardia. We have passed several reviews on long term patients who were exactly as you described because of documentation and careful careplanning.

[Kittypower123, BSN, RN]

If they can feed themselves they are not appropriate, Also, pts on hospice should have some sort of change every 2 weeks when we do IDG meeting. If they are not changing, they should be discharged. You also have to be careful because if someone reports this to medicare and they infact investigate and find pt not appropriate to hospice, you as a RN can be in trouble with my license.

That is not actually the case. AZ patients who qualify for hospice meet a FAST of 7A and a PPS of 50 or less. They may still be ambulatory (loss of that ability is further down on the scale) and still feed themselves. In addition, decline is documented over time not just in 2 week increments. A patient with AZ may have times of relative stability with little change punctuated by issues such as recurring UTIs, PNA, and falls. Weight loss over the last 6 months is considered, changes in medications and functional ability, increased in falls, etc all contribute to determining if a patient is still appropriate for hospice care. Good documentation and chart reviews to assess for decline are important in determining continued appropriateness. Ultimately, it is up to the doctor to certify/re-certify the patient. If a potential patient is questionable, it is important to discuss the patient with the doctor, including comorbidities and recent decline.