NEW Hospice RN Case Manager Question!!

ShimmaShimma0304 · Sep 16, 2011

I want to mention one other thing... I NEVER was under the impression that I'd walk into a facility and have them drop what they were doing to help me with all of my needs while I was visiting my patient... But I have been to a few places where the patient was confused, not exactly tiny OR cooperative with turning so that you could get a good skin assessment in. Since you have to visit 2x per week... And many are nursing home patients... That's a lot of solo turning, pulling and tugging. I just wondered what most people do... That's all. There is one patient who is TINY and not cooperative, stiff as a board with tons of contractures and he is SOOOOOOOOO hard to turn... I guess I will get in a niche and figure it out as I go. ;0)

camoflower · Sep 21, 2011

Case Manager, I worked in "the worst hell whole" said a patient that got to leave. Other patients sang the song Hotel California along with the CNAs whilst I worked there. My experience, and I'm a nurse w/2 years (YaY!!), with hospice...was an eye opener. One the LPNs murmered because of the "lack"of help in our facility, and yes those in hospice care are the dead weight back breakers, belong to hospice. I had to, as wound care nurse and night supervisor, educate LPNs - just because she is hospice...doesn't mean when Hospice Nurse yells for help on getting a change of status for the worst on vital signs that you can walk away from the situation and say "that patient belongs to hospice..not our problemo". Our hospice gals would roll their eyes at meee from the frustration - yes the DON and ADON .."were aware" - and did not care..when hospice went to the office LPNs laughted. Hospice at this facility were called even when I went to the patients bedside and told the LPNs that did not want to answer bedside families questions "Don't call hospice - its not time" they would run and call hospice anyway then hospice would be called in for another round of vital signs and come to me and say "why was I called the patient is dying but it may be another 3 days..?" I'd be wasting my time replying.."duhh because an LPN went behind my back..and nothing will be done or said to the LPN because our turnover was 90% a year". Our CNAs were pathetic but we did not have enough of them, I was a CNA/Wound Care/Supervisor/feeder/admissions clerk and was expected to do wound care, chart, schedule, assign baths, call in CNAs when someone called in, which took up to two hours every day...and cared for my patients, loved them dearly. The ADON thought I was after her job..I would have lived there but liked being the wound nurse. Now my hospice gals would come to me and I'd take them and show them the wound and did the wound dressing change and we'd have the same measurements and full descriptions together. If she was running late I'd have her call and I'd leave a copy for her at the nurses station of my would care. But to get to know one another when I first met hospice I'd go with them, my nurse would also hands on help me put that dressing back on the coccyx on those dead weight..or the ones that had several skin tears. Our hospice gals would have the best smelling patients and other families would come in and ask can my dad get on hospice - look how clean they are and fresh smelling they are. Even when State would come into the building...the hospice who had great shampoo, great care, good smelling deoderant etc...and the nurse kept it with her or the CNA's would steal her products. I believe every hospice nurse should bring her CNA with her, marketing themselves by having the best smelling, best cared for patients...some of our hospice patients could tell others that they were cared for by hospice. The families of our facility stood very firmly behind hospice because our attitude of the DON and ADON -backwoods hillbilly Drank BIG OL SONIC shakes -stuck together - which ran everybody off - were severly lacking. Sorry you have to ever walk into a hell hole prison of a glorious retirement community. The money that the facility makes ...the CEO's are way way way overpaid, the DONs need to get out of the office and onto the floor and be feeders at lunch at least 3x per week. Even the marketing needs to get certified as a CNA and be a feeder at lunch time...and the recreation person too..they treat their little dogs better than granny/grandpa at the nursing home.

tenadick · Sep 21, 2011

There is an association of case managers called CMSA and they have a communities page where CMs from various work settings swap ideas. You may be able to find a group of CMs with hospice experience who could be of help to you. Here's the link: http://www.cmsa.org/groups

NurseNed · Sep 21, 2011

Well - in this one instance, I was making a visit to a patient in one of the more "difficult" facilities I visited - yup - with the State Surveyor in tow. A couple of the NH staff did not make the connection and began giving me a hard time about me seeing the patient when it was not convenient for them.

Long story short: The surveyor identified herself, invited those staff and their supervisor, ADN and DON into the Administrator's office, and advised them all regarding the law, whose patient this really is, regardless of domicile, and unless they did not want her to make a quick phone call to get an impromptu survey of their own underway, they had better "fix this here and now ...". The looks on their faces were studies . . . . !

She went on to add that the hospice staff was not only essentially "free help" for the facility, but with hospice charting in the facility's chart, it actually made their NH charts look better to them, the surveyors, for their own surveys in the "coordination of care" arena at the very least, especially if charting shows notification of Hospice for changes in patient status and appropriate followup charting in both directions.

This surveyor had not done surveys in this facility for a few years due to focusing on home care and hospice, but the administrator and DON did remember her.

She finished our little meeting by saying " ... seeing evidence of good team work makes me very happy ...", looking at all of us with what I took to be her best shark-grin. We got the picture.

They discovered Hospice helps them in other ways: supplies, doctor calls, meds and trying to be available as a friend in need.

