CHPN1680

The mega corporate hospices - Vitas, Odyssey, Vistacare, all do about 80% of their business in nursing homes where the length of stay is much longer. They mostly invest their marketing dollars in the nursing facilities. They hire nursing home medical directors to be their medical directors which gets them more patients at an earlier time. All of the mega hospices tell you that they do charity care and they do, but this is very limited because patients in nursing facilities are 100% funded. I just wanted to take the opportunity to go on record since I work for one of these "mega hospices". The 80% statement is not even close to correct. I would say that if you averaged the nursing home among all of our programs, you might get a figure of 20-30%. The majority of our patients are at home. I would be interested to know where the 80% figure came from. It seems that there is a prevailing opinion that for profit hospices are "bad" and not for profit hospice are "good". My experience with a for profit has been very positive. I have never found the company to be unethical or unwilling to take the tough patients. If your prognosis is less than 6 months, then you are eligible for service whatever treaments you may be receiving. That means the expensive patients on vents,TPN,radiation, etc... Now, neither a for profit or not for profit hospice could survive if all patients on service were this complex. That's why you have a balanced approach to marketing that assures that you have enough profitable patients, so that you can provide care to those that are not profitable. Our "mega hospice" has a heart and does the right thing by it's patients and families. I can't speak for all of the large companies but please know that there are some large companies who provide equal or better care than some non profits. It is all in how the programs are managed.

We take many patients with TPN as many hospices will not. Every situation is different. Most often, these patients are coming from an acute care setting where the focus has been on curative measures. Most often, doctors and other health care professionals have not discussed the discontinuation of TPN with their patients in these settings. When the patient comes to us with TPN, the patient and the family are assessed in terms of where they are in the disease process. The very thought of discontinuing a feeding (even in the form of TPN) often does not seem right, especially to family members. Just as we must discuss the importance of honoring the patients desire not to eat at the end of life, we must discuss the effect of administering TPN to a body that is dying. It is our job to help them understand the benefits and risks of being on TPN based on their current physical condition. Each family must reach the decsion to discontinue TPN in their own way. As long as with the TPN, the prognosis is less than 6 months, they are eligible for hospice even with TPN.

I agree. I work for a for profit and have not experienced the "trolling". I have always been proud that we continue to do the right thing for the patient and family regardless of the cost. I have heard of less than ethical practices in both non profit and for profit hospices. Sweeping generalizations don't solve the problems, they just create animosity.

I have not heard of this approach but I think that I like it! I know that the prospect of this kind of interview seems a bit overwhelming but view it as an opportunity for you to ask them what they value in an RN Case Manager. I think that it speaks highly of an organization that views the team important enough to be involved in the interview process. If I were one of the team members, my questions would focus mostly on communication skills and your ability to recognize when you need the expertise of the rest of the team. They will be trying to assess how you would fit in. The most important part of it all is to be authentic. Don't try to bluff your way through anything or to be what you think they want you to be. Just be yourself! Good Luck to you!

I was an LPN for 12 years. I worked sub-acute and LTC. I always wanted to work in hospice but LPN's were really not employed in hospice in my area either. When I finally finished the RN program, I applied for a job as a case manager in hospice and got the job. I love hospice and after 1.5 years as a case manager, I became a Patient Care Manager (equivalent to Director of Nurses). Hospice is demanding and rewarding. Burnout happens but not so much if you are aware of setting boundaries and keep to your role on the hospice team. I have seen too many nurses act as social workers as well. We have Social Workers on the team and they should be utilized for their expertise. After all, you don't see Social Workers administering medications. We have LPN's working for us but more on a PRN basis as they cannot act as case managers due to scope of practice. This is unfortunate as you and I know how capable most LPN's are at providing care. If you are unable to work as an LPN in hospice where you live, I would suggest becoming a volunteer for now. It would give you great exposure to hospice patients and an opportunity to meet hospice nurses. Take opportunities to learn pain and symptom management. If it is truely what you wish to do, you will pursue it after you become an R.N.

Check out http://www.hpna.org . There are lots of links etc.. that may help you find some good info and advice.

