holistic1028

My agency seems to not have a set boundary of when they will decline to care for a patient. They wanted me to admit a patient that was an hour and 30 minute drive from office to hospice and I believe that is way too far to provide quality service! Just the drive time will be 3 hours total plus the visit which would be at least an hour. Thats already half the work day for one patient!! How do they expect me to case manage and see this patient weekly?! I've explained all of this and they decided to have a HH LVN that lives near the pt to see her weekly, however I would still need to see her biweekly for RN visits. And the problem still remains. Does your agency have set boundaries? And how far should be too far? What would you do in this situation? It's not fair to the patient or family, what if there is a crisis or a PRN visit is needed?!

I'm a little confused since I've never worked hospice with patients in group homes. It seems that my current agency have some kind of unwritten agreement that the hospice nurse will fill pill boxes scheduled AND as needed amongst some other things. Of course I don't mind filling pill boxes while im on my scheduled visit but if the patient was to start a new med and it would be delivered later that day or next day they are expecting the nurse to drive back out and add that med to the pill box as well. From experience they are adamant with this and unwilling to take instructions by phone if there is something they aren't sure on. One of the group home owners said hospice is required by state to fill pill boxes every time. I am a resourceful person but I have yet to come across this CMS guideline. From my understanding, PRN visits are written in the care plan and right now all of our PRN visits are for symptom management/acute distress. I don't get it? It seems like I'm butting heads more in group homes about hospice scope more than any other place. They expect hospice aides to be in the homes before sunrise to bathe and dress patient, make bed etc. I've always viewed hospice as added support not THE ONLY support. The agency is desperate for patients since their census is low so they will concur with jst about anything the group home owners request. I end up looking like an errand woman really.. Not a nurse. One patient was started on duonebs and they expected the nurse would come out every time the patient needed one to give it.. Really? We can TEACH you how to give breathing treatments, do wound care etc, but it is not our responsibility to provide 24/7 nursing assistance. It sounds mean, especially coming from working on a floor in a nursing home bcause I would break sweats all day caring for my patients. But as a hospice case manager it is just not realistic to request this practice. Does anyone else have experience with working with group homes??

I do that..is what I'm saying..ALL of that is in my narrative on why they meet criteria ..SEE what your saying is how its supposed to be..this doctor actually wants someone else to write his brief narrative ..all he wants to do is sign ...

I know this may sound crazy but the hospice agency I work with now has a MD director that expects for his narratives to be written by the nurse and he signs! The nurse DON that was doing it for him no longer works there and now I am the only hospice RN left but its like he has the same expectations. He is not a BRAND NEW hospice doctor so Im sure he knows certifications require a brief physician narrative. I am a nice person and help out as much as I can but I am NOT taking on that responsibility of doing someone elses job! And that just sounds fraudulent to me in someway. I have to write my own nurse narrative and I do a pretty darn good job with detailed information of why patient meets criteria. I have worked at other hospice agencies before and most review the nurse narrative and composed their own from that (since they dont have to see pt F2F). I have never had this problem before and it is kinda uncomfortable for me to address it! None of my recent admissions have physician narratives attached! I mentioned it to admin and she suggested I should just copy and paste my nurse narrative to the physician narrative and he signs them in IDT meeting!! I told her that would not work and would be suspect because both narratives are apart of the certification. After our last meeting, I mentioned that they needed to be done and he kinda acted like he didnt know what I was talking about so I showed him... he then made a copy of a form he uses at another hospice agency he works for and gave me this "guide" of how another nurse broke down pt's information with spaces in between each.. ie terminal dx, co-morbids, functional limitation, weight loss, PPS FAST scores etc. (I do this in my nurse narrative anyway! just not in bullet form like he the one he showed me) then at the bottom it says "Based on the information and examination the patient meets the criteria for Hospice with prognosis likely less than 6 months" then there is space for him to sign under it.. Now I know legally a physician can delegate dictation but that is as he is speaking it right?! Also I am not a secretary and have time for that regardless, I have my own work to do and I dont think its fair to expect me to do physician narratives as well as nurse narrative! Has anyone else heard of or had this problem before? Can you please SHARE how this is done with your agency? When or how does your physician certify terminal illness?

No, and since they didnt inform you ahead its not right to insist you take on-call. Yes they should have had a back -up plan. Are they going to be paying you on-call availabilty hours and for after hour visits??

Question, are there CMS guidelines on transferring a hospice patient? If so can someone pls send me a link? This agency I currently work for have no clue what CMS guidelines are for anything and it scares me. I have to learn all on my own, I am okay with that but what bothers me is when someone goes over me and does something for a patient I am case managing that doesnt follow guidelines, and without my knowledge. If you had a patient that was transferring to another state and needed assistance with transferring hospice agencies, isnt that something the SW would help with? Nope, this agency didnt even have a SW so I had to find one for patient. If your patient's set move date was 2 weeks AFTER recert date wouldnt it make sense to go ahead and recertify the patient and then do transfer when patient is transferred?? Nope, this agency discharged my patient, without my knowledge after I had already completed re-cert documentation which was jst sitting in the computer, in void. They discharged instead 2 weeks PRIOR to transfer/move date, didnt tell me as Case Manager or the Hospice Aide, so I've been visiting and following up with patient and also the aide has been going 3x week. And isnt there guidelines for even "discharging" a patient ie. ABN, 5 day noticed, DME pickup etc? This agency just discharged, thats it, no documentation, didnt inform me or patient. Doesnt make sense to me.