Life was better after that and being able to relate this first hand experience to the proper people in my other facilities helped too as well as being able to bring some of my Army Chaplain skills into the mix.

thnx,

ned

withasmilelpn · Sep 21, 2011

Why are you counting narcotics? We have hospice come and I worked for hospice. That never happens. The nurses at the facility count at the start of a shift and at the end of shift.

To count again would be annoying.

And while the wound nurse was out of line - our wound nurse has a day where she has to document, measure and determine tx. A lot of our treatments are weekly now. You might explain to her first your requirements and see if it's helpful to do it at a certain time - or work together. And having been in a position where I finished all my txs only to have the doctor remove it to look at them. Ugh. Of course he didn't put a new one on as I'm sure you did.

asare rn · Sep 21, 2011

No manners where is this place? no professionalism at all. When we work we address each other with courtesy even we do not agree with the person.

withasmilelpn · Sep 21, 2011

Also - if a nurse calls Hospice - they are looking for support. They do not always know the answers to families questions. Or they simply aren't comfortable. Or with their 20 - 30 or more patients - they simply cant give the time the patients and families need and deserve. don't have any problem with talking to families. As I said - I was a hospice nurse. If you resent them calling you then I can understand why they might resent you.

Remember this is a team effort. And although legally it's your patient, hospice is (usually) only there for visits. You leave while the nurses and CNAs remain for the 8 + hours.

gerigal · Sep 22, 2011

I always try to help the Hospice nurses that come to my facility, but my load is great, and we have to get our work done, we aren't allowed overtime, and it seems they show up at the worst possible times, and need help when I am in the middle of a situation I can't walk away from at that moment. Sometimes it seems that Hospice causes more time consuming work, than just taking care of the residents ourselves. However, I really do appreciate them, most of them try to help, and take some of the load .

Namaste79 · Sep 26, 2011

I was a Case Manager for many years at a "less than ideal" LTCF. It took several months but I worked this place. I let them know I was not only there to manage the patient's care but to HELP them.

When any orders were changed I not only wrote the dr's orders in the hospice section and in the Dr order section of their chart but, after making sure it was okay with the DON and the floor nurses, I would also write then on the med cart's med sheet and update any of their corresponding Care Plans (after finishing I would always review them with the floor nurse).

I would also not only leave a copy of my schedule (along with the rest of the hospice team) in the chart but I would call in the morning to let them know I was coming and that I WOULD DO THE WOUND CARE FOR THEM. For one patient with very deep and moist wounds myself or my LVN would visit daily to change and assess.

When patients were challenging emotionally I would make sure that at least one of our team members visited daily. And of course when patients declined and began the dying process we would increase our support to not only the patient and family but also to the staff, making sure that symptoms were not only well-manged but that needs were anticipated thus the nurses would have what the needed when the time came. They should never have to call in a panic for morphine, lorazepam, atropine, acetaminophen.

Also, sometimes if interventions were having to be changed daily and the situation warranted Continuous Care rather than In Patient was the way to go. Believe me the nurses were calling to request our hospice within six months.

Good luck!!!

LMTRN · Sep 27, 2011

Ultimately, you're playing in their sandbox.

When I was doing facilities, I would ask staff what THEIR schedule was, and see the patients with them when they were getting personal care done. If you help them a time or two, you may see a change.

Good luck!

tewdles, RN · Sep 27, 2011

Part of the case manager's job is to try to develop a good professional relationship with the staff that are providing care for our patients in their LTC. It is generally not an easy thing to do, and it is additionally complicated when we partner with facilities that have any level of staff or management dysfunction. Although many of us don't like it we are all salesmen when we are in facilities. Marketing is part of our job and so it is important that we do not intentionally,or unintentionally create animosity with our potential referral sources. All patients deserve good hospice care regardless of how bad a facility they live in.

It sounds like you have been assigned responsibility for patients in a facility that has a reputation for being difficult. You have several options for this dilemma. First, you can ask to have that facility and it's patients transferred to another CM's caseload - perhaps you could trade a facility. Or, you could opt to always visit the patient with the HA, or when a volunteer, or other hospice staff are present so that they can help you.

I, personally, would accept the challenge of creating as good of a working relationship with that staff as I could. I would meet with as many of them, at all levels of care, personally and talk with them about the patient. I would ask their opinions and then listen carefully. We learn critical communication skills in nursing school, use that and the nursing process to guide you in those interactions.

We build trust with facility staff by getting to know them and letting them get to know us. It is important that they like you. Don't underestimate the power of treats, you know - bring donuts some morning, or some other treat later in the day. ALWAYS be professional, polite, and helpful. DON'T get involved in their politics. (the bathroom is a good place to hide for a moment if there is drama) DO get to know the management and the charge nurses. I am terrible with names but I try really hard, that is important to people.

Make sure you go to their care conferences for your patients. That is a good place to validate the work they are doing and include them in the hospice POC. Work WITH their MSW staff, the wound care nurse, OT/PT, CNAs, etc. Make them feel like they are part of your hospice team.

There are many facilities that don't provide very good patient care, have bad management, and/or are difficult to work with when they have hospice eligible residents. Not every nurse can work in every facility, but it IS possible for the right person willing to give it a go. Maybe that's you.

Good luck with your patient and with this challenge.