I have run into similar problems with patients as ALF's. Often, the problem becomes a financial one because some patients are often running low on financial resources and the addition of private caregivers can threaten their financial ability to stay at the facility. This is especially a problem when it has truely become their home and they wish to live out the rest of their days in this place. If the patient is alert and oriented enough to understand the risks associated with staying in his/her current situation, then one should consider the patients right to make the decision to stay in his/her home even if you don't think that it is the right decision. If the patient does not have the capacity to understand the risks, then the situation is more complicated. The sad part is that for the most part, LTC facilities are institutional in feeling and don't necessarily mean that the pt. will have any less falls. This is not to criticize LTC employees. It is just a fact. I worked LTC for 12 years. Great co-worker's but a frustrating environment. Too low on resources which translates in too little time to focus on the individual. These situations are going to increase in number as the population ages. I hope that we can find better and more dignified ways to care for our elders.

The nursing program is ovewhelming for everyone. You stated yourself that you haven't been doing the reading or studying enough. There many things that you can do to improve your grades. Without knowing your situation with other obligations, it's hard to make suggestions but here are a few anyway. Find a study partner or two but no more. If you study in larger groups, it tends to be too easy to turn into a social thing. Optimally, study in a place free of distractions (kids,husbands,wives etc... My study partner and I would get together on Sunday Mornings, enjoy coffee and pastry and then get to it. We both had prepared separately and usually had notes written about things that we were having difficulty with. Plan little rewards or presents to yourself for meeting study goals. It can be as simple and a bowl of ice cream, a glass of wine or an hour of leisure reading. When you get an assignment back with a less that stellar grade, find someone who did well and ask them if you may compare to see what you might improve on. This works well for things like care plans. Some people are very good at them. Identify the differences and learn what you could do better. You obviously have the ability to do this if you could get an A in A & P, Microbiology, etc... Don't beat yourself up about the grades. Just be truthful with yourself about why your grades and low and make a committment to yourself to do better. I worked full time throughout the program and managed decent grades. I am no Einstein! I was tired often and complained and moaned often to blow off steam. The result was well worth it. Good Luck to you. You can do it!

My mom has been working in CT for many years. I have heard her speak of this ridiculousness of having an R.N. co-sign orders. This is something fairly recent. Not only has she been charge nurse for many years, but often the only IV certified nurse on her shift requiring her to run to the sub-acute floor to check IV's and complete the flowsheets every hour per facility protocol. Mind you, there were R.N.'s on the floor but were not IV certified. Does this make any sense? I realize that practice acts vary from state to state. I was an LPN in LTC for many years. I am an R.N. now but cannot imagine having to co-sign a fellow nurse's orders. I do think that it is degrading. You can be trusted to pass cardiac meds but can't take a simple lab order for a PT/INR? Come on! What a poor use of resources. This has motivated me to do a bit of research now.l I wonder if it is a facility interpretation or a change in the practice act.

Congratulations! Enjoy the rewards resulting from your hard work. Welcome to Nursing!

As I sit here reading postings, I can hear in the backgound continuous reports on Fox news about Terri's case. It is rather unfortunate that what should be a personal matter has become such a media circus! At least some good has come of this. People are actually completing Living Wills and designating Health Care POA's. One can only hope that the courts will upohold our written wishes!

When I first started in LTC, I worked for a facility that still used the old ticket system for meds. I thought that it worked great! You would pre-pour meds and the tray had holes in it for the med cups with slots behind each cup for the ticket with the pt. name and drug. I agree, that you leave room for error by prepouring. It is definately a challenge to get those meds out within the prescribed time when you have so many patients. A patient falls, a new admit rolls in, short on CNA's and have to help feed etc..... Our system surely is flawed. I agree with one of the above posters. Get them off so many meds! Really, do you think that at 80 years old, it is time to be starting someone on meds to lower cholesterol! If I took 17 pills in the morning, I wouldn't eat breakfast either!

Thanks for the info. I will check it out.

I have been using Epocrates on my PDA for 2 years and am quite pleased with it. I have not seen the Davis Drug Guide for PDA's. Is there anyone out there who has used both and what is your opinion? Thanks!

We do lab work quite often and for different reasons. It is very appropriate to use lab work for diagnostic reasons in order to provide the correct treatment. We also will draw labs if there is a question of eligibility especially in the case a patients with failure to thrive ie... albumin levels. If there are labs that need to be drawn that are not related to the hospice dx. we will do them so that the patient does not have to leave home. It's all about quality of life for as long as possible. Sometimes labs help us to determine what we need to do to maintain the highest level of function.