I never said anything about dark humor, nothing "dark" about it. But i enjoyed reading it... like a mini novel. Yes REALLY

Omg the last poster have me LMAO! Felt like I was reading a mini novel.. good writing

Great idea! and makes much sense. I will try this next time I do it. Thanks for your response

I would say the main thing to remember is to take ownership of the patient as case manager HOLISTICALLY. If you notice patient or family needing psychosocial support refer to sw asap, spiritual support refer to chaplain asap. Stay very organized, get a really cute small spiral to keep all pt notes in. Take notes during visit, don't think you will remember cause seeing 5-6 patients in one day will make you forget. Hopefully your agency will offer you a laptop so you can do bedside charting, that is best way, even though it may seem like your visit is longer you have your note in and out the way.. you don't want to bombard yourself with charting when you're actually off at night.. don't get into that habit because it will seem like you're working all the time. If the patient needs refills on meds go all head and call them in while you're there. If patient needs something that requires MD approval go ahead and call or text doctor while you're there. Don't put too many things off until after the visit. You have to stay organized. Keep you a couple of admission packs and continuous care packs in your car. You never know when your agency will be calling you to do an eval and don't want to be running to the office to get those. Also keep extra supplies in your trunk ie wipes, chux etc..wound care supplies. Keep your own soap and paper towels in trunk.. sanitizer wipes to clean vital sign equipment between patients ... that's all I can think of for now :)

I currently have a home health case to apply wound vac. This patient has 2 stage 4s.. 1 to upper sacral area and the other to lower left ischium. I am new at bridging and it seems like I keep getting a leak, not a constant noise but intermittently every 10 seconds or so.. I've pressed every area and still can never find it. The patient gets frustrated and says to just forget it, she'll deal with the noise so I end up leaving (almost an hour and half later) feeling incompetent and unsatisfied with my work. These are the steps I take: Remove old wound vac drapes and tubing, cleanse area measurements etc. spray peri wound areas with no sting barrier film skin prep measure and cut granufoam to fit inside each wound (I think this is my problem area because I've been told to make sure theres enough foam to completely fill wound and I've also been told to make foam slightly smaller than wound) cut tegaderm strip to cover both wound with foam #1, cut another to cover wound with foam #2 Then I cut opening to tegaderm over each foam Next I cover skin with tegaderm where bridging will be (one vertically inbetween each wound and another off to the side where I plan to apply suction) Confusing huh Then I put foam bridge on top of both openings (which is hard because the foam is curled) and I put another foam as close to or on top of the bridge to extend it out (the bigger round part of the foam) Apply tegaderm on top of all of this (which is hard because it moves) So i do it in strips Cut hole in extended bridge and apply suction there What am I doing wrong? Any tips? Most videos only show how to do one wound but I havent come across any online on how to do 2 wounds and bridging them together.

I see, just asking bcause I've accepted an offer with a much better equipped agency but I hate to leave SOME of my cases behind

I know it may sound cold, but is it illegal to take my patients from another hospice company I'm working for to a better one I will be starting? Not really "taking" but transfer with their consent of course.

Oh I see, so that facility hiring a licensed nurse is more for sales or for glory? Because from what I've noticed the LVN at this particular ALF sits in an office as the "director of resident services". It seems more as an office administrative position rather than a nursing position. I guess I'm having a hard time understanding because when I was a LVN I also used to work in an ALF and we passed all meds and administered all within scope of LVN as needed and assessed patients as needed. I've already spoken to family about transferring to a LTC because pt is total care and this facility is not able to provide the care the patient needs but they are not able to afford it so the facility just passes the buck to hospice to care for patient. I've already changed frequency to 5x week, I as RN case manager visit 2x week and LVN visits 3xweek but they also call on weekends for on call weekend nurse to visit for petty issues (something that could be handled by nurse there or instructions given over phone). This patient is not actively dying. Something has to change! Its ridiculous.

I was using that only as an example regarding giving a PRN suppository. This particular patient is already on a bowel regimen of senna BID. But let's say the patient has hemorrhoids and is in pain from it, and there is an order for PRN hemorrhoid supp such as prep H in place, is it hospice responsibility to come out daily to administer a suppository PRN because this facility licensed nurse refuses to do so? From my understanding it is not. But like I said, when I am there during my visit I will definitely give whatever the patient may need since nothing is done by facility nurse. But we are not there daily, so is it fair the patient is in pain from hemorrhoids AND there is an order in place to give PRN medication but it isn't being given because hospice is expected to do it? Just like if this was a patient at home, that is not something hospice would do. We wouldn't up our visits to daily to do wound care, give suppositories or check vital signs for example. Thats home health care. We can TEACH the primary care giver on how to do those and assist in managing symptoms for the patient. Unless my understanding and what I was taught wrong about hospice? I understand that an ALF is not a SNF and the care they can provide is very limited, but it would be easier for me to understand if they did not have a LVN on duty. What is the purpose of a licensed nurse working in a facility if they're not going to do anything clinically or any interventions with a patient? I don't get it. We will get called over the weekend to make a visit because the patient has an intact blister.. WTH?