nursing home difficulties

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Specializes in hospice.

I am with a hospice who is "affiliated" but not "owned" by a nursing home. We are having much trouble with the nursing home as far as us getting referrals from "anyone", the nursing home wants to "screen" for appropriateness before it goes to hospice, so unfortunatly there are many patients who could use our help however are deemed inappropriate by the nursing home... and no, they have no experience in hospice. Also, we are now having problems with the nursing home dc'ing our orders when they feel it is not appropriate as well as dc'ing problems we initiate on the POC. This has been getting worse over time and is now interfering with the treatment of the patient. Hospice is not notified when things are dc'd. Any suggestions??

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Specializes in Hospice, Palliative Care, Gero, dementia.

Have there been any discussion on the DON level? Opportunities for in-services for the NH about what hospice is, how it works?

Just a couple of thoughts off the top of my head. Must be so frustrating?

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Specializes in Rehab, LTC, Peds, Hospice.

It may be billing issues, unfortunately. As long as a person can be medicare skilled the NH gets reimbursed hirer than if they are on hospice. I loved bringing on Hospice at the nursing home I worked at, but I do know that it can be hard to be collaborative with the hospice nurses sometimes. Truthfully LTC is so busy they often don't notify the family with changes and forget to notify hospice as well. And you have to remember all the orders we get from you have to be approved by the doc that follows them at the NH. Makes for a morass of issues, certainly. I agree that an inservice may be in order, hoever.

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Specializes in Hospice, Palliative Care, Gero, dementia.

The whole payment thing is a major issue, for sure. The latest issue of The Gerontologist has an article co-authored by Susan Millar who has done a lot of work on hospice in nursing homes. In it she interviews NH and Hospice personnel about the referral, or lack thereof, of specific NH pts. It looks to be a pretty well designed study, and may help us understand a bit more about how this situation unfolds.

Here's the citation (forgive the lack of appropriate format, I'm just doing a quick cut and paste):

Referral and Timing of Referral to Hospice Care in Nursing Homes: The Significant Role of Staff Members

Lisa C. Welch, PhD, Susan C. Miller, PhD, Edward W. Martin, MD,

and Aman Nanda, MD

The Gerontologist Vol. 48, No. 4, 477-484

This is the first time I've tried this, so if the attachment doesn't work, either a mod will help me or I can send it out to anyone who is interested.

[ATTACH]6645[/ATTACH]

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Specializes in Hospice, Palliative Care, Gero, dementia.

Sorry to self reply but woo hoo! Looks like it works. (another reason to be happy that I upgraded my membership)

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As far as them d/c'ing orders without consulting you, you may need to gently remind them that it is HOSPICE who is supposed to drive the plan of care. If the care plans don't dovetail, THEY will be sited as well.

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I work in N.H. as a case manager for Hospice. It does sound like an inservice is in order. I also tend to think that if the DON is pro-Hospice, that helps tremendously. I also make myself indispensable to the nurses by calling Doc's for them, measuring wounds, doing wound-care, etc.....on my Hospice pts. This frees up the N.H. nurses so they really appreciate me and go to "bat" for me when it comes down to who's skilled and who's billed. Bottom line, skilling for p.t., o.t., speech are big $$ makers for the N.H., and with the recent cutbacks, they (management) get aggressive with Hospice and state that their nurses can provide end-of-life care just as well as Hospice can. Grrrrr!!!!! That's when I fire back diplomatically (to management), "Oh yeah? Have your nurses been trained for end-of-life care? They respond with, "Yes." But I know they haven't been.

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Specializes in hospice.

Thanks for all the input. I will suggest an inservice on this to the NH staff. Unfortunatly, the DON is one of the people who is dc'ing orders. Quite frustrating.

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Specializes in LTC,Hospice/palliative care,acute care.

Is it common for the nursing home to present you with a list of approved policies and procedures? We are now consulting a local hospice (after years of in- house "comfort care" protocols that were sometimes anything BUT comforting) I saw the minutes from the inservice and we have listed the meds that are approved for use-we will not allow the use of IM haldol which I hear is very effective for terminal agitation.I don't know why or who really wants it prohibited (med. director or don) How would you deal with something like this? Would your company accept the contract with that type of condition? The DOH finally forced us to offer real hospice services to our residents -the prevailing attitude amongst the admin has always been "we don't need nurses coming in here telling us what to do" Well--yes-if it is beneficial to the resident we do need the expertise.It looks like admin is going to have a difficult time learning to work WITH this hospice.

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Specializes in Rehab, LTC, Peds, Hospice.

Yes it is common. My Hospice mentioned that in the Nursing Homes they could not use Atropine eye gtts orally for increased secretions, because it was an off label use. They could only use Levsin. Nursing homes are SO regulated. There is a list of drugs the are not recommended for geriatric use due to the side effects. (I can't remember the name, I'm sure it will come to me later.) There has to be a lot of supporting documentation that assures them that it is necessary. Often times that documentation doesn't get done. This is when Haldol is used a a behavioral intervention, nevermind for nausea... On state surveys they can get defieciencies for inproper use of restraints which is what Haldol is. There probably needs to be some legislation that allows Hospice to do in the NH setting what it does at home and on my inpatient unit, (and perhaps there is) but expect it will always be a struggle.

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I've never heard of the Beers list affecting those residents on Hospice. Wow.

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Specializes in Hospice, Palliative Care, Gero, dementia.
Yes it is common. My Hospice mentioned that in the Nursing Homes they could not use Atropine eye gtts orally for increased secretions, because it was an off label use. They could only use Levsin. Nursing homes are SO regulated. There is a list of drugs the are not recommended for geriatric use due to the side effects. (I can't remember the name, I'm sure it will come to me later.) There has to be a lot of supporting documentation that assures them that it is necessary. Often times that documentation doesn't get done. This is when Haldol is used a a behavioral intervention, nevermind for nausea... On state surveys they can get defieciencies for inproper use of restraints which is what Haldol is. There probably needs to be some legislation that allows Hospice to do in the NH setting what it does at home and on my inpatient unit, (and perhaps there is) but expect it will always be a struggle.

I have a feeling that the problem may not be so much with the policies as it is with the interpretation of policies. I find this true a lot -- people will say they can't do X b/c of legislation when it really is a matter of policy, or of having interpreted a rule one way and not being willing to go back and see if that is the true intent.

Is there a state level hospice organization? That might be a place to get some help and/or input...